Pam Health Rehabilitation Hospital of Greeley

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52287 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance. A-0144- The patient has the right to receive care in a safe setting. Based on observations, interviews, and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure interventions were implemented to prevent at-risk patients from leaving the facility unattended. This failure was identified in two of two patients who left the facility unattended. (Patients #4 and #5)”

“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: 52287 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 document reviews and interviews, the facility failed to ensure staff medicated, assessed, and reassessed patients’ pain per facility policies and national guidelines. This failure impacted three out of six patients prescribed pain medications. (Patients #4, #7, and #8) Additionally, the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care provided by a licensed practical nurse (LPN). Specifically, the facility failed to ensure patients were assessed by RNs every 24 hours according to facility policy. This failure was identified in three of five medical records reviewed of patients assessed by LPNs. (Patients #5, #6, and #8)”

“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: 52287 Based on observations, interviews, and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure interventions were implemented to prevent at-risk patients from leaving the facility unattended. This failure was identified in two of two patients who left the facility unattended. (Patients #4 and #5) Findings include: Facility policies: According to the Fall Prevention policy, the purpose is to provide a guide for assessing patients at risk of falling and for implementing precautionary measures to reduce the probability of a patient falling or to reduce the probability the patient will sustain a serious injury in the event of a fall. Patients are assessed for fall risk indicators and given a score which identifies them as low, moderate, or high fall risk. Universal fall prevention interventions are implemented for patients who score low risk on the modified Morse Fall Scale (zero to 26). These patients will have the following interventions considered by the healthcare team: Orient the patient to surroundings and routine, bed in low position, use treaded socks for patients when out of bed, room cleared of all unnecessary equipment, personal items, call bell, cane/walker within reach, and all movable equipment will be locked. Patients who score moderate risk on the modified Morse Fall Scale (score of 26-45) will have the following interventions considered in addition to the universal interventions: Assess the patient’s coordination and balance before assisting with transfer and mobility activities, staff will assist and monitor patients in the bathroom, all ambulatory aids within reach on functional side, facilitate the use of bed and/or chair alarms, ensure alarms are at exits where available, family member with patient, and increase observation levels of patients. According to the Patient Rights and Responsibilities policy, the purpose is to ensure that every patient is aware that his/her basic rights for independence of expression, decision, and concern for personal dignity are preserved. Patient responsibilities include those actions on the part of patients that are needed so that healthcare providers can provide appropriate care, make accurate and responsible care decisions, address patients’ needs, and maintain a sound and viable healthcare facility. Patients have the right to receive care in a safe setting, free from neglect. Patients must follow the care, treatment, and service plan developed. The facility makes every effort to adapt the plan to the specific needs and limitations of the patient. Patients are responsible for the outcomes if they do not follow the care, treatment, and service plan. If the patient chooses not to be an active participant in their care, the treatment team may recommend discontinuation of treatment. Reference: According to the Elopement Risk Assessment in the electronic medical record (EMR), if the patient is at a high risk for elopement, the following interventions would be implemented: The patient will be oriented to the hospital, including patient responsibilities and facility requirements. The patient and/or family will be educated regarding the dangers of leaving the facility unannounced. Reassessment will occur during team rounds. All staff will be alerted, and the patient will be moved closer to the nursing station. The family will be encouraged to stay with the patient if in a private room. If elopement risk persists with valid documentation, recommend one-to-one supervision. 