Pam Health Specialty Hospital of Stoughton

“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: 41143 The Hospital was out of compliance for the Condition of Participation for Nursing Services. Findings included: Based on interviews and records reviewed, the Hospital failed to 1. ensure Hospital staff appropriately assessed the condition of the skin and wounds per Hospital policy for one Patient (#1) and 2. administer medications, in accordance with Hospital policy and/or physician order for three patients (Patient #1, Patient #2 and Patient #8) out of a total sample of 10 patients. Cross Reference: 482.23(b)(6) - Standard: Supervision of Contract Staff (398) 482.23(c) - Standard: Preparation and Administration of Drugs (405)”

“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: 41143 Based on record review and interview, the Hospital failed to ensure 1.) Hospital staff appropriately assessed the condition of the skin and wounds per Hospital policy for one Patient (#1) out of a total sample of 10 patients. Patient #1 was admitted to the Hospital with pressure injuries to the back of his/her head from an outside hospital, which were not assessed or treated by the Hospital nor was the Patient placed on an air mattress as ordered to reduce pressure to his/her skin. 2.) Hospital staff used a bracing device as ordered for one Patient (#1) out of a total sample of 10 patients while lifting the Patient out of bed with a mechanical lift. Patient #1 was ordered to have a Thoracolumbar Sacral Orthosis (TLSO) brace when out of bed secondary to managing a thoracic-lumbar (T-L) vertebral fracture of the spine, however, was lifted from his/her bed mechanically without the brace on. Findings include: 1. Review of the Hospital policy titled “Wound Care Assessment and Reassessment”, revised 10/6/23, indicated the following: -To ensure the optimization of all wounds and to monitor high-risk patients for skin breakdown. -The Hospital identified and protects patients who have wounds and who are at high risk for developing wounds. -As part of the initial admission process the Registered Nurse (RN) will perform an initial head-to-toe assessment to include wound photographs and documentation of the wound to include size-length, width, depth, and tunneling as well as the appearance of the wound to include any drainage or odor and complete the Norton scale. -The nurse will obtain wound care orders per hospital protocol. Patient #1 was admitted to the Hospital on 10/22/25 following a transfer from another Hospital with diagnoses of coronary artery disease, atrial fibrillation, nephrolithiasis, chronic renal failure, T12-L1 vertebral fracture, and C6-C7 vertebral injury. Review of Patient #1’s medical record indicated the Patient was evaluated by a Physician Assistant for an initial history and physical examination (H&P) on 10/22/25 at 7:56 P.M. Patient #1’s H&P on 10/22/25 indicated the Patient was admitted to the Hospital with pressure areas to the back of his/her head and left heel with a plan to have the Hospital’s wound team follow the Patient. Review of Patient #1’s nursing shift assessment dated 10/22/25 indicated the Patient had two wounds to the back of his/her head and right heel without any description. Patient #1 was also assessed to have a Norton Pressure Injury Risk of 11 and was at a high risk for skin breakdown. Review of Patient #1’s nursing shift assessment dated 10/23/25 and signed on 10/23/25 at 1:05 P.M., indicated the Patient had a wound on his/her left heel but failed to indicate any other wounds. Review of Patient #1’s nursing shift assessment dated 10/23/25 and signed on 10/24/25 at 12:04 A.M., indicated the Patient had a left heel unstageable pressure injury and a chronic non-healing wound to his/her right lateral calf but failed to indicate any other wounds on the Patient. Review of Patient #1’s physician’s orders indicated an order for a low air loss mattress for Patient #1 dated 10/23/25 but failed to indicate any orders for the treatment of wounds to the back of the Patient’s head. Review of Patient #1’s nursing shift assessment dated 10/24/25 and signed on 10/25/25 at 2:51 A.M., indicated the Patient had a wound to his/her left heel and right lower shin/calf, but failed to indicate any other wounds. Review of Patient #1’s nursing shift assessment dated 10/25/25 and signed on 10/26/25 at 6:50 A.M., failed to indicate the Patient had any wounds. Review