Sage Specialty Hospital

“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: 47397 Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by: 1) failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders (See findings in A-0398); 2) failure of nursing staff to document vital signs per physician orders for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed (See findings in A-0395); 3) failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed (See findings in A-0398); 4) failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed (See findings in A-0398); and 5) failure of the nursing staff to administer Patient #1’s medications per physician order (See findings in A-0402).”

“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: 47397 Based on observation, record review and interview the hospital failed to ensure care in a safe setting as evidenced by: 1) failure of nursing staff to follow infection control guidelines and don the appropriate Personal Protective Equipment (PPE) before entering 1 (#3) of 1 (#3) patients observed on contact precautions; and 2) failure to ensure each employee’s personnel file contained documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S2RN) of 1 (S2RN) contract nurse personnel files reviewed. Findings: 1) Failure of nursing staff to follow infection control guidelines and don the appropriate Personal Protective Equipment (PPE) before entering 1 (#3) of 1 (#3) patients observed on contact precautions. Review of hospital policy provided by S1ADM titled “Infection Control Plan”, last approved 05/2023, revealed in part: “Policy: Infection Control Program: The infection Control Program allows for a systemic, coordinated and continuous approach and is accomplished by: 8. Providing education to employees, staff patients visitors, with particular emphasis on proper use of personal protective equipment (PPE). Review of hospital policy provided by S1ADM titled “Guidelines for Transmission Based Isolation Precautions”, last revised 04/2021, revealed in part: Procedure: “A. Contact Precautions: Use Contact Precautions for patients with known or suspected infections. Use of Personal Protective Equipment (PPE): Perform hand hygiene prior to applying PPE. 2. Gloves. 3. Gowns.” Review of hospital job description provided by S1ADM titled “RN”, last revised 09/2016, revealed in part: “Job Description and Responsibilities”, in part: 10) Follows infection control guidelines as per Sage nursing policy and procedure. Observation on 04/14/2025 at 8:16 AM revealed room ‘a’ with a sign on the door stating the following: Contact Precautions, Do Not Enter, Perform appropriate hand hygiene before donning required PPE. Personnel Protective Equipment (PPE): When entering a Patient Room-You Must Wear, in part: Gown. Continued observation revealed S5CN walked into room ‘a’ without donning a gown. Review of Patient #3’s medical record revealed admission date of 04/03/2025 with diagnoses of sepsis, pseudomonas pneumonia, and tracheostomy. On antibiotics, Meropenem 1 gram and Gentamicin 80 mg. During an interview on 04/14/2025 at 8:18 AM, S5CN stated Patient #3 was in room ‘a’, was on contact precautions for tracheal aspirate and she should have donned a gown before entering the room, but she was unable to find one. 2) Failure to ensure each employee’s personnel file contained documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S2RN) of 1 (S2RN) contract nurse personnel files reviewed. Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: “A. [formerly paragraph 2:022] All persons, including employees, students or volunteers, having no history of latent tuberculosis infection or tuberculosis disease, prior to or at the time of employment, beginning clinical rotations in the healthcare profession, or volunteering at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the Louisiana Department of Health or at any Louisiana Department of Health, Office of Public Health (LDH-OPH) parish health unit or an LDH-OPH outpatient health care facility, whose duties include direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either: 1. a negative purified protein derivative skin test for tuberculosis, 5 tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration; 2. a normal chest X-ray, if the skin test or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration is positive; or 3. All initial screening test results and all follow-up screening test results shall be kept in each employee’s, Student’s, or volunteer’s health record or facility’s personnel record. D. Annually, but no sooner than 6 months since last receiving tuberculosis educational information (more fully described at the end of this sentence) or symptom screening, all employees, students in the healthcare professions, or volunteers at any medical or 24-hour residential facility requiring licensing by LDH or at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the LDH or at any LDH-OPH parish health unit or and LDH-OPH out-patient health care facility shall receive, at a minimum, educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.” Review of hospital policy provided by S1ADM titled “Infection Control Plan”, last approved 05/2023, revealed in part: “Policy: Infection Control Program: The infection Control Program allows for a systemic, coordinated and continuous approach and is accomplished by: 8. emphasis is