1. The facility failed to ensure interventions were implemented to prevent at-risk patients from leaving the facility unattended. A. Document Review i. Medical record review revealed Patient #5 was admitted to the facility on 4/14/25 with a traumatic brain injury (TBI) and cognitive impairment (decline in mental abilities). The nursing admission assessment revealed Patient #5 scored a 13 on the Elopement Risk Assessment, which indicated they were at risk for elopement. Patient #5 eloped from the facility four times during their stay. a. On 4/25/25 at 11:33 a.m., provider documentation revealed Patient #5 had eloped to a fast food restaurant across the street and returned to the facility. b. On 4/26/25 at 11:20 a.m., provider documentation revealed Patient #5 had left the facility unsupervised and returned on their own the night before. c. On 4/27/25 at 11:07 a.m., the nursing shift assessment revealed Patient #5 had been found at a local grocery store by a family member and Patient #5 was returned to the facility. d. On 5/16/25 at 9:05 p.m., the case management weekly note read, at 5:30 p.m., Patient #5 eloped from the building and was unable to be located at any local establishments. There was no evidence in the medical record of additional interventions, other than patient re-education and frequent staff rounding, implemented after each elopement to prevent Patient #5 from leaving the facility. Review of Interdisciplinary Patient Care Conference Reports (team rounds) from 4/17/25 to 5/15/25 revealed Patient #5 was not reassessed for elopement risk during their stay. Patient #5’s medical record review was in contrast to the Elopement Risk Assessment, which read, the patient should have been reassessed for elopement risk during team rounds. If elopement risk persisted with valid documentation, one-on-one supervision was recommended. The review of Patient #5’s medical record was also in contrast to the Patient Rights and Responsibilities policy, which read, patients had the right to receive care in a safe setting, free from neglect. Patients followed the care, treatment, and service plan developed. The facility should have made every effort to adapt the plan to the specific needs and limitations of the patient. ii. Medical record review revealed Patient #4 was admitted to the facility on 3/3/25 with a diagnosis of malaise (general feeling of weakness). Patient #4 used mobility aids, and nursing and physical therapy (PT) assessments documented the patient was unable to walk longer distances or navigate obstacles unaccompanied. Patient #4 was a current two-pack-a-day cigarette smoker and refused offered smoking cessation aids. Patient #4 left the facility unattended to smoke cigarettes outdoors on multiple occasions during their stay. Review of nursing shift assessments from 3/3/25 to 3/18/25 revealed Patient #4’s fall risk assessments varied from 15 (low risk) to 75 (high risk). The fall risk portions of these assessments, although scored inconsistently across shifts, revealed the nursing staff had Patient #4 on fall risk precautions due to their impaired mobility, cognition, awareness of their limits, and judgment. Review of the nursing shift assessment from 3/11/25 at 8:01 p.m. revealed Patient #4 had a moderate fall risk assessment score of 40. Review of the psychiatric provider’s documentation from 3/12/25 at 3:00 p.m. revealed Patient #4 was leaving the facility to smoke cigarettes across the street. Review of the nursing shift assessment from 3/12/25 at 8:23 p.m. revealed Patient #4 was weak, was educated on safety, although this education required reinforcement, and was at a moderate risk of falling (scored 40). There was no evidence in the medical record of increased observations or bed/chair alarms in use for Patient #4 during this time period, as outlined in the Fall Prevention policy for moderate fall risk patients. Additionally, review of the provider’s discharge summary from 3/17/25 at 2:15 p.m. revealed, on 3/12/25, staff had informed the provider Patient #4 was leaving the facility to smoke. A nursing note on 3/18/25 at 1:35 a.m. revealed the patient continued to leave the facility in order to smoke cigarettes. Although the nursing and provider notes revealed Patient #4 left the facility to smoke on more than one occasion, there was no evidence in the medical record of specific dates and times when staff were aware that Patient #4 left the facility. There was also no evidence in the medical record of interventions, other than re-education, implemented to keep Patient #4 safe from falls and other risks when they left the facility to smoke cigarettes. Additionally, there was no evidence in the medical record of Patient #4 leaving the facility with a staff member in attendance to ensure the patient’s safety. Review of Interdisciplinary Patient Care Conference Reports for 3/6/25 and 3/13/25 revealed Patient #4’s care team did not discuss Patient #4’s ability to leave the facility safely to smoke. The review of Patient #4’s record was in contrast to the Patient Rights and