Landmark Hospital of Columbia, LLC

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the Governing Body failed to ensure accountability and effective oversight of the hospital and hospital staff when they failed to: - Ensure the CEO provided effective oversight and management of the entire hospital; (A-0057) - Ensure the safety of all patients that required BiPAP (a noninvasive device that helps with breathing) devices when they failed to educate all staff following an adverse event for one discharged patient (#18) of two incident reports reviewed; (A-0144) - Complete a background check for one temporary agency staff (DD) of two personnel files reviewed; (A-0144) - Safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) in the hallway outside of the patient rooms of the hospital; (A-0147) - Obtain a physician’s order for the initial application and reapplication of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for two current patients (#2 and #7) and four discharged patients (#12, #26, #27 and #28) of six restraints reviewed; (A-0168) - Implement the restraint type ordered by the physician for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed; (A-0168) - Ensure restraint orders were authenticated by a provider within 24 hours for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed; (A-0168) - Ensure required restraint documentation was completed every-two hours for two current patients (#2 and #7) and four discharged patients (#12, #26, #27, and #28) of six restraints reviewed; (A-0175) - Ensure staff received restraint training on a periodic basis for three staff (F, G and M) of six staff, whose personnel files were reviewed; (A-0206) - Ensure qualified hospital staff members provide care to patients with percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tubes; (A-0386) - Ensure wound care staff were qualified for one Staff (Z) of two wound care Registered Nurse (RN) personnel files reviewed; (A-0386) - Appropriately turned and repositioned four current patients (#2, #6, #7 and #14) and one discharged patient (#12) out of five patients reviewed; (A-0395) - Provided appropriate hygiene for four current patients (#2, #6, #7 and #14) and one discharged patient (#12) out of five patients reviewed; (A-0395) - Appropriately labeled tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube) formula containers, accompanying water bag and tubing for three current patients (#4, #5 and #14) out of five patients observed; (A-0395) - Appropriately date, time and initial all peripheral inserted venous catheter (PIV, a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg, or foot] or in a vein in the scalp) sites and peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) line dressings for eight current patients (#3, #5, #6, #8, #9, #15, #16 and #21) out of 17 patients observed; (A-0395) - Complete PICC line dressing changes per policy for one current patient (#3) out of two patients observed; (A-0395) - Appropriately date, time and initial wound dressings for six current patients (#2 #3, #5, #6, #8 and #23) of nine patients observed; (A-0395) - Receive and implement wound care orders for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; (A-0395) - Document wound care consistently and clearly for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; (A-0395) - Document wound care in a timely fashion for one current patient (#30) and one discharged patient (#12) of four patients reviewed; (A-0395) - Complete incident reports for three current patients (#6, #7 and #8) out of four patients reviewed with reportable events; (A-0395) - Safely secure medications in patient rooms for four current patients (#8, #10 #14 and #21) and one discharged patient (#12) of 10 patients observed; (A-0405) - Ensure medications were administered at the time they were documented for three current patients (#3, #6 and #8) and one discharged patient (#34) of 10 patients observed or reviewed; (A-0405) - Administer insulin (medication that regulates the amount of sugar in the blood) using a double-check system per policy for one discharged patient (#33) of three patients observed or reviewed; (A-0405) - Administer Time Critical Medications (medications that when administered early or late may cause harm or have a negative impact to the intended therapeutic effect) within 30 minutes of the scheduled time due for three current patients (#2, #3 and #33) and one discharged patient (#34) of six patients observed or reviewed; and (A-0405) - Administer Humalog (a rapid-acting blood-glucose-lowering medication) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for two current patients (#7 and #33) and one discharged patient (#34) of three patients reviewed. (A-0405) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.12 CoP: Governing Body. Please refer to A-0057, A-0115, A-0144, A-0147, A-0168, A-0175, A-0206, A-0385, A-0386, A-0395, and A-0405.