placed on educating staff regarding TB and TB Exposure Plan. 12. Collaborating with employee health to provide appropriate screening, counseling, follow-up, and guidelines for staff and others who have the potential for exposure to communicable infectious disease, or have been exposed to or have such a disease. Risk Assessment and Prioritization Goals, in part: Characteristics of Population Served, in part: Louisiana State Office of Public Health, TB control is located within the geographic service area which serves patients with confirmed TB. Review of the personnel file of S2RN failed to reveal evidence she free of TB (tuberculosis) in a communicable state. During an interview on 04/15/2023 at 11:08 AM, S10HR confirmed S2RN employee’s personnel file failed to reveal documented evidence she was free of TB (tuberculosis) in a communicable state.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the patient’s right to be free from all forms of neglect. This deficient practice was evidenced by failure of the facility to ensure wound care consults occurred in a timely manner to avoid delay in care in 1 (#3) of 2 (#2 and #3) patients reviewed for wound care consults. Findings: Review of hospital policy provided by S1ADM titled “Wound Care Management”, last approved 05/2023, last revised 10/2012, revealed in part: “Purpose, in part: To identify responsibilities of the wound care team. Procedure, in part: 1. There must be physician order for wound care. 2. Each wound is documented by the registered nurse or designee on initial interdisciplinary assessment and plan of care at the initial assessment weekly, and prn to effectively maintain an accurate record of care. Wound Assessment, in part: 4. Within 24 hr of receipt of the consult order, the consulting physician will assess the wounds, design a plan of care, collaborate with the interdisciplinary team orders for wound care, and implementation. Review of Patient #2’s History and Physical dated 04/08/2025 revealed admission date of 04/08/2025 with diagnoses of Acute respiratory failure with hypoxia with tracheostomy and paraplegia. Patient was in a high-speed motor vehicle accident (MVA) with semi-truck. Status post C5-C6 Anterior Cervical Discectomy and Fusion (ACDF) on 03/03/2025. Arrived at hospital with acute traumatic pain, blood loss vertebral artery narrowing bilaterally, left wrist fracture left trapezoidal fracture, left 2nd metacarpal base fracture, left upper extremity levophed infiltration. Right hand laceration repaired. Incomplete tetraplegia/paraplegia. Dysphagia, obesity. Resolved pneumothorax. Neurogenic shock and pneumonia. Anemia. Right superficial cephalic clot 3/10. No movement beneath nipple line. 3-column fracture at c5-c6. Peg. Review of Patient #2’s admission orders dated 04/08/2025 revealed: Wound Care Consult. Review of Patient #2’s medical record on 04/15/2025 at 11:37 AM guided by S9DON, failed to reveal the wound consulting physician/provider assessed the wounds, designed a plan of care, collaborated with the interdisciplinary team orders for wound care, and implemented a plan of care. During an interview on 04/15/2025 at 11:37 AM, S9DON confirmed the Wound Care Consulting provider had not assessed Patient #2 because she was out of town as of 04/15/2025 at 11:37 AM.”

“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: 47397 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of nursing staff to document vital signs per physician orders for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed; and Findings: Patient #1 Review of physician orders dated 12/04/2024 and discontinued on 12/31/2024 revealed vital signs every six hours. Review of Patient #1 document titled “Vital Signs-By Date and Type” dated 12/03/2024-12/31/2024 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders: 12/30/24 at 3:34 PM Pulse 54, temperature 96.5. No retake or vitals until 12/31/24 at 5:23 AM. 12/29/24 at 7:00 PM temperature 96.2. No retake or vitals until on 12/30/24 at 5:22 AM. 12/28/24 vitals taken at 7:00 PM with no retake until 12/29/24 at 5:54AM. 12/27/24 vitals taken at 6:20 PM no retake until 12/28/24 at 5:33AM. 12/27/24 vitals taken at 7:12 AM, temperature 96.9 with no retake until 12/27/24 at 334 PM when Patient #1’s temperature was 96.5. 12/26/24 vitals taken at 3:19 PM temperature “unable”, pulse 100 with no retake until 12/27/24 at 4:57 AM when Patient #1’s pulse was 100 beats per minute. 12/25/24 vitals taken at 8:33 PM with no retake until 12/26/24 at 5:38 AM. 12/25/24 vitals taken at 7:00 AM with no retake until 12/25/24 at 8:33 PM. 12/24/24 vitals taken at 7:11 PM with no retake until 12/25/24 at 5:06 AM. 12/23/24 vitals taken at 7:00 PM with no retake until 12/24/24 at 4:58 AM. 12/22/24 vitals taken at 8:09 PM with no retake until 12/23/24 at 4:51 AM. 12/21/24 vitals taken at 8:23 PM with no retake until 12/22/24 at 5:22 AM. 12/20/24 vitals taken at 9:40 PM with no retake until 12/21/24 at 5:02 AM. 12/19/24 vitals taken at 7:00 PM with no retake until 12/20/24 at 5:15 AM. 12/18/24 vitals taken at 7:30 PM with no retake until 12/19/24 at 5:37 AM. 12/17/24 vitals taken at 8:42 PM with no retake until 12/18/24 at 5:12 AM. 12/17/24 vitals taken at 7:00 AM with no retake until 12/17/24 at 4:07 PM. 12/16/24 vitals taken at 9:47 PM with no retake until 12/17/24 at 5:37 AM. 12/15/24 vitals taken at 3:38 PM with no retake until 