of Patient #1’s Treatment Administration Record (TAR) indicated the Patient had a low air loss mattress in place on 10/23/25, 10/24/25, and 10/25/25. Review of Patient #1’s Nurse Practitioner (NP) note dated 10/25/25 indicated Patient #1 had pressure areas to the back of his/her head and left heel, present on admission and the Patient was followed by the wound care team. Patient #1’s wound care/wound team documentation failed to indicate if the Patient had a wound present on the back of his/her head nor if it had resolved. During an interview on 12/17/25 at 8:15 A.M., RN#3 said on the evening of 10/25/25 Patient #1 was being transferred from a regular mattress to an air mattress by two Patient Care Assistants (PCA) and they were assisting the PCAs because Patient #1’s skin was at risk for breakdown. During an interview with PCA#1 they said on the evening of 10/25/25, they and another PCA went into Patient #1’s room to transfer him/her to an air mattress. They said Patient#1 was lifted off a regular mattress with a mechanical lift and the regular mattress was replaced with an air mattress. During an interview with the Chief Nursing Officer on 12/22/25 at 11:35 A.M., they said the wound team had evaluated Patient #1 but did not document if the Patient was assessed for wounds to the back of his/her head. The Hospital failed to ensure Patient #1’s plan of care was accurately developed for assessment and treatment of existing pressure ulcers to the back of his/her head and the timely implementation of an air mattress as ordered for the Patient to reduce the risk of further skin breakdown. 2. Patient #1 was admitted to the Hospital on 10/22/25 following a transfer from another Hospital with diagnoses of coronary artery disease, atrial fibrillation, nephrolithiasis, chronic renal failure, T12-L1 vertebral fracture, and C6-C7 vertebral injury. Review of Patient #1’s medical record indicated the Patient was evaluated by a Physician Assistant for an initial history and physical examination (H&P) on 10/22/25 at 7:56 P.M. Patient #1’s H&P on 10/22/25 indicated the Patient was admitted to the Hospital with a C-collar for his/her cervical fracture and a TLSO brace for his/her T12-L1 fracture, which was being managed non-surgically. The Impression/plan for Patient #1’s T12-L1 fracture was to wear the brace when out of bed and Patient would receive Physical Therapy (PT) and Occupational Therapy (OT) to manage his/her significant weakness. Review of Patient #1’s physician orders indicated the following: -A physician’s order dated 10/22/25 for TLSO brace when out of bed. -A physician’s order dated 10/22/25 for spinal precautions every shift. Review of Patient #1’s Treatment Administration Record (TAR) failed to indicate Patient #1’s TLSO brace use was ever documented from 10/22/25 to 10/25/25 by nursing staff. Review of Patient #1’s Nursing Assessments from 10/22/25 - 10/25/25 failed to indicate the TLSO brace was utilized as an orthopedic device; Patient #1’s Nursing Assessments further failed to indicate spinal precautions were documented as nursing safety interventions. Review of Patient #1’s Activity of Daily Living (ADL) documentation from 10/22/25 - 10/25/25 failed to indicate spinal precautions nor any bracing devices were documented under the safety section. During an interview with Licensed Practical Nurse (LPN)#1 on 12/16/25 at 4:00 P.M., they said Patient #1 was to be switched to an air mattress on the evening shift on 10/25/25. During an interview with Registered Nurse (RN)#4 on 12/16/25 at 4:35 P.M., they said they entered Patient #1’s room on 10/25/25. They said the Patient Care Assistants (PCA)s and Charge Nurse were lifting Patient #1 using the mechanical lift to switch his/her mattress out for an air mattress. They said while in the mechanical lift, Patient #1 was in a sitting position with his/her head upright and arms and legs hanging out in a seated position. They said Patient #1 had a neck brace on but did not remember if any other brace was on the Patient. During an interview with RN#3 on 12/17/25 at 8:15 A.M., they said Patient #1 was lifted using the mechanical lift off his/her bed on the evening of 10/25/25 in order to change his/her mattress to an air mattress. They said the Patient had a C-collar on at the time of the mechanical lift from bed. During an interview with RN#5 on 12/17/25 at 10:50 P.M., they said Patient #1 was to be transferred to