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure the safety of all patients that required BiPAP (a noninvasive device that helps with breathing) devices when they failed to educate all staff following an adverse event for one discharged patient (#18) of two incident reports reviewed; (A-0144) - Complete a background check for one temporary agency staff (DD) of two personnel files reviewed; (A-0144) - Safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) in the hallway outside of the patient rooms of the hospital; (A-0147) - Obtain a physician’s order for the initial application and reapplication of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for two current patients (#2 and #7) and four discharged patients (#12, #26, #27 and #28) of six restraints reviewed; (A-0168) - Implement the restraint type ordered by the physician for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed; (A-0168) - Ensure restraint orders were authenticated by a provider within 24 hours for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed; (A-0168) - Ensure required restraint documentation was completed every-two hours for two current patients (#2 and #7) and four discharged patients (#12, #26, #27, and #28) of six restraints reviewed; and (A-0175) - Ensure staff received restraint training on a periodic basis for three staff (F, G and M) of six staff personnel files reviewed. (A-0206) The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 11/19/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on BiPap safety and assessment. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0144, A-0147, A-0168, A-0175 and A-0206.”

“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: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure qualified hospital staff members provide care to patients with percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tubes; (A-0386) - Ensure wound care staff were qualified for one Staff (Z) of two wound care Registered Nurse (RN) personnel files reviewed; (A-0386) - Appropriately turned and repositioned four current patients (#2, #6, #7 and #14) and one discharged patient (#12) of five patients reviewed; (A-0395) - Provide appropriate hygiene for four current patients (#2, #6, #7 and #14) and one discharged patient (#12) of five patients reviewed; (A-0395) - Appropriately labeled tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube) formula containers, accompanying water bag and tubing for three current patients (#4, #5 and #14) of five patients observed; (A-0395) - Appropriately date, time and initial all peripheral inserted venous catheter (PIV, a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg, or foot] or in a vein in the scalp) sites and peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) lines dressings for eight current patients (#3, #5, #6, #8, #9, #15, #16 and #21) of 17 patients observed; (A-0395) - Complete PICC line dressing changes per policy for one current patient (#3) of two patients observed; (A-0395) - Appropriately date, time and initial wound dressings for six current patients (#2 #3, #5, #6, #8 and #23) of nine patients observed; (A-0395) - Receive and implement wound care orders for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; (A-0395) - Document wound care consistently and clearly for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; (A-0395) - Document wound care in a timely fashion for one current patient (#30) and one discharged patient (#12) of four patients reviewed; (A-0395) - Complete incident reports for three current patients (#6, #7 and #8) of four patients reviewed with reportable events; (A-0395) - Complete incident reports for three current patients (#6, #7 and #8) out of four patients reviewed with reportable events; (A-0395) - Safely secure medications in patient rooms for four current patients (#8, #10 #14 and #21) and one discharged patient (#12) of 10 patients observed; (A-0405) - Ensure medications were administered at the time they were documented for three current patients (#3, #6 and #8) and one discharged patient (#34) of 10 patients observed or reviewed; (A-0405) - Administer insulin (medication that regulates the amount of sugar in the blood) using a double-check system per policy for one discharged patient (#33) of three patients observed or reviewed; (A-0405) - Administer Time Critical Medications (medications that when administered early or late may cause harm or have a negative impact to the intended therapeutic effect) within 30 minutes of the scheduled time due for three current patients (#2, #3 and #33) and one discharged patient (#34) of six patients observed or reviewed; and (A-0405) - Administer Humalog (a rapid-acting blood-glucose-lowering medication) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for two current patients (#7 and #33) and one discharged patient (#34) of three patients reviewed. (A-0405) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0386, A-0395 and A-0405.