12/16/24 at 5:41 AM. 12/15/24 vitals taken at 6:30 AM with no retake until 12/15/24 at 3:58 PM. 12/14/24 vitals taken at 3:18 PM with no retake until 12/15/24 at 6:30 AM. 12/13/24 vitals taken at 5:25 PM with no retake until 12/14/24 at 4:41 PM. 12/12/24 vitals taken at 7:00 PM with no retake until 12/13/24 at 10:18 AM. 12/11/24 vitals taken at 8:02 AM with no retake until 12/12/24 at 4:58 AM. 12/10/24 vitals taken at 3:14 PM with no retake until 12/11/24 at 5:22 AM. 12/09/24 vitals taken at 8:56 PM with no retake until 12/10/24 at 5:14 AM. 12/08/24 vitals taken at 9:08 PM with no retake until 12/09/24 at 4:53 AM. 12/07/24 vitals taken at 8:52 PM with no retake until 12/08/24 at 4:12 AM. 12/06/24 vitals taken at 6:49 PM with no retake until 12/07/24 at 7:12 AM. 12/05/24 vitals taken at 6:44 PM with no retake until 12/06/24 at 7:00 AM. 12/05/24 vitals taken at 7:54 AM with no retake until 12/05/24 at 4:50 PM. Patient #2 Review of physician orders dated 04/08/2025 revealed vital signs every six hours. Review of Patient #2 document titled “Vital Signs-By Date and Type” dated 04/08/2025-04/15/2025 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders: 04/14/25 vitals taken at 9:24 PM with no retake until 04/15/25 at 5:41 AM. 04/13/25 vitals taken at 5:44 PM with no retake until 04/14/25 at 4:29 AM. 04/12/25 vitals taken at 9:24 PM with no retake until 04/13/25 at 5:40 AM. 04/11/25 vitals taken at 8:50 PM with no retake until 04/12/25 at 5:33 AM. 04/09/25 vitals taken at 8:53 PM with no retake until 04/10/25 at 5:34 AM. Patient #3 Review of physician orders dated 04/03/2025 revealed vital signs every six hours. Review of Patient #3 document titled “Vital Signs-By Date and Type” dated 04/03/2025-04/15/2025 revealed the following vital signs were not assessed by nursing staff within the time-span indicated per physician orders: 04/14/25 vitals taken at 11:04 AM with no retake as of 04/15/25 at 11:51 AM. 04/13/25 vitals taken at 6:30 PM with no retake until 04/14/25 at 11:04 AM. 04/12/25 vitals taken at 7:19 AM with no retake until 04/13/25 at 6:02 AM. 04/11/25 vitals taken at 8:41 PM with no retake until 04/12/25 at 5:29 AM. 04/10/25 vitals taken at 9:42 PM with no retake until 04/11/25 at 8:41 AM. 04/08/25 vitals taken at 8:14 PM with no retake until 04/09/25 at 5:45 AM. 04/08/25 vitals taken at 9:45 AM with no retake until 04/08/25 at 8:14 PM. 04/07/25 vitals taken at 9:26 AM with no retake until 04/07/25 at 6:30 PM. 04/06/25 vitals taken at 6:30 PM with no retake until 04/07/25 at 9:26 AM. 04/06/25 vitals taken at 8:15 AM with no retake until 04/07/25 at 4:47 PM. 04/05/25 vitals taken at 2:00 PM with no retake until 04/06/25 at 4:52 AM. 04/04/25 vitals taken at 6:30 PM with no retake until 04/05/25 at 9:38 AM. 04/03/25 vitals taken at 8:00 PM with no retake until 04/04/25 at 5:02 AM. During an interview on 04/15/2025 at 11:04 AM, S9DON confirmed Patients #1, #2, and #3’s vital signs were not assessed as per physician orders”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 Based on observation, record review and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital as evidenced by: 1) failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders; 2) failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed; and 3) failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed. Findings: 1) Failure to monitor telemetry patients #1, #2, #3, #R1, #R2, and #R3 per hospital policy and physician orders. Review of hospital policy provided by S1ADM, titled “Telemetry Monitoring” last approved 05/2023, revealed in part: Policy: C. All Telemetry Patients will be monitored through a central monitor located at the Nurse’s Station or via bedside monitor by a competency verified RN, LPN, or Monitor Tech. Procedure, I part: 1. Cardiac rhythms will be monitored by a qualified observer at all times. It is the responsibility of the assigned Monitor Technician to assure that a qualified observer covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended. Any variance from this must be reported to the Charge Nurse or DON immediately. 2. A Physician’s Order must be written for a Patient to be placed on Telemetry: The monitor alarms are turned on at all times. The Monitor Technician verifies that the alarms are on at the beginning of each shift. 1, Rhythm strips are printed every four hours on medical/surgical and High Observation Patients, or as ordered and in the event of an abnormal arrhythmia. The rhythm strip will be printed and include Patients Name, Date and Time, Heart Rate, PR interval, QRS width, regularity and rhythm interpretation. Observation of nurses’ station on 04/14/2025 at 8:08 AM revealed 1 unit clerk and one nurse in the medication room. Continued observation revealed an unattended telemetry monitor with a WOW (Workstation On Wheels) parked in front of the monitor. Flashing alarms on 5 (#2, #3, #R1, #R2, and #R3) of 5 (#2, #3, #R1, #R2, and #R3) patients on telemetry with no sound coming from the telemetry monitor. At 8:10 AM S5CN entered nurse station. During an interview on 04/14/2025 at 8:10 AM, S5CN confirmed she was responsible for observing the monitor and that she was not aware the alarms were flashing. S5CN confirmed no alarm sound and did not know who silenced the alarms. Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #2 flashing a red alarm icon without sound registering a heart rate of 54. Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R1 flashing a red alarm icon without sound registering “Check Electrodes”. Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R2 flashing a red alarm icon without sound registering a heart rate of 61. Review of Patient #R2’s Alarm History Record on 04/14/2025 at 10:03 AM revealed heart rate of 120 with silenced alarms at the following times: 8:20:46 AM, 8:20:47 AM, 9:59:17 AM, 9:59:20 AM, and 10:02:30 AM. Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #R3 flashing a red alarm icon without sound and no visible heart rate. Observation of telemetry monitor on 04/14/2025 at 8:21 AM revealed monitor labeled Patient #3 flashing a red alarm icon and an icon of a battery with a red “X” struck through it registering “Check Electrodes”. During an interview on 04/14/2025 at 8:21 AM, S5CN confirmed the Patients #2, #3, #R1, #R2, and #R3 telemetry monitor alarms were silent and did not know why. S5CN stated she needed to assess the leads on all of the patients and determine why the alarms were flashing. Review of Patient #1’s physician orders revealed the following: 12/04/2024 at 2:00 AM Continuous Cardiac Monitoring every four hours. Review of Patient #1’s medical record for cardiac monitoring: 12/05/2024 failed to reveal cardiac monitoring between 6:01 AM - 22:00 PM. 12/06/2024 failed to reveal cardiac monitoring between 10:01 AM - 22:00 PM. 12/09/2024 failed to reveal cardiac monitoring between 10:01 AM - 22:00 PM. During an interview on 04/14/2025 at 3:45 PM, S8QA confirmed cardiac monitoring was not implemented per physician orders and hospital policy for Patient #1. 2) Failure to ensure nursing staff documented patient assessment as per hospital policy in 1 (#1) of 3 (#1-#3) patient records reviewed. Review of hospital policy provided by S1ADM titled “Nursing Assessment” last approved 05/2023, revealed in part: “Responsibilities and Procedures: Nursing Assessment, in part: Assessment of the patient care needs will include consideration of: Neurological; Safety Risk; Cardiovascular; Plumonary; Nutrition; Communication; Gastrointestinal; Genitourinary; Pain; Integumentary; Functional; Educational; Discharge Planning Factors; An other care needs indentified by the admission care nurse. Reassessment, in part: All patients admitted will be reassessed every nursing shift (12 hour shift) by the RN or LPN.” Review of Patient #1’s History and Physical revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with emboli, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, Polycythemia Vera, malaise, and hyperkalemia. Of note, Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019. Review of Patient #1’s nursing assessment dated 12/05/2024 at 3:05 PM failed to reveal the following assessments were addressed: Ambulatory Aid Continuous IV infusion or Heplock Gait Mental Status Morse Fall Scale Score Sepsis Screening Pain Goal Able to verbalize pain Neurological Cardiovascular Respiratory Skin / Wounds Braden Pressure Injury Risk Genitourinary Gastrointestinal Musculoskeletal Nursing Discharge Planning During an interview on 04/14/2025 at 2:48 PM, S8QA confirmed the assessment was incomplete. Review of Patient #1’s medical record failed to reveal a nursing assessment completed on the day shift of 12/31/2024 as per hospital policy. During an interview on 04/14/2025 at 9:10 AM, S8QA confirmed there was no evidence of a nursing assessment completed on 12/31/2024 before patient discharged at 9:35 AM. 3) Failure to ensure nursing staff repositioned as per hospital policy 1 (#1) of 3 (#1-#3) patients reviewed. Review of hospital policy provided by S1ADM, titled “Turning and Repositioning” last approved 12/2024, revealed in part: Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injry prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Poly Explanation and Compliance Guidelines: 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule. 4. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. 5. The frequency of turning and repositioning will be documented in the resident’s plan of care. Review of Patient #1’s Rounding & ADLs document dated 12/05/2024 revealed the following: 6:30 PM: positioning: supine/back 8:30 PM: positioning: supine/back 10:30 PM: positioning: supine/back 12:20 AM: positioning: supine/back 2:30 AM: positioning: supine/back 4:30 AM: positioning: supine/back During an interview on 04/14/2025 at 2:54 PM, S8QA confirmed the medical record failed to reveal evidence that Patient #1 was repositioned/turned per hospital policy.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician’s orders. The deficient practice is evidenced by failure of the nursing staff to administer Patient #1’s medications per physician order. Findings: Review of Patient #1’s medical record revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with embolis, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, Polycythemia Vera, malaise, and hyperkalemia. Of note Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019. Review of Patient #1’s physician orders revealed the following in part: -Order date 12/04/2024-Discontinue date 12/31/2024: Tacrolimus 1 Mg (Prograf). Give 2.5 mg (2 ½ capsule(s)) per tube twice daily. Time critical at 8 AM and 6 PM: medication must be given within 30-minute window before or after the scheduled administration due time. Order failed