an air mattress on the evening shift of 10/25/25. They said Patient #1 was in the mechanical lift when they walked by his/her room on the night of 10/25/25. RN#5 said when they went into Patient #1’s room, the Patient had a neck brace on, but no other brace was on the Patient; they said the Patient had not worn a body brace that shift. She said spinal precautions are to be maintained when a patient gets out of bed to a chair. During an interview with RN #6 on 12/17/25 at 11:05 A.M., they said spinal precautions include orders for braces/devices, utilizing two staff members for moving patients with log rolling technique, and no twisting or sudden movements of a patient. She said if a patient requires a TLSO brace, the brace should be utilized for a mechanical lift. During an interview with the Director of Rehab on 12/17/25 at 3:00 P.M., they said therapy services will apply the TLSO brace to a patient requiring one during any transfer. They said the TLSO brace is meant to prevent twisting of a patient’s back to prevent further spinal injury. During an interview with the Nurse Practitioner on 12/17/25 at 3:50 P.M., they said in regard to a TLSO brace, the best practice would be to use the brace any time using a mechanical lift. They also said the TLSO brace should be used when a patient who requires one is moved to an upright position. The Hospital failed to provide any policy or procedure for the use of a TLSO brace or any orthopedic device/brace, nor any policy or procedure for the use of spinal precautions after requested by the surveyor on 12/16/25. The Hospital failed to ensure that Hospital staff implemented an order for a TLSO brace for Patient #1 during a mechanical lift out of his/her bed.”

“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: 41143 Based on interviews and records reviewed, the Hospital failed to administer medications, in accordance with Hospital policy and/or physician order for three patients (Patient #1, Patient #2 and Patient #8) out of a total sample of 10 patients. Patient #1 was administered medication doses incorrectly according to physician orders and medications ordered for the Patient were omitted/not administered per order. Patient #2 was incorrectly administered another patient’s medications. Patient #8 was inadvertently administered medication prescribed for another patient necessitating increased monitoring. Findings include: Review of the Hospital policy titled Medication Administration Record and Medication Administration, revised 3/20/24, indicated the following: -Administration Procedure: -The patient will be positively identified using the 2 patient identifiers -Patient Name and Date of Birth (found on the identification bracelet) prior to any medication being administered. -Prior to administering the medication, the nurse will verify against the Medication -Administration Record (MAR): -The patient’s name and date of birth -The name of the drug -The dose strength of the package or unit dose package -The route of administration, and -The time of administration -All administered, refused, or omitted medication will be recorded on the patient’s MAR. 1. Patient #1 was admitted to the Hospital on 10/22/25 following a transfer from another Hospital with diagnoses of coronary artery disease, atrial fibrillation, nephrolithiasis, chronic renal failure, T12-L1 vertebral fracture, and C6-C7 vertebral injury. Review of Patient #1’s medical record indicated the Patient was evaluated by a Physician Assistant for an initial history and physical examination (H&P) on 10/22/25 at 7:56 P.M. Patient #1’s H&P was listed to have bumetanide (a loop diuretic medication used to treat fluid retention) 2mg (milligrams) via g-tube four times a week on Sunday, Tuesday, Thursday, and Saturday, fludrocortisone acetate (a medication used to help retain sodium and water while excreting potassium to increase blood volume and pressure) 0.1mg via g-tube daily on Monday, Wednesday, and Friday, and Insulin Lispro 100units/ml (milliliters) sliding scale subcutaneously before meals and bedtime as active medications. Patient #1’s H&P impression/plan indicated bumetanide was to help manage his/her heart failure on non-dialysis days, the fludrocortisone acetate was to help manage his/her blood pressure on dialysis days, and the insulin lispro was in place to help manage his/her type 2 diabetes. Review of Patient #1’s physician’s orders indicated the