Responsibilities policy, which read, patients had the right to receive care in a safe setting, free from neglect. Patients followed the care, treatment, and service plan developed. The facility should have made every effort to adapt the plan to the specific needs and limitations of the patient. B. Observations i. On 6/9/25 at 4:24 p.m., observations conducted in the main hallway revealed the materials hallway door was opened by waving a hand in front of the lock to gain entrance. The materials hallway led to an ambulance exit, which was not equipped with a door alarm. Additionally, the outpatient rehabilitation gym door was opened by waving a hand in front of the lock to gain entrance. The gym door led to an exit which was not equipped with a door alarm. This was in contrast to the Fall Prevention policy, which read, the use of exit alarms should have been used for moderate fall risk patients. C. Interviews i. On 6/11/25 at 10:51 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 stated elopement interventions included shift huddles, patients and family were educated every shift, and staff members rounded on patients every 15 minutes. LPN #1 stated staff members watched patients who were at risk of elopement. LPN #1 also stated patients were at risk if they left the facility and were not kept safe. ii. On 6/11/25 at 11:24 a.m., an interview was conducted with the charge registered nurse (RN) #2. RN #2 stated patients who scored greater than a nine on the Elopement Risk Assessment were considered a high risk for elopement. RN #2 stated a patient with cognitive impairment who was observed trying to leave the facility would be placed on a one-to-one. This was in contrast to Patient #5’s medical record, which revealed this patient, who had cognitive impairments, had eloped four times and was not placed on a one-to-one. Additionally, RN #2 stated patients who were alert and oriented were allowed to leave the facility to smoke. This was in contrast to the Fall Prevention policy, which read, patients who scored as moderate risk should have had bed/chair alarms, alarms at exits, and increased levels of observation. This was also in contrast to the Patient Rights and Responsibilities policy, which read, patients had the right to receive care in a safe setting, free from neglect. Patients followed the care, treatment, and service plan developed. The facility should have made every effort to adapt the plan to the specific needs and limitations of the patient. iii. On 6/10/25 at 2:46 p.m. and on 6/11/25 at 9:00 a.m., interviews were conducted with assistant chief nursing officer (ACNO) #3. ACNO #3 stated Patient #5 had exited the facility through the gym door, which at that point had not been alarmed. ACNO #3 stated Patient #5 had been placed on a visual watch and was not placed on a one-to-one throughout their stay. ACNO #3 also stated Patient #5’s cognitive testing determined they did not have the capacity to make safe decisions. ACNO #3 stated Patient #5 was at a high risk for elopement, and the facility staff had been on high alert for Patient #5. This was in contrast to Patient #5’s medical record, which revealed they had eloped four times without additional interventions, other than patient re-education, implemented after each elopement to prevent Patient #5 from leaving the facility. Additionally, ACNO #3 stated the facility was a smoke-free building, and patients like Patient #4 were required to leave the facility to smoke. ACNO #3 stated the medical provider, case management, nursing, therapy, and the patient’s family would determine if it was safe for the patient to leave the facility to smoke. This was in contrast to Patient #4’s Interdisciplinary Patient Care Conference Reports for 3/6/25 and 3/13/25, which failed to reveal Patient #4’s exits from the facility, and their ability to safely leave the facility unattended was discussed with the care team. iv. On 6/11/25 4:30 p.m., an interview was conducted with medical director (Director) #4. Director #4 stated, due to Patient #5’s elopement risk, a wanderguard (a device worn to trigger an alarm when a patient attempted to exit an area) had been ordered; however, it had not been used. They stated patients who eloped were at risk of injury, for example, getting hit by a car or by wandering into someone’s home. Director #4 stated the facility was responsible for ensuring patients’ safety. Director #4 stated the facility was smoke-free and required patients, such as Patient #4, who wanted to smoke to leave the grounds. They also stated if patients left the grounds, the patients were leaving against medical advice (AMA). Director #4 stated if a patient wanted to go outside, they would be accompanied by a staff member and still not permitted to smoke. Director #4 stated patients who left the facility grounds were no longer patients as they had chosen to leave, which was in contrast to the interview with RN #2.”