to reveal indication. Review of Medication Administration Record dated 12/05/2024, 12/06/2024, 12/07/2024, 12/08/2024, 12/09/2024, 12/10/2024 and 12/31/2024 failed to reveal Tacrolimus 2.5 mg (2 ½ capsule(s)) per tube twice daily was administered per physician order. -On 12/05/2024 administered at 8:55 AM, approximately 25 minutes outside the prescribed window for scheduled administration due time. -On 12/06/2024 administered at 9:49 AM, approximately 1 hour and 20 minutes outside the prescribed window for scheduled administration due time. -On 12/06/2024 Tacrolimus was not administered at 6:00 PM or during the night shift on the 6th. S9DON confirmed the medical record failed to reveal documentation the Tacrolimus was administered and failed to reveal documentation as to why the Tacrolimus was not administered as per physician order. -On 12/07/2024 administered at 5:07 PM, approximately 23 minutes outside the prescribed window for scheduled administration due time. -On 12/08/2024 administered at 10:10 AM, approximately 1 hour and 40 minutes outside the prescribed window for scheduled administration due time. -On 12/08/2024 administered at 5:14 PM, approximately 15 minutes outside the prescribed window for scheduled administration due time. -On 12/09/2024 administered at 9:55 AM, approximately 1 hour and 25 minutes outside the prescribed window for scheduled administration due time. -On 12/31/2024 Tacrolimus was not administered. S9DON confirmed the medical record failed to reveal documentation the Tacrolimus was administered and failed to reveal documentation as to why the Tacrolimus was not administered as per physician order. Review of Patient #1’s physician orders revealed the following in part: -Order date 12/04/2024-Discontinue date 12/31/2024 Mycophenolate mofetil. Give 200 mg per tube twice daily. Take 2.5 ml per PEG tube BID Indication: Liver Transplant. Review of Medication Administration Record dated 12/05/2024-12/07/2024 failed to reveal Mycophenolate mofetil 200 mg per tube twice daily was administered per physician order. During an interview on 04/15/2025 at 10:32 AM, S9DON verified the Mycophenolate mofetil was not administrated per physician order. S9DON stated that Mycophenolate was administered on 12/04/24 at 10:00 PM but the medication was not administered again until 12/07/2024 at 9:00 PM after the night shift nurse notified the pharmacy on 12/06/2024 at 8:00 PM that the Mycophenolate was not on the nursing unit. Review of Patient #1’s physician orders revealed the following in part: -Order date 12/05/2024-Discontinue date 12/10/2024 Enteral Flush every four hours. Flush type: Water, Flush (in mLs): 100, Route: G-Tube. Indication: Ventilated, Malnutrition. Review of Medication Administration Record dated 12/06/2024 and 12/09/2024 failed to reveal Enteral Flushes every four hours were administered per physician order. -On 12/06/2024 at 2:00 PM and 6:00 PM, documentation failed to reveal the enteral flush was administered. -On 12/09/2024 at 2:00 PM and 6:00 PM, documentation failed to reveal the enteral flush was administered. During an interview on 04/15/2025 at 11:15 AM, S9DON verified the enteral flushes were not administrated per physician order. Review of Patient #1’s physician orders revealed the following in part: -Order date 12/09/2024-Discontinue date 12/09/2024: Kayexalate Suspension 15 G/ 60 mL, give 15 grams (60 mL) by mouth once. Indication: Hyperkalemia Review of Medication Administration Record dated 12/09/2024 failed to reveal the Kayexalate Suspension 15 G/ 60 mL, give 15 grams (60 mL) was administered per physician order. During an interview on 04/15/2025 at 10:25 AM, S9DON verified the Kayexalate suspension was not administrated per physician order. S9DON confirmed the medical record failed to reveal documentation as to why the Kayexalate suspension was not administered. Review of Patient #1’s physician orders revealed the following in part: -Order date 12/13/2024-Discontinue date 12/15/2024: Furosemide 20 mg (2 ML) IV push daily. Review of Medication Administration Record dated 12/14/2024 failed to reveal the Furosemide 20 mg was administered per physician order. During an interview on 04/15/2025 at 10:20 AM, S9DON verified the furosemide was not administrated per physician order. S9DON confirmed the medical record failed to reveal documentation as to why the furosemide was not administered. -Order date 12/13/2024-Discontinue date 12/13/2024: Enteral Flush every four hours. Flush type: Water, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with Pedialyte not water. Indication: Ventilated, Malnutrition. -Order date 12/13/2024-Discontinue date 12/23/2024: Enteral Flush every four hours. Flush type: Normal Saline, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with 1 gm saline tablet in 1000cc water after Pedialyte completes. Indication: Ventilated, Malnutrition. -Order date 12/23/2024-Discontinue date 12/24/2024: Enteral Flush every four hours. Flush type: Normal Saline, Flush (in mLs): 250, Route: G-Tube. Comments: Flush G-Tube with Pedialyte only. Indication: Ventilated, Malnutrition. Review of provider note dated 12/23/2024 revealed the following: Patient #1’s sodium was back down to 119 due to her getting water as flushes instead of the pedialyte that was ordered. During an interview on 04/15/2025 at 111:45 AM, S9DON confirmed the above findings.”