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Conditions of Participation (CoP): Patient’s Rights and 42 CFR 482.23 CoP: Nursing Services. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Landmark Columbia Local Organizational Chart,” dated 2025, showed all administrative leaders reported to Staff V, Chief Executive Officer (CEO). During an interview on 11/25/25 at 11:44 AM, Staff V, CEO, stated that as CEO she was responsible for full oversight of the hospital’s operations.”

“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: 50321 Based on interview, record review and policy review, the hospital failed to ensure the safety of all patients that required BiPAP (a noninvasive device that helps with breathing) devices when they failed to educate all staff following an adverse event for one discharged patient (#18) of two incident reports reviewed and failed to complete a background check for one temporary agency staff (DD) of two personnel reviews filed. Findings Included: Review of the hospital’s policy titled, “Incident Reporting,” reviewed 02/2025, showed: - An incident was an unusual event or circumstance not consistent with quality and safe patient care or hospital standards. That included situations that might potentially or actually result in injury, harm, or loss to any patient, visitor, or employee. - An adverse event was a healthcare event causing harm that was not related to the natural course of the patient’s illness or underlying condition. A serious adverse event might require significant additional treatments but was not life threatening and did not result in a major loss of function. - All incidents were risk rated. Where appropriate, a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) and/or action plan would be developed for change of process, practice, policy and/or education. Review of the hospital’s policy titled, “Applicant Background Checks,” revised 08/2023, showed: - Human Resources (HR) department would perform initial and ongoing background screening to prevent employment of any ineligible individual. - Additionally, all individuals being considered for employment would be required to consent to criminal background checks. - HR staff were responsible for performing a criminal background screening of every applicant as part of the employment process. Review of an email sent on 10/07/25 at 4:17 PM to Staff U, Quality Management Director, showed: - On 10/04/25, respiratory therapy (RT) staff heard a call for assistance to Patient #18’s room. On arrival he was dusky in color. His heart rate/pulse (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) was 40, and he had a BiPAP mask on his face. The BiPap device was on standby, and Patient #18 was agonal breathing (gasping, labored breathing). - At 2:58 AM, staff were unable to feel a pulse and a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was initiated. - At 3:02 AM, return of spontaneous circulation (ROSC, the resumption of a sustained heart rhythm after cardiac arrest) was achieved. - RT confirmed that Staff R, RN, had placed Patient #18 on BiPap without the knowledge of his assigned RT. After doing so, Staff R had felt something wasn’t right. She then left Patient #18’s room to find his primary nurse, as she was not assigned to Patient #18. She thought the BiPap device would automatically trigger and did not realize she had not turned it on. - A debriefing was performed, and the provider educated the nursing staff on shift. Review of an incident report filed on 10/05/25 showed: - The incident category was a Code/Rapid Response. - On 10/05/25 at 2:58 AM, RT was called to Patient #18’s room and found he was agonal breathing with a HR of 40. His BiPAP mask was on his face but was on standby/not ventilating. A code blue was initiated, and ROSC was achieved. - The injury or adverse outcome was a respiratory arrest. - The actions taken included that a code was called and that he was transferred to a higher level of care. - Follow up documentation showed he was transferred to a higher level of care related to an abnormal chest x-ray (test that creates pictures of the structures inside the body-particularly bones). Nursing staff immediately underwent training at the bedside in regard to BiPap device troubleshooting, mask placement, and standby mode. The plan was to train all nursing staff upon discussion of the incident. - On 10/11/25, the incident report was reviewed by Staff M, Chief Nursing Officer (CNO), at 8:43 AM, and Staff U, Quality Management Director, at 10:00 AM. Review of patient #18’s medical record showed: - On 09/18/25, he was admitted for ventilator (a machine that supports breathing) weaning. - On 10/01/25, an order showed he was to be placed on BiPap as needed during the day and continuously at night. - On 10/05/25 at 2:58 AM, documentation showed a RT responded to a call to his room. He was dusky in color, with agonal breathing and a HR of 40. His BiPap mask was not operating. He did not have a pulse, and a code blue was initiated. Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was performed, and ROSC was achieved at 3:02 AM. - At 3:57 AM, an order showed he was to be placed on ventilary support. - At 8:42 AM, he was transferred to Hospital B, acute care hospital. During an interview on 11/19/25 at 10:50 AM and 11:45 AM, Staff U, Quality Management Director, stated that she had reviewed Patient #18’s safety event, and was directed by corporate to provide immediate education to all nursing staff following a RCA. Nursing staff were not trained to initiate BiPap device treatment and were not expected to do so. Staff R, RN, was not trained to initiate BiPap and should not have done so at the time, or presently. Education for all nursing staff began immediately, however, nursing staff felt the initial education provided was inappropriate and had declined to sign the attestation. The education was then revised and was to begin on 11/13/25. The education was not completed as of 11/19/25. Staff who had not received the education had and were actively caring for patients with BiPap devices. She expected the education to have been completed as she had assigned the education to the RT and Nurse Manager. The provider who gave education to nursing staff who were on shift during the event had not made a record of what that education consisted of or who was present. Review of the hospital’s staffing sheet, dated 06/04/25, showed Staff DD, Patient Care Technician (PCT), was assigned to an orientation shift from 6:00 AM through 6:30 PM and was noted to be from a temporary staffing agency. On 11/20/25 at 3:07 PM, a background check for Staff DD, PCT, was requested by survey staff. During an interview on 11/20/25 at 5:30 PM, Staff V, Chief Executive Officer (CEO), and Staff CC, HR Assistant, stated that they were unable to locate Staff DD, PCT’s, personnel file. They contacted both temporary staffing agencies he could have been contracted through, and they were also unable to locate his employee file. All staff were expected to have a background check prior to providing patient care. They had since stopped using the temporary staffing agency. On 11/25/25 at 2:01 PM, five days after initially requested, the hospital produced a background screening for Staff DD, PCT. Review of Staff DD’s background screening showed on 08/29/25, a request was made in regard to a background screening. The results of the background screening were provided as of 09/10/25.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 47504 Based on observation, interview and policy review, the hospital failed to safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) of patients. This failure had the potential to affect the confidentiality of all patients in the hospital. Findings included: Review of the hospital’s policy titled, “PHI Rights,” reviewed 10/2025, showed PHI was any information related to the health or condition of a patient and the provision of care to a patient, transmitted or maintained in any form or medium. PHI included the patient’s name, medical history, care, and treatment. The hospital was responsible for safeguarding the confidentiality of a patient’s PHI. Observation on 11/17/25 at 2:30 PM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/17/25 at 2:50 PM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where Patient #6’s information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/18/25 8:30 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where Patient #14’s information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/18/25 at 8:45 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where Patient #31’s information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/18/25 at 9:15 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where Patient #21’s information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/18/25 at 9:30 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient’s care. Observation on 11/19/25 at 1:01 PM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where Patient #32’s information was visible by staff and visitors, who were not involved in the patient’s care. During an interview on 11/25/25 at 11:59 AM, Staff M, Chief Nursing Officer (CNO), stated