“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: 52287 Based on document reviews and interviews, the facility failed to ensure staff medicated, assessed, and reassessed patients’ pain per facility policies and national guidelines. This failure impacted three out of six patients prescribed pain medications. (Patients #4, #7, and #8) Additionally, the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care provided by a licensed practical nurse (LPN). Specifically, the facility failed to ensure patients were assessed by RNs every 24 hours according to facility policy. This failure was identified in three of five medical records reviewed of patients assessed by LPNs. (Patients #5, #6, and #8) Findings include: Facility policies: According to the Pain Management policy, the purpose was to recognize pain interfered with the optimal level of function and/or participation in rehabilitation and all patients had the right to appropriate assessment and management of pain. Pain reassessment occurred within four hours of administration and was documented in the medical record. According to the Guidelines for Nursing Care policy, the purpose was to outline nursing routines and guidelines for patient care. Nursing staff were to reassess pain within four hours after an as-needed (PRN) pain intervention to maintain quality care. According to the Nursing Documentation policy, a patient-focused assessment will be documented in the patient care record once per 24-hour period by an RN. According to the Guidelines for Nursing Care policy, 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. Patients will be assessed every shift and with significant condition changes. The RN must assess once every 24 hours. The LPN may gather data for the RN to conduct the assessment. Reference: According to Lippincott Pain Management guidelines, pain was the sensory and emotional experience associated with actual or potential tissue damage. It included not only the patient’s perception of an uncomfortable stimulus but also the response to that perception. The patient’s report of pain was the most reliable indicator of the existence of pain. Assessing and managing pain required listening to the patient’s subjective description of the pain and using objective tools. Each facility should have defined criteria to screen for, assess, and reassess a patient’s pain. To evaluate progress toward pain management goals, pain should be reassessed at designated intervals according to the type of pain intervention. Assess for adverse reactions and risk factors for adverse events that may result from treatment. Documentation associated with pain management included location, quality, and duration of the pain, pain management interventions selected, the response to those interventions, and the pain rating before and after interventions Safety was a special concern, with an increased risk of falling because of impaired mobility from pain and adverse effects of pain medications. The complications associated with pain management included untreated or undertreated pain, multisystemic effects (such as pallor (pale skin), elevated blood pressure, dilated (larger) pupils, skeletal muscle tension, dyspnea (trouble breathing), tachycardia (increased heart rate), and diaphoresis (sweating)), adverse effects of opioids or other medications for pain treatment, respiratory depression (inhibited breathing), drowsiness (tiredness) or sedation (state of relaxation or sleepiness). According to the Licensed Vocational Nurse (LVN)/LPN Job Description, the LPN is responsible for providing appropriate nursing care as directed by a RN on the nursing unit. Under the direct supervision of an RN, the LPN assumes responsibility for the care of assigned patients on a designated shift. The LPN reviews and updates care plans as appropriate and monitors patients for changes in medical condition. 1. The facility failed to ensure staff medicated, assessed, and reassessed patients’ pain per facility policies and national guidelines. A. Document review i. Patient #4 was admitted to the facility on 3/3/25 for malaise (general weakness) and used mobility aids to ambulate (walk). On 3/4/25 at 8:25 p.m., according to the medication administration record (MAR), nursing staff administered oxycodone (an opioid pain medication) 5 milligrams (mg) one tablet for Patient #4’s 6/10 abdominal/groin pain. The directions included in the MAR for this medication read, staff were to administer oxycodone 5mg one tablet (5mg) PRN pain levels 7-10 pain. The physician’s orders read, staff were to administer oxycodone 5mg one-half tablet (2.5 mg) PRN pain levels 4-6/10. This medication administration of oxycodone 5mg for 6/10 pain was in contrast to the physician’s order for oxycodone 2.5mg. This was also in contrast to the Lippincott pain management guidelines which read, safety was a special concern, with an increased risk of falling because of impaired mobility