“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: 47397 Based on record review and interview, the hospital failed to provide re-evaluation of the patient’s condition to identify changes that required modification of the discharge plan in 1 (#1) of 3 (#1-#3) patient records reviewed. Findings: Review of hospital policy provided by S1ADM titled “Discharge Planning and Transfers”, last approved 05/2023, revealed in part: “Procedure: 5. Discharge planning will include the identification of the patient’s continuing needs upon discharge from this facility. 7. The facility will re-evaluate the discharge plan regularly and update as needed to reflect any changes.” Review of Patient #1’s medical record revealed an admission date of 12/03/2024 with diagnoses of chronic respiratory failure with hypoxia, toxic encephalopathy, Budd-Chairi syndrome, Paracoccidioidomycosis (PCM), pneumonia due to klebsiella, Vent weaning, gastronomy, acute kidney failure, chronic kidney disease, immunodeficiency due to drugs, deep vein thrombosis with embolis, Hypo-osmality and hyponatremia, ESBL resistance, tracheostomy, anticoagulants, malaise, and hyperkalemia. Of note Patient #1 was being treated with anti-rejection medications, tacrolimus (Prograf) and mycophenolate (CellCept) following liver transplant in 2019. Review of Patient #1’s provider note dated 12/30/2024 revealed patient was to continue Tacrolimus as per hepatology with a target range of 4-6 ng/mL. Review of Laboratory report revealed the following liver enzyme reference values: Aspartate aminotransferase (AST)=13-56 U/L. Alanine Transaminase (ALT)=15-37 U/L. Alkaline Phosphatase (Alk Phos)=45-117 U/L. Review of Patient #1’s laboratory results revealed the following liver enzyme values and tacrolimus (TAC) levels: 12/02/2024: AST 16 U/L, ALT=12 U/L, Alk phos=98 U/L. TAC=3.8 ng/mL. 12/05/2024: AST=15 U/L, ALT=22 U/L, Alk phos=112 U/L. No TAC level. 12/09/2024: AST=11 U/L, ALT=30 U/L, Alk phos=159 U/L. No TAC level. 12/12/2024: AST=11 U/L, ALT=30 U/L, Alk phos=159 U/L. No TAC level. 12/13/2024: TAC level 3.0 ng/mL. 12/16/2024: AST=21 U/L, ALT=32 U/L, Alk phos=120 U/L. TAC level 3.9 ng/mL. 12/23/2024: AST=26 U/L, ALT=41 U/L, Alk phos=141 U/L. No TAC level. 12/25/2024: AST=39 U/L, ALT=56 U/L, Alk phos=159 U/L. No TAC level. 12/30/2024: AST=129 U/L, ALT=209 U/L, Alk phos=200 U/L. No TAC level. (last labs before discharge on 12/31/2024). Review of Patient #1’s laboratory results revealed the following lab values in part with the White Blood Count (WBC), Hemoglobin (Hgb) and Hematocrit (Hct) reference values: WBC=4.0-11.0 K/uL Hgb=11.2-15.7 g/dL Hct=34.1-44.9% 12/02/2024: Hgb=10 and hct=31.7 12/05/2024: WBC=11.58, Hgb=10.4, and Hct=33.6. 12/09/2024: WBC=17.38, Hgb=11.6, and Hct =35.7. 12/16/2024: WBC=12.69, Hgb =9.1, Hct =29.2. 12/23/2024: WBC=6.31, Hgb =9.9, Hct =30.1. 12/30/2024: WBC=1.41 Hgb=7.8, Hct=23.9. (last labs drawn before discharge on 12/31/2024). Review of provider note dated 12/27/2024 at 10:16 AM stated provider spoke with the patient’s mother and sister, who were at bedside, and provided an update on the clinical exam and findings. The patient was not yet ready to wean, as she was not showing progress towards weaning at this time. She had no muscle tone, not initiating spontaneous breaths on the ventilator, and lacked a gag reflex. Provider noted she addressed all their questions. The Patient will be transferred to nursing home ‘A’ from LTAC. The family requested a neurology consult. Provider would ask the case manager to arrange a follow-up. However, it may take time to set up or may need to be coordinated with nursing home ‘A’. The provider note failed to reveal documentation regarding the rising liver enzymes or the TAC levels below therapeutic range. Review of provider note dated 12/28/2024 revealed the following regarding liver transplant and long-term use of immunosuppressant medication: Liver transplant in 2019. Was stable up until August 2024 when