that nurses were not to leave PHI screens visible. Computer screens were to be minimized if the nurse walked away. During an interview on 11/20/25 at 10:19 AM, Staff F, Registered Nurse (RN), stated that computers with patient information should not be viewed by people in the hallway. Monitors should be turned to face toward the patient’s room. 50321 51264 51509”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to: - Obtain a physician’s order for the initial application and reapplication of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for two current patients (#2 and #7) and four discharged patients (#12, #26, #27 and #28) of six restraints reviewed; - Implement the restraint type ordered by the physician for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed; and - Ensure restraint orders were authenticated by a provider within 24 hours for two current patients (#2 and #7) and three discharged patients (#12, #26 and #27) of six restraints reviewed. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion,” revised 02/2025, showed: - Restraints were the use of any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely. - The use of hand mittens (restrictive mitt that hinders picking and tube pulling) would not be considered a restraint, however, pining or otherwise attaching/tying those same mittens to bedding/rails or using a wrist restraint in conjunction with the hand mittens would meet the definition of a restraint. If the mittens were so bulky that the patient’s ability to use their hands was significantly reduced, that would be considered a restraint (i.e. double padded mittens). - The use of four side rails to prevent the patient from exiting the bed would be considered a restraint. - Four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) used to restrain all four extremities was not allowed. - Restraints were used in accordance with the order of a physician or other Licensed Independent Practitioner (LIP) who was responsible for the care of the patient. Physician orders to continue all restraint types were renewed minimally on a weekly basis. Orders for restraints were documented on the applicable restraint order set in the patient’s medical record. - When restraints were removed before the order expired, the original order could not be used to reapply the restraint. A new order must be obtained. If a different restraint type was needed, the provider would discontinue the previous restraint order and write a new order. - Telephone restraint orders would be authenticated by the provider within 24 hours. Review of Patient #2’s medical record showed: - On 11/02/25 at 8:00 AM, a verbal order for bilateral (pertaining to both right and left sides) secured mittens was obtained for a duration of seven days. Bilateral wrist restraints were initiated. - At 7:00 PM, bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/04/25 at 7:52 AM, the right secured mitten was removed. - At 7:48 PM, all restraints were removed. - On 11/05/25 at 7:40 AM, a left secured mitten was applied. A new order was not obtained. - On 11/09/25 at 8:00 AM, a telephone order was placed for a left padded mitten for a duration of seven days. The order was not authenticated by a provider until 11/14/25 at 7:29 AM. He remained in a left secured mitten. - On 11/11/25 at 7:00 PM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/12/25 at 7:50 AM and 7:00 PM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/13/25 at 7:32 AM and 7:00 PM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/14/25 at 7:24 AM and 7:00 PM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/15/25 at 4:00 PM, all restraints were removed. - On 11/16/25 at 12:00 AM, a left secured mitten was applied. - At 12:15 AM, a telephone order for a left secured mitten was obtained for a duration of seven days. He remained in a left secured mitten. - At 10:32 AM, all restraints were removed. - At 8:23 PM, a telephone order for a left secured mitten was obtained. The order was not authenticated by a provider by 11/20/25 at 9:45 AM when the medical record was obtained. - At 9:00 PM, a left secured mitten was applied. - On 11/17/25 at 9:54 AM, all restraints were removed. - On 11/18/25 at 12:00 AM, a telephone order was obtained for a left secured mitten for a duration of seven days. A left secured mitten was applied. - At 8:00 AM, a left wrist restraint was applied, and a left secured mitten was removed. A new order was not obtained. - At 7:36 PM, a left secured mitten was applied, and the left wrist restraint was removed. A new order was not obtained. - On 11/21/25 at 7:33 AM, a left ankle restraint was applied, and the left secure mitten was removed. A new order was not obtained. - On 11/22/25 at 7:25 AM, a left secured mitten was applied, and the