from the adverse effects of pain medications. Patient #4’s pain was not reassessed until 3/5/25 at 5:19 a.m. (eight hours and 54 minutes later), according to the MAR. This late assessment was in contrast to the Pain Management and Guidelines for Nursing Care policies which read, all patients had the right to appropriate assessment and management of pain. Pain reassessment occurred within four hours of administration and was documented in the medical record. Also, nursing staff were to reassess pain within 4 hours after a PRN pain intervention to maintain quality care. ii. Patient #7 was admitted to the facility on 3/2/25 for altered mental status (AMS). On 3/3/25 at 5:54 p.m., according to the MAR, nursing staff administered oxycodone 5mg for Patient #7’s headache rated 5/10. The MAR failed to reveal a follow-up assessment of Patient #7’s pain until 3:14 a.m. (nine hours and 20 minutes later). This late assessment was in contrast to the Pain Management and Guidelines for Nursing Care policies which read, all patients had the right to appropriate assessment and management of pain. Pain reassessment occurred within four hours of administration and was documented in the medical record. Also, nursing staff were to reassess pain within 4 hours after a PRN pain intervention to maintain quality care. On 3/5/25 at 9:35 a.m., according to the MAR, nursing staff administered oxycodone 10mg for Patient #7’s headache rated 8/10. At 1:00 p.m. (three hours and 25 minutes later), according to the MAR, the follow-up assessment of Patient #7’s pain was performed by nursing staff. Staff documented in the MAR the medication was “effective” as the patient was sleeping, despite the Patient Rounding sheets documenting Patient #7 having been awake and in therapy or at the nurses’ station from 9:39 a.m. to 12:16 p.m. On 3/24/25 at 8:29 a.m., according to the MAR, nursing staff administered gabapentin (a medication for nerve pain) 600mg for Patient #7’s 8/10 headache. At 8:32 a.m., nursing staff also administered lidocaine (pain medication) 4% cream to the patient’s head. The MAR failed to reveal nursing staff reassessed the efficacy of these medications in reducing the patient’s pain. On 3/23/25 at 11:52 a.m., the MAR documented the provider administered a lidocaine 4% cream to the patient’s head for pain. The MAR failed to reveal nursing staff reassessed the efficacy of this medication. The pain section of the Patient Rounding notes from 11:00 a.m. onward revealed Patient #7 was not in pain which was in contrast to the MAR. This lack of reassessment after pain medication was administered was in contrast to the Lippincott pain management guidelines which read, to evaluate progress toward pain management goals, pain was to be reassessed at designated intervals according to the type of pain intervention. Documentation associated with pain management included location, quality, and duration of the pain, pain management interventions selected, the response to those interventions, and the pain rating before and after interventions. This was also in contrast to the Pain Management policy which read, all patients had the right to appropriate assessment and management of pain. Pain reassessment occurred within four hours of administration and was documented in the medical record. iii. Patient #8 was admitted on 2/26/25 for left-sided hemiparesis (weakness or inability to move one side of the body) after a stroke (lack of oxygenated blood flow to the brain). On 3/6/25 at 8:53 a.m., according to the MAR, nursing staff administered diclofenac (pain medication) 1% gel to Patient #8’s shoulder for 5/10 pain. The MAR failed to reveal nursing staff reassessed the efficacy of this medication. The pain section in the Patient Rounding notes also failed to reveal any assessment of pain until 2:00 p.m. (five hours and seven minutes later). On 3/7/25 at 9:57 a.m., the MAR documented staff administered diclofenac 1% gel to Patient #8’s shoulder for 3/10 pain. The MAR failed to reveal any other pain interventions or pain assessments until 10:46 p.m. (12 hours and 49 minutes later) when diclofenac was reapplied. The pain section in the Patient Rounding notes also failed to reveal a pain assessment until 10:52 a.m. when nursing staff documented Patient #8 was “out of building” but also described Patient #8 as being in pain and medicated per orders at this time. This patient rounding documentation was in contrast to the MAR which failed to reveal any medications administered to Patient #8 around 10:52 a.m. On 3/13/25 at 8:54 a.m., the MAR documented staff administered a lidocaine patch to Patient #8’s shoulder for 5/10 pain. The MAR failed to reveal a follow-up assessment of Patient #8’s pain. The pain section of the Patient Rounding notes from 8:50 a.m. onward documented Patient #8 was not in pain, which was in contrast to the MAR during this time, which documented patient was in 5/10 pain and had been medicated. On 