she developed UTI. Continue mycophenaolate 200 mg BID and prograf 2.5 BID. Failed to reveal documentation of rising liver enzymes and TAC levels Review of provider note dated 12/30/2024 at 10:00 AM revealed in part: Weekly labs and tacrolimus level were pending. Lab results listed for 12/05/2024-12/29/2024 revealed the rising liver enzymes and only one TAC level listed at 3.8 (below therapeutic level) on 12/05/2024. Values for Vital signs listed a temperature of 96.9 and a pulse of 58. The progress note stated vitals were stable, eyes and mouth were open but patient did not respond to verbal or tactile stimuli. Non-Verbal. Did not track with eyes. Thin, ill appearing, female. Flaccid extremities. Bilateral hand edema. Wasting muscle mass, temporal wasting, no energy reserves. Peg in place with tube feedings. Neurologically unresponsive, Glasgow Coma Scale=eye 4, verbal 1, motor 1. The plan for Liver transplant recipient stated in part: Liver transplant in 2019. Tacrolimus Management: Current therapeutic level. Continue tacrolimus as per hepatolgy with a target range of 4-6 ng/mL. The progress note failed to reveal documentation of rising LFTs and TAC level below therapeutic range. The note stated vital trends and labs would continue to be monitored. No changes in plan of care noted. Review of physician orders dated 12/30/2024 at 1:34 PM stated discharge to nursing home ‘A’. Diet as follow Jevity 1.5 at 45 mL/hr, give 2 tablets of sodium chloride mixed in 250 mL every 4 hours, flush peg tube with 600 mL of H2O. Review of nursing note dated 12/31/2025 at 10:05 AM revealed patient discharged to Skilled Nursing ‘A’ via EMS at 9:35 AM. Patient with stable vitals, 0 signs of pain prior to discharge. AM meds given, oral and peri-care preformed, PICC line pulled and report called in by S3RN. Review of nursing note dated 12/31/2025 at 2:58 PM revealed S3RN spoke with nursing home ‘A’ stated Patient #1 arrived at facility with eyes bulging. Told nursing home ‘A’ that when Patient #1 left the LTAC her eyes were not bulging. Nursing home ‘A’ would notify their MD of new onset eye bulging. Nursing home requested sputum culture to be faxed. Sputum culture and final report faxed at this time. Of note, there was no evidence of a nursing assessment completed on 12/31/2024. Review of discharge summary dated 12/31/2024 at 8:36 AM revealed the following in part: The plan for status post liver transplant and long-term use of immunosuppressant medication stated liver transplant in 2019. Was stable up until August 2024 when she developed UTI. Continue mycophenolate 200 mg BID and Continue Prograf 2.5 BID. The discharge summary failed to reveal documentation of rising liver enzymes and TAC levels below therapeutic range. During an interview on 04/15/2025 at AM, S9DON stated she did not think the providers were aware of the laboratory values from 12/31/2025. S9DON verified Patient #1’s medical record failed to reveal the hospital/provider contacted the nursing home or family regarding the abnormal laboratory values from 12/31/2025. S9DON confirmed there was no evidence of a nursing assessment completed on 12/31/2024 before discharge in order to identify changes that required modification of the discharge plan.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 50453 Based on record review and interviews, the hospital failed to ensure clinical staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 3 (S6CNA, S7CNA, and S8RT) of 7 (S6CNA, S7CNA, S8RT, S9LPN, S10LPN, S11RN, and S12RN) clinical staff reviewed for Orientation with Patient Rights education. Findings: Review of personnel files for S6CNA, S7CNA, and S8RT revealed no evidence indicating successful completion and competency regarding Patient Rights education. During an interview on 08/27/2024 at 11:42 a.m., S1ADM, S2DON, and S13DOQ confirmed there was no evidence indicating successful completion and competency regarding Patient Rights education for S6CNA, S7CNA, and S8RT.”