following: -An order with a start date of 10/23/25 for fludrocortisone acetate 0.1mg, give one tablet per tube daily on hemodialysis (HD) days Monday, Wednesday, and Friday. -An order with a start date of 10/23/25 for bumetanide, give 2 mg per tube daily at 6:00 A.M. on non-dialysis days Tuesday, Thursday, Saturday, and Sunday. -An order with a start date of 10/22/25 for Insulin Lispro 100/ml, inject subcutaneously before meals and at bedtime - see sliding scale 150-199 give 2 units. Review of Patient #1’s Medication Administration Record (MAR) indicated a dose of fludrocortisone acetate 0.1mg was administered on 10/23/25 (Thursday) at 9:11 A.M. and on 10/25/25 (Saturday) at 8:52 A.M., which were non-dialysis days. Patient #1’s MAR failed to indicate Patient #1’s 6:00 A.M. dose of bumetanide was ever administered on 10/25/25 as ordered. Further review of Patient #1’s MAR failed to indicate he/she received a dose of insulin lispro per sliding scale at bedtime despite a blood sugar check at 8:32 P.M. indicating the Patient’s blood sugar being 175 at that time. Further review of Patient #1’s medical record failed to indicate the incorrect doses of fludrocortisone acetate, missed dose of bumetanide, nor missed dose of insulin lispro were ever reported to the pharmacist nor provider for Patient #1. During an interview with Licensed Practical Nurse (LPN)#1 on 12/16/25 at 4:00 P.M., they said if a medication error occurs or is discovered it should be reported to the charge nurse and typically reported to a provider. During an interview with Registered Nurse (RN)#2 on 12/17/25 at 7:54 A.M., they said if a medication error occurs or is identified, the pharmacist should be contacted, the charge nurse should be notified, the provider should be notified, and the Patient should be monitored for adverse effects. They said when administering medications for a patient, the nurse must scan the patient’s barcode and the medication. They said the Hospital’s Electronic Medical Record (EMR) will alert the nurse if the medication is not due at that time or incorrect. During an interview with RN#3 on 12/17/25 at 8:15 A.M., they said after a physician enters a medication order into a patient’s EMR, the medication is scheduled on the MAR after the Pharmacist verifies the medication order. They said the process to administer medication is to first scan a patient’s band, then scan the individual medications prior to administration. They said the EMR won’t allow a nurse to administer a medication outside of its ordered time or parameters. They said sometimes there is a glitch in the MAR in the EMR with medication scheduling after a medication is ordered. During an interview with the Chief Nursing Officer on 12/17/25 at 9:10 A.M., they said during medication pass/administration a patient’s barcode must be scanned first before preparing a medication. They said the nurses prepare the medications from Med Dispense, which won’t alert a nurse if the medication selected is being administered during the wrong date/time. During an interview with RN#5 on 12/17/25 at 10:50 P.M., they said they had cared for Patient #1 on the evening shift of 10/25/25. They said they did not see that Patient #1 had any issues with medication administration. They said they did not recall administering insulin to Patient #1 that shift. During an interview with the Pharmacist on 12/17/25 at 11:27 A.M., they said medication orders for patients are first entered by a provider into the EMR. They said once the order has been entered, it is viewable by the pharmacy staff in the EMR for verification of the order. They said after all the data necessary has been reviewed by a pharmacist and the order had been verified by the pharmacist; the medication order is then transferred to a patient’s MAR in the EMR. They said the nurse administering the medication must scan a patient’s barcode first then scan the medication to be administered. They said that while the EMR will trigger a warning if the medication is being administered incorrectly, the Med Dispense will not. They said Med Dispense will not differentiate between the correct days of the week if medications are only ordered for specific days of the week. There was no evidence that the Hospital had reviewed the medication errors on 10/23/25 and 10/25/25 for Patient #1. 