3/14/25 at 9:21 a.m., the MAR documented staff administered a lidocaine patch to Patient #8’s shoulder for 6/10 pain. The MAR failed to reveal a follow-up assessment of Patient #8’s pain. The pain section of the Patient Rounding notes from 9:00 a.m. to 10:00 a.m. documented Patient #8 was not in pain, which was in contrast to the MAR which documented the patient was in 6/10 pain and was medicated during this time. This lack of reassessment after pain medications were administered was in contrast to the Lippincott pain management guidelines which read, to evaluate progress toward pain management goals, pain was to be reassessed at designated intervals. Documentation associated with pain management included location, quality, and duration of the pain, pain management interventions selected, the response to those interventions, and the pain rating before and after interventions. This was also in contrast to the Pain Management policy which read, all patients had the right to appropriate assessment and management of pain. Pain reassessment occurred within four hours of administration and was documented in the medical record. B. Interviews i. On 6/11/25 at 8:12 a.m., an interview was conducted with registered nurse (RN) #5. RN #5 stated staff performed pain reassessments an hour after administering pain medications given the half-life (the time it takes for the amount of a drug’s active substance to reduce by half in the body) of most pain medications. They stated their electronic medical system (EMR) prompted staff to reassess pain an hour after pain medications were administered. RN #5 stated this was important to ensure the medications were effective and the patients were comfortable. They stated if pain was not addressed, the patients were not able to participate in rehabilitation therapies. They stated the risks of pain medications included an allergic reaction, a change in breathing, respiratory depression (cessation of breathing), and inability to rouse (wake up), especially with opioid pain medications. ii. On 6/11/25 at 11:24 a.m., an interview was conducted with charge nurse (RN) #2. RN #2 stated pain assessments were performed to address patient needs and help manage pain. They stated their pain policy required pain assessments four hours after pain medications were administered; however, the EMR prompted for a reassessment an hour after medication administration. RN #2 stated patients were at risk for uncontrolled pain and an inability to participate in the therapies they needed to restore their health if pain was not reassessed. iii. On 6/11/25 at 4:30 p.m., an interview was conducted with medical director (Director) #4. Director #4 stated pain was to be reassessed after each pain intervention, including lower-risk interventions such as diclofenac and lidocaine. They stated staff were to reassess pain within one to one and a half hours after pain medications were administered, the approximate half-life of pain medications, to capture the efficacy of the intervention and to assess for any side effects of the medications. iv. On 6/12/25 at 7:30 a.m. and 9:50 a.m., interviews were conducted with regional quality director (Director) #6. Director #6 stated quality staff audited PRN pain medication administration every month. They stated quality staff had not identified any concerns with pain assessments or reassessments. This was in contrast to the medical record reviews which revealed patients’ pain had not been assessed and reassessed according to facility policies and national guidelines. 2. The facility failed to ensure patients were assessed by RNs every 24 hours according to facility policy. A. Document Review i. A medical record review of the nursing assessments for Patient #5 revealed two instances in which they were not assessed by an RN every 24 hours. a. On 5/1/25 at 9:30 p.m., Patient #5 was assessed by an RN. Patient #5 was assessed by LPNs on 5/2/25 at 7:05 a.m., 5/2/25 at 9:30 p.m., and on 5/3/25 at 9:00 a.m. Patient #5 was next assessed by an RN on 5/3/25 at 9:41 p.m., 48 hours and 11 minutes later. b. On 5/12/25 at 8:00 p.m., Patient #5 was assessed by an RN. Patient #5 was assessed by LPNs on 5/13/25 at 8:15 a.m., 5/13/25 at 8:40 p.m., and on 5/14/25 at 7:25 a.m. Patient #5 was next assessed by an RN on 5/14/25 at 8:00 p.m., 48 hours later. ii. A medical record review of the nursing assessments for Patient #6 revealed two instances in which they were not assessed by an RN every 24 hours. a. On 5/15/25 at 8:47 a.m., Patient #6 was assessed by an RN. Patient #6 was assessed by LPNs on 5/15/25 at 9:24 p.m., 5/16/25 at 7:30 a.m., and on 5/16/25 at 7:20 p.m. Patient #6 was next assessed by an RN on 5/17/25 at 12:15 p.m., 36 hours and 33 minutes later. b. On 5/21/25 at 8:20 p.m., Patient #6 was assessed by an RN. Patient #6 was assessed by LPNs on 5/22/25 at 9:45 a.m., 5/22/25 at 9:30 p.m., and on 5/23/25 at 8:00 a.m. Patient #6 was next assessed by an