left ankle restraint was removed. A new order was not obtained. - At 7:42 PM, all restraints were removed. - On 11/23/25 at 7:33 AM, a left secured mitten was applied. A new order was not obtained - At 7:00 PM, all restraints were removed. - On 11/24/25 at 7:24 AM, a left wrist restraint was applied. A new order was not obtained. - At 7:00 PM, a left secured mitten was applied, and the left wrist restraint was removed. A new order was not obtained. - On 11/25/25 at 7:00 AM, a left secured mitten was initiated. A new order was not obtained. Review of Patient #7’s medical record showed: - On 10/26/25 at 4:00 PM, a telephone order for bilateral secured mittens was obtained for a duration of seven days. - At 4:30 PM, bilateral secured mittens were applied. - On 10/27/25 at 7:30 AM, the left secured mitten was removed. - At 7:00 PM, a right secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/29/25 at 12:12 AM, all restraints were removed. - At 7:30 AM, a right secured mitten was applied. A new order was not obtained. - On 11/02/25 at 7:00 PM, a right wrist restraint and a left secured mitten were applied. A new order was not obtained. - At 7:42 PM, the right wrist restraint and left secured mitten were removed. - At 11:38 PM, a telephone order for a right wrist restraint and right secured mitten was obtained for a duration of seven days. The order was not authenticated by a provider until 11/07/25 at 5:19 AM. The right wrist restraint was not applied. - On 11/03/25 at 7:53 AM, a right wrist restraint and left secured mitten were applied. A new order was not obtained. - At 7:00 PM, a right wrist restraint and bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/04/25 at 7:49 AM and 7:27 PM, a right wrist restraint and bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/05 at 7:30 AM, the left secured mitten was removed. - At 7:00 PM, a right wrist restraint and right secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/06/25 at 8:00 AM, a left secured mitten was applied, and the right wrist restraint was removed. A new order was not obtained. - At 7:00 PM, a right wrist restraint and a right secured mitten were applied, the left secured mitten was removed. A new order was not obtained. - On 11/07/25 at 7:00 AM, a left secured mitten was applied, and the right wrist restraint was removed. A new order was not obtained. - At 7:00 PM, bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/08/25 at 7:00 PM, bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/09/25 at 10:16 PM, a telephone order for a right secured mitten was placed for a duration of seven days. The order was not authenticated by a provider until 11/14/25 at 7:29 AM. She remained in bilateral secured mittens. - On 11/10/25 at 12:32 AM, the left secured mitten was removed. - At 7:00 AM, a left secured mitten was applied. A new order was not obtained. - At 7:00 PM, the left secured mitten was removed. - On 11/11/25 at 7:29 PM, a right wrist restraint and bilateral secured mittens were initiated. A new order was not obtained. - On 11/12/25 at 7:30 AM, the left secured mitten was removed. - At 7:01 PM, a right wrist restraint and right secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/13/25 at 4:00 AM, a right wrist restraint was initiated, and the right secured mitted was removed. A new order was not obtained. - At 11/13/25 at 9:40 PM, a right wrist restraint was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/16/25 at 10:16 PM, a telephone order for a right secured mitten was placed for a duration of seven days. It had not been authenticated by a provider by 11/18/25 at 8:41 AM when the medical record was obtained. She remained in only a right wrist restraint. Review of Patient #12’s medical record showed: - On 10/10/25 at 8:24 PM, a telephone order for bilateral ankle and a left wrist restraints was placed for a duration of seven days. Bilateral ankle restraints and a left secured mitten were initiated. - On 10/11/25 at 9:00 PM, the bilateral ankle restraints were removed. - On 10/12/25 at 2:31 PM, a left wrist restraint was applied, and the left secured mitten was removed. A new order was not obtained. - At 3:41 PM, bilateral ankle restraints were applied. A new order was not obtained. - At 3:49 PM, a telephone order for bilateral ankle restraints and a left secured mitten was placed for a duration of seven days. The left secured mitten was not applied, and the left wrist restraint remained on. He remained in bilateral ankle restraints and a left wrist restraint. - At 7:00 PM, a left secured mitten was applied. A new order was not obtained. - On 10/13/25 at 7:54 AM, a right wrist restraint was applied, and the left secured mitten was removed, meaning he was in four-point restraints. A new order was not obtained. - At 7:19 PM, a