40928 2. Patient #2 was admitted to the Hospital from an outside acute care hospital on 12/4/25 for continued medical oversight, respiratory management and therapy services. Patient #2 has a past medical history including respiratory failure resulting in a tracheostomy (a surgically created hole in the windpipe to allow air to pass through). Patient #2 was ordered for nothing by mouth (NPO) except for ice chips and had a Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube placed directly through the skin and abdominal wall into the stomach, used for nutrition, hydration and medication delivery) in place. Review of Patient #2 ’ s Nursing Note written by Registered Nurse (RN) #2, dated 12/6/25 at 5:34 A.M., indicated RN #2 had mixed Patient #2 up with another patient (Patient #4) and administered Patient #4 ’ s medications to Patient #2 by mistake. The Note further indicated that the pharmacy and provider were notified and that Patient #2 had increased monitoring initiated after the wrong medications were administered to him/her. Review of Nurse Practitioner Note dated 12/7/25 at 5:05 P.M indicated Patient #2 had agitation at times and had intermittent confusion during the day on 12/6/25. The Note further indicated a medication error from 12/6/25 at approximately 1:00 A.M. was disclosed to Patient #2 and his/her relative. The Note indicated Patient #2 received the following medications in error: klonopin (a benzodiazepine used to calm the central nervous system), Seroquel (an antipsychotic medicine), atorvastatin (a medication to lower cholesterol), Pepcid (a medication that reduces stomach acid), gabapentin (a medication used to manage nerve pain and control seizures), metoprolol (a medication used to lower blood pressure), oxycodone (an opioid medication for pain management) and Zosyn (a broad spectrum antibiotic). Review of Patient #2 ’ s Medication Administration Record indicated the following medications were not administered as ordered: 12/5/25 9:00 P.M. -An order dated 12/4/25 for Sennosides (a laxative) 17.2 milligrams (mg) per tube at bedtime -An order dated 12/5/25 for Linezolid (an antibiotic) 600mg per tube twice a day -An order dated 12/4/25 for Methadone (a medication to treat opioid withdrawal) 10mg per tube three times a day 12/5/25 10:00 P.M. -An order dated 12/4/25 for Midodrine (a medication used to treat low blood pressure) 20mg per tube every 8 hours -An order dated 12/5/25 for Heparin Sodium (a medication to prevent blood clot formation)5000 units/milliliter (ml) injection subcutaneously every 8 hours -An order dated 12/4/25 for Gabapentin (a medication to treat nerve pain) 900mg per tube every 8 hours 12/6/25 12:01 A.M. -An order dated 12/5/25 for Meropenem (an antibiotic) 500mg in 0.9% Sodium Chloride Intravenous (IV) every 6 hours During an interview on 12/17/25 at 7:54 A.M., RN #2 said the usual process for medication administration is to scan the patient ’ s barcode and then scan the medication prior to administering medication. RN #2 said they accidentally administered Patient #4 ’ s medications to Patient #2 and that Patient #2 did not receive his/her medications as ordered. RN #2 said they alerted their charge nurse to the medication errors and the charge nurse notified the pharmacy and the provider. RN #2 said there was increased monitoring initiated for Patient #2 after he/she received the wrong medications. RN #2 said they couldn ’ t remember any follow up or re-education that was done after the event. During an interview on 12/17/25 at 9:10 A.M., the Chief Nursing Officer said the Hospital completed a Root Cause Analysis (RCA) on 12/10/25 for Patient #2 ’ s medication errors. The Chief Nursing Officer said corrective actions identified included re-education for all nurses on medication administration, bedside shift report and scanning patient bar codes with attestations. The Chief Nursing Officer said these corrective actions have not been implemented yet. 45980 3) For Patient #8, the Hospital failed to administer medication, in accordance with Hospital policy; Patient #8 was administered another patient ’ s medications and subsequently required increased monitoring. Review of Patient #8 ‘s medical records indicated he/she was admitted to the Hospital on 12/5/25 from an outside acute care hospital for continued medical management, hemodialysis and therapy services. Review of the Nurses Note documented by RN # 7 dated 12/10/25 at 12:40 A.M., indicated Patient #8 was given the wrong medications. The note indicated that RN #7 