RN on 5/23/25 at 8:27 p.m., 35 hours and 40 minutes later. iii. On 3/7/25 at 10:51 a.m., Patient #8 was assessed by an RN. Patient #8 was assessed by LPNs on 3/7/25 at 7:00 p.m. and 3/8/25 at 1:13 p.m. Patient #8 was next assessed by an RN on 3/8/25 at 7:00 p.m., 32 hours and 9 minutes later. These medical record reviews were in contrast to the Nursing Documentation and Guidelines for Nursing Care policies which read, to ensure quality patient care, certain standards of care must be upheld. The LPN could gather data for the RN to conduct the assessment; however, the RN should have assessed the patients once every 24 hours. This was also in contrast to the LVN/LPN Job Description, which read, LVN/LPNs performed patient care under the direct supervision of an RN. B. Interviews i. On 6/11/25 at 10:51 a.m., an interview was conducted with LPN #1. LPN #1 stated LPNs did not assess patients; they collected information as outlined in their scope of practice. LPN #1 stated RNs performed assessments, or they cosigned the LPNs’ assessments, every 24 hours per facility policy. This was in contrast to medical record reviews for Patient #5, #6, and #8, which revealed RNs had not assessed, or cosigned the LPNs’ assessments, every 24 hours. LPN #1 also stated there was not a risk to patients if LPNs performed shift assessments without RN oversight, as it was possible both RNs and LPNs could miss a patient’s sign or symptom. They stated the reason RNs were primarily responsible for shift assessments and provided oversight to the LPNs was due to facility policy. ii. On 6/11/25 at 11:24 a.m., an interview was conducted with RN #2. RN #2 stated RNs completed head-to-toe assessments on patients. RN #2 also stated LPNs worked within their scope of practice, which RNs oversaw. They stated they did not have concerns with the LPNs performing the shift assessments. iii. On 6/11/25 at 8:12 a.m., an interview was conducted with assistant chief nursing officer (ACNO) #3. ACNO #3 stated patient assessments could be completed by an LPN if an RN cosigned or assessed the patient within 24 hours. ACNO #3 also stated if an LPN had cared for a patient, on the next shift, an RN would care for those patients to ensure each patient was assessed by an RN every 24 hours. This was in contrast to medical record reviews for Patient #5, #6, and #8, which revealed RNs had not assessed, or cosigned the LPNs’ assessments, every 24 hours. Additionally, ACNO #3 stated there was a potential for critical issues to be missed by the LPNs who assessed patients if the assessments were not reviewed by an RN.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 DISCHARGE PLANNING was out of compliance. A-0821 STANDARD: DISCHARGE PLAN (c)(4) - The hospital must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan. Based on interviews and document reviews, the facility failed to reassess the discharge plan of one of one dialysis patients reviewed, who had a significant change in post-discharge care availability. (Patient #3)”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 44751 Based on interviews and document reviews, the facility failed to reassess the discharge plan of one of one dialysis patients reviewed, who had a significant change in post-discharge care availability. (Patient #3) Findings include: Facility policy: The Discharge Planning policy read, the discharge planning process will be coordinated by the Case Manager in collaboration with the patient, designated patient support caregiver, physician, and other members of the interdisciplinary healthcare team. The Case Manager will monitor, re-evaluate, and modify the discharge plan of care as indicated by patient progression, condition, and preference. The case manager or designee will initiate referrals to extended care providers, specialized ambulatory services, and/or community-based resources as applicable and relevant to the discharge plan and patient goals/treatment preferences. The Case Manager will secure acceptance for post-discharge care services as applicable to the discharge plan of care. Documentation should include details of acceptance of the service/provider and information shared to obtain acceptance for post-discharge care needs. The Case Manager will confirm and/or assist with the arrangements for the following, but not limited to, in preparation for discharge: arrange for outpatient services such as dialysis, infusions, outpatient therapies, and Coumadin clinics as applicable. 