left secured mitten was applied, and the bilateral ankle restraints, and right wrist restraint was removed. A new order was not obtained. - On 10/14/25 at 7:30 AM, the left wrist restraint was removed. - At 7:51 PM, bilateral ankle restraints were applied. A new order was not obtained. - On 10/17/25 at 7:00 PM, bilateral ankle restraints and a left secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/18/25 at 7:30 PM, a left wrist restraint was applied, and the left secured mitten was removed. All four side rails were raised. A new order was not obtained. - On 10/19/25 at 8:00 AM, all four side rails were no longer raised. - At 12:19 AM, a telephone order for bilateral ankle and a left wrist restraints was placed for a duration of seven days. He remained in bilateral ankle restraints and a left wrist restraint. - At 7:00 PM, all four side rails were raised. A new order was not obtained. - On 10/21/25 at 7:49 PM, a left secured mitten was applied. A new order was not obtained. - On 10/22/25 at 7:34 AM, bilateral ankle restraints and a left secured mitten were initiated, and the left wrist restraint was removed. A new order was not obtained. - At 6:29 PM, a left wrist restraint and a left secured mitten were initiated, and bilateral ankle restraints were removed. A new order was not obtained. - At 2:59 PM, bilateral ankle restraints, a left wrist restraint and a left secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 8:06 PM, bilateral ankle restraints were applied. A new order was not obtained. - On 10/23/25 at 7:26 AM, bilateral ankle restraints were initiated and the left wrist restraint and left secured mitten were removed. A new order was not obtained. - At 3:30 PM, all restraints were removed. - At 8:00 PM, a left secured mitten was initiated. A new order was not obtained. - At 10:00 PM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/24/25 at 12:00 AM, restraints were removed, but a left secured mitten was also initiated. A new order was not obtained. - At 2:00 AM, a left secured mitten was initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 4:00 AM, all restraints were removed. - At 7:30 PM, a left secured mitten was applied. A new order was not obtained. - On 10/26/25 at 9:49 AM, a provider order for bilateral ankle restraints was placed for a duration of seven days. He remained in a left secured mitten. - At 9:50 AM, a provider order for bilateral secured mittens was placed for a duration of seven days. He remained in a left secured mitten. - At 11:45 PM, bilateral ankle restraints were applied. - at 11:45 PM, the left secured mitten was removed. - On 10/27/25 at 7:56 AM, a left secured mitten was applied. A new order was not obtained. - On 10/28/25 at 9:00 AM, the bilateral ankle restraints were removed. - On 10/29/25 at 12:00 AM, bilateral ankle restraints and a right secured mitten were applied, meaning he was in four-point restraints. A new order was not obtained. - At 7:30 AM, the bilateral ankle restraints and right secured mitten were removed. - At 11:13 PM, bilateral ankle restraints, a right wrist restraint and a left secured mitten were initiated, meaning he was in four-point restraints. A new order was not obtained. - On 10/30 at 7:00 PM, the right wrist restraint was removed. - On 10/31 at 7:38 AM, a left wrist restraint was applied. A new order was not obtained. - At 7:00 PM, bilateral ankle restraints and a left secured mitten were initiated, and the left wrist restraint was removed. A new order was not obtained. - On 11/01/25 at 7:18 AM, bilateral ankle restraints and a left secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/02/25 at 5:56 PM, a telephone order for bilateral ankle restraints was placed for a duration of seven days. The order was not authenticated by a provider until 11/07/25 at 5:19 AM. The left secured mitten remained on. He remained in bilateral ankle restraints and a left secured mitten. - At 7:00 PM, a left wrist restraint was applied, and the left secured mitten was removed. A new order was not obtained. - On 11/03/25 at 4:00 PM, a telephone order for a left wrist restraint was placed for a duration of seven days. He remained in bilateral ankle restraints and a left secured mitten. - At 4:09 PM, a telephone order for bilateral ankle restraints was placed for a duration of seven days. He remained in bilateral ankle restraints and a left secured mitten. - At 7:00 PM, a left wrist restraint was applied. A new order was not obtained. - On 11/04/25 at 9:25 AM, the left wrist restraint was removed, and a right secured mitten was applied, meaning he was in four-point restraints. All four side rails were raised. A new order was not obtained. - At 11:03 PM, bilateral ankle restraints, a left wrist restraint and a left secured mitten were