mistakenly wrote the wrong patient’s name under Patient #8 ’ s room number. The note further indicated that the provider was notified, and the plan was to continue to monitor. Review of the Progress Note documented by the Provider, dated 12/10/25 at 12:53 P.M., indicated that they were made aware by nursing staff of a medication error that occurred the previous night. The Patient received melatonin, atorvastatin, lactobacillus, Flagyl and oxycodone (an opioid analgesic medication used to treat pain). Patient #8 is documented as having an allergy to atorvastatin, with muscle cramps noted as the reaction. Patient #8 endorsed abdominal discomfort and gastrointestinal upset, which may or may not be related to the incorrect medications administered. The note further indicated that Patient #8 will be monitored closely. During an interview on 12/10/25 at 9:55 A.M., the Chief Nursing Officer (CNO) said the medication error with Patient #8 was investigated and identified that the nurse did not identify the patient using the two patient identifiers, did not scan the patient ’ s armband and did not conduct bed side shift report. The CNO further said that in response to the incident, staff were reassigned to review the Medication Administration Policy and would be reeducated on conducting bedside shift report and scanning patient bar codes. The CNO said corrective actions in response to the medication error have not yet been implemented.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 41143 Based on record review and interview, the Hospital failed to ensure an order for a Thoracolumbar Sacral Orthosis (TLSO) brace was complete in order to promote continuity of care among providers for one Patient (#1) out of a total sample of 10 Patients. Findings include: Patient #1 was admitted to the Hospital on 10/22/25 following a transfer from another Hospital with diagnoses of coronary artery disease, atrial fibrillation, nephrolithiasis, chronic renal failure, T12-L1 vertebral fracture, and C6-C7 vertebral injury. Review of Patient #1’s medical record indicated the Patient was evaluated by a Physician Assistant for an initial history and physical examination (H&P) on 10/22/25 at 7:56 P.M. Patient #1’s H&P on 10/22/25 indicated the Patient was admitted to the Hospital with a C-collar for his/her cervical fracture and a TLSO brace for his/her T12-L1 fracture, which was being managed non-surgically. The Impression/plan for Patient #1’s T12-L1 fracture was to wear the brace when out of bed and Patient would receive Physical Therapy (PT) and Occupational Therapy (OT) to manage his/her significant weakness. Review of Patient #1’s physician orders indicated a physician’s order dated 10/22/25 for TLSO brace when out of bed. The order contained no further specification as to what out of bed indicated. During an interview with RN #6 on 12/17/25 at 11:05 A.M., they said spinal precautions include orders for braces/devices, utilizing two staff members for moving patients with log rolling technique, and no twisting or sudden movements of a patient. They said if a patient requires a TLSO brace, the brace should be utilized for a mechanical lift. During an interview with the ACNO on 12/17/25 at 1:15 P.M., they said an order to apply a brace when out of bed indicates a brace should be applied when a patient is transferring out of bed to a chair or to walk. They said based on Patient #1’s order, the Patient would not require the TLSO brace to be mechanically lifted a few inches off his/her bed to change out his/her mattress. During an interview with the Director of Rehab on 12/17/25 at 3:00 P.M., they said therapy services will apply the TLSO brace to a patient requiring one during any transfer. They said they could not speak to nursing staff practices. During an interview with the Nurse Practitioner on 12/17/25 at 3:50 P.M., they said in regard to a TLSO brace, the best practice would be to use the brace any time using a mechanical lift. They said sometimes the orders for devices, such as a TLSO brace, will specify what out of bed means for application of the brace. They also said the TLSO brace should be used when a patient who requires one is moved to an upright position. The Hospital failed to ensure a physician’s order for a TLSO brace for Patient #1 was entered into his/her medical record with complete directions in order to promote the continuity of care among his/her healthcare providers”