1. The facility failed to ensure outpatient dialysis treatment was arranged and confirmed before discharging the patient. As a result, the patient was discharged without secured acceptance from an outpatient dialysis facility. A. Document review and interviews revealed outpatient dialysis treatment was not established for Patient #3 before the patient was discharged. This resulted in Patient #3 missing an ordered hemodialysis treatment. i. Medical record review for Patient #3 revealed the patient had end-stage renal disease (when the kidneys no longer work) and required hemodialysis (a treatment performed to clean the blood and remove waste, extra fluids, and toxins from the blood). According to Patient #3’s medical record, Patient #3 received hemodialysis treatments every Monday, Wednesday, and Friday. According to the progress note entered by Physician #1 on 1/20/25 at 5:43 p.m., Patient #3 required outpatient hemodialysis after the patient was discharged. Additionally, the progress note revealed Case Manager #2 had arranged outpatient dialysis treatment for the patient, and discharge was anticipated for the patient on 1/21/25. ii. The case management notes and addendums were reviewed and revealed Patient #3 was discharged without an established outpatient hemodialysis treatment schedule. a. On 1/22/25 at 10:54 a.m., twenty-four hours and 58 minutes after Patient #3 had been discharged, Case Manager #2 entered a case management addendum note. According to the note, on 1/20/25 at 11:06 a.m. and 3:36 p.m., Case Manager #2 called the outpatient hemodialysis contact center to obtain the hemodialysis treatment schedule for Patient #3. However, during the call, the contact center could not provide confirmation hemodialysis treatment was established for Patient #3. Further review of the addendum note revealed on 1/21/25 at 8:18 a.m., one hour and 38 minutes before Patient #3 was discharged, Case Manager #2 called the outpatient hemodialysis contact center again and attempted to obtain confirmation of a hemodialysis treatment schedule for Patient #3. During this call, the contact center informed Case Manager #2 that outpatient hemodialysis treatment was still not confirmed for Patient #3. However, the patient was documented as discharged at 9:56 a.m. iii. On 3/4/25 at 2:30 p.m., an interview was conducted with Case Manager #2. Case Manager #2 stated they performed the discharge planning evaluation, oversaw patient care coordination, and ensured any post-discharge care services were arranged and confirmed before patients were discharged. However, Case Manager #2 stated before Patient #3 was discharged, outpatient hemodialysis treatment had not been confirmed. Case Manager #2 stated they had expected to receive a confirmation of the dialysis treatment schedule shortly after Patient #3 had been discharged. Case Manager #2 stated the outpatient hemodialysis contact center told them Patient #3 could be discharged even though the patient did not have a confirmed hemodialysis treatment schedule. Case Manager #2 stated they had not notified Patient #3’s physician about the lack of a confirmed outpatient hemodialysis treatment schedule and did not reassess the discharge plan. Case Manager #2 stated they did not receive a confirmed outpatient dialysis treatment schedule for Patient #3 until 1/22/25 at 3:14 p.m. Case Manager #2 stated because the facility discharged Patient #3 before outpatient hemodialysis was confirmed, the patient did not receive their scheduled hemodialysis treatment on 1/22/25. Case Manager #2 further stated that without dialysis treatment, the patient experienced a risk of toxin and fluid buildup, which could lead to severe complications such as electrolyte imbalances, high blood pressure, organ failure, and potentially life-threatening conditions. The interview with Case Manager #2 contrasted with the facility’s Discharge Planning policy, which stated the Case Manager would arrange and confirm outpatient dialysis services in preparation for patient discharge. The Case Manager would also ensure acceptance of post-discharge dialysis care as required by the patient’s discharge plan. a. On 3/6/25 at 8:01 a.m., an interview was conducted with regional case manager (Regional Manager) #3. Regional Manager #3 stated the discharge planning process included establishing outpatient dialysis services. Regional Manager #3 stated patients who required outpatient dialysis should have a confirmed start date, clinic location, and confirmed scheduled dialysis treatment time. Regional Manager #3 stated dialysis treatments were life-sustaining medical treatments, and without them, patients could experience severe complications and significant harm. However, when asked whether this occurred for Patient #3, Regional Manager #3 stated that after reviewing Patient #3’s medical record, outpatient dialysis treatment had not been established before the patient was discharged. Regional Manager #3 stated the discharge plan for Patient #3 should have been reassessed. Regional Manager #3 stated there was no evidence in Patient #3’s medical record indicating the physician had been informed outpatient dialysis treatment had not been confirmed. Upon request, the facility was unable to provide a formal process or policy case management staff were to follow to ensure dialysis patients were not discharged without a confirmed hemodialysis treatment schedule.”