“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: 50453 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the care for each patient. This deficient practice is evidenced by failing to document a post fall assessment on 1 (#2) of 3 (#1-#3) patients reviewed. Findings: Review of hospital policy titled, “Assessment and Reassessment,” last approved 05/2023, revealed in part: A. Nursing Documentation: 7. Reassessment of the Patient shall be performed at regular intervals in the course of care by medical and Nursing Staff. Reassessments shall take place when there is a significant change in a Patient’s condition or a change in diagnosis. Review of the hospital policy titled, “Incident Reporting,” last approved 05/2023, revealed in part: Procedure: 5. If the occurrence involves a patient/resident injury or fall or potential injury, a Registered Nurse must perform a patient assessment and document the assessment in the medical record. 15. Other actions to be taken after completion of incident report: c. Document the event and follow up assessment and actions in the medical record. Review of an Incident Report Form revealed, in part, that Patient #2 had an unwitnessed fall on 07/17/2024 at 5:40 p.m. Patient #2 was found on the floor on his knees and had a skin laceration to right knee. Review of Patient #2’s medical record revealed, in part, the patient was a 69 year old admitted to the hospital 07/09/2024. Patient #2 had an admit diagnosis of acute respiratory failure with hypoxia. Further review of Patient #2’s medical record failed to reveal documentation regarding the incident of Patient #2 having a fall or documentation of a post fall assessment. In an interview on 08/26/2024 at 12:31 p.m., S2DON confirmed Patient #2 did not have a post fall assessment completed after the fall on 07/17/2024 or any additional documentation regarding the fall. S2DON also confirmed a post fall assessment should have been completed by the nurse.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient’s goals and the nursing care expected to meet the patient’s needs. This deficient practice was evidenced by failing to update a care plan after a fall for 1 (#2) of 3 (#1-#3) patients reviewed. Findings: Review of the hospital policy titled “Incident Reporting,” last approved and effective date 05/2023, revealed in part: Procedure: 5. If the occurrence involves a patient/resident injury or fall or potential injury, a Registered Nurse must perform a patient assessment and document the assessment in the medical record. 15. Other actions to be taken after completion of incident report: d. Update the patient’s care plan as necessary (i.e: after a fall, after an injury). Review of Incident Report Form revealed, in part: Admit date 07/09/2024. Date of report 07/17/2024. Report Time: 6:52 p.m., Event Date: 07/17/2024, Time 5:40 p.m. Reporter’s Name & Title. S12RN. No witness. Severity Level 3. Location: patient room. Nature of event: fall with injury. Review of Additional Information revealed, in part: Notification. The section for Family/Legal Representative “No” was checked. Overview of incident: CNA found patient on floor on knees, patient stated that he was trying to pull out dirty pad from beneath himself. Patient stated that he rolled off the side of the bed. Side rails x2 in place. Call light in reach. Fire department called to assist staff to get patient off the floor. Clinical supervisor and NP on call notified. Patient alert and oriented x4. Vital signs BP 91/49, HR 66, temperature 98.6, respiratory rate 18, O2 96% on 2L NC. Patient denies LOC or head trauma. Skin laceration to right knee. Review of Patient #2’s electronic medical record revealed no evidence that Patient #2’s care plan was updated after a fall on 07/17/2024. In an interview on 08/26/2024 at 11:44 a.m., Patient #2 stated that he had a fall out of the bed at the hospital trying to reach over. Patient #2 stated that he thinks his sister was notified of incident. In an interview on 08/26/2024 at 12:42 p.m., S2DON confirmed Patient #2’s care plan was not updated after the fall by the nurse, but should have been.”

“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: 50453 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the care for each patient. This deficient practice is evidenced by failing to document a post fall assessment on 1 (#2) of 3 (#1-#3) patients reviewed. Findings: Review of the hospital policy titled, “Incident Reporting,” last approved 05/2023, revealed in part: Procedure: 11. Notify the immediate supervisor, physician, and family/legal representative and document the name of person notified in each section including the date and time of notification. Review of an Incident Report Form revealed, in part, that Patient #2 had an unwitnessed fall on 07/17/2024 at 5:40 p.m. Further review of this form revealed the section for family/legal representative notification was blank. Review of Patient #2’s medical record failed to reveal documentation that the family/legal representative was notified of Patient #2 having an incident involving a fall. In an interview on 08/26/2024 at 12:36 p.m., S2DON confirmed there was no documented evidence that Patient #2’s family/legal representative was notified of the fall in the medical record or on the incident report.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure all patient records included a completed discharge summary within 30 days of discharge. This deficient practice was evidenced by failure of the hospital to ensure a delegated discharge summary was co-authenticated with a date to verify its contents for 3 (#1-#3) of 3 patients sampled. Findings: Review of Patient #1’s medical record revealed an admit date of 06/26/2024 and a discharge date of 07/22/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician. Review of Patient #2’s medical record revealed an admit date of 07/09/2024 and a discharge date of 07/19/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician. Review of Patient #3’s medical record revealed an admit date of 07/10/2024 and a discharge date of 07/19/2024. Further review revealed the discharge summary was completed by S5NP and that it was not co-authenticated by a physician. During an interview on 08/26/2024 at 3:05 p.m., S2DON confirmed that the above mentioned patients had discharge summaries completed and signed by the midlevel provider and that they were not co-authenticated by a physician.”