initiated. The right secured mitten was removed. A new order was not obtained. - On 11/05/25 at 4:00 AM, a left ankle restraint, left wrist restraint and left secured mitten were initiated. The right ankle restraint was removed. A new order was not obtained. - At 7:20 PM, the left wrist restraint was removed. - On 11/06/25 at 7:49 AM, a left wrist restraint was applied. - At 7:56 AM, a telephone order for bilateral secured mittens was placed for a duration of seven days. He remained in left ankle restraint, left wrist restraint and a left secured mitten. - At 7:35 PM, bilateral ankle restraints, a left wrist restraint and bilateral secured mittens were applied, meaning he was in four-point restraints. A new order was not obtained. - On 11/07/25 at 7:22 AM, the right ankle restraint and right secured mitten were removed. - On 11/08/25 at 7:00 AM, a telephone order for a left ankle restraint was placed for a duration of seven days. He remained in a left ankle restraint, left wrist restraint, and a left secured mitten. A second order for a left secured mitten was placed for a duration of seven days. - On 11/09/25 at 7:00 AM, the left wrist restraint was removed. - At 7:16 PM, a left wrist restraint was applied. A new order was not obtained. - On 11/11/25 at 10:10 AM, a left ankle restraint, left wrist restraint and left secured mitten were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 7:00 PM, a left ankle restraint and left secured mitten were initiated, and a left wrist restraint was removed. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/12/25 at 7:00 AM, a left wrist restraint was applied, and the left secured mitten was removed. A new order was not obtained. - On 11/12/25 at 7:00 PM, a left ankle restraint and a left secured mitten were initiated, and the left wrist restraint was removed. A new order was not obtained. - On 11/13/25 at 3:00 AM, all restraints were removed. - At 7:12 AM, a left ankle restraint and a left wrist restraint were applied. A new order was not obtained. - At 3:00 PM, a provider order for bilateral wrist restraints was placed for a duration of seven days. He remained in a left ankle restraint and a left wrist restraint. - At 7:02 PM, a left ankle restraint and a left wrist restraint were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 11/14/25 at 8:10 PM, a right wrist restraint was applied, and the left ankle restraint was removed. A new order was not obtained. - On 11/16/25 at 7:47 AM, the right wrist restraint was removed. - At 7:03 PM, a right wrist restraint was applied. A new order was not obtained. - On 11/17/25 at 7:37 AM, the right wrist restraint was removed. - On 11/18/25 at 4:09 PM, he was transferred to Hospital B. Review of Patient #12’s medical record from Hospital B showed on 11/18/25 at 7:21 PM, he arrived from Hospital A in bilateral wrist restraints. Review of Patient #26’s medical record showed: - On 07/17/25 at 7:00 PM, bilateral wrist restraints were initiated. No order was obtained. - On 07/18/25 at 7:00 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 07/20/25 at 12:14 PM, bilateral secured mittens were applied, the bilateral wrist restraints were removed. A telephone order was not obtained. - On 07/21/25 at 7:53 AM, bilateral wrist restraints were applied, and bilateral secured mittens were removed. - On 07/22/25 at 12:56 PM, a telephone order for bilateral mittens was obtained for a duration or seven days. She remained in bilateral wrist restraints. She remained in bilateral wrist restraints. - On 07/25/25 at 7:30 PM, all restraints were removed, and bilateral ankle restraints were applied. A new order was not obtained. - At 9:00 PM, bilateral ankle restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 11:00 PM, all restraints were removed. - On 07/26/25 at 7:30 AM, bilateral wrist restraints were applied. A new order was not obtained. - At 7:00 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 07/29/25 at 7:44 PM, all restraints were removed. - On 07/30/25 at 7:30 AM, bilateral wrist restraints were applied. A new order was obtained. - On 08/03/25 at 8:00 AM, 12:00 PM, 2:30 PM, 3:00 PM, 4:30 PM and 5:30 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation - At 8:00 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. She remained in bilateral wrist restraints. - On 08/09/25 at 7:41 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/11/25 at 7:41 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - 10:40 AM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. The order was not authenticated by a provider until 08/12/25 at 1:35 PM. She remained in bilateral wrist restraints. - On 08/12/25 at 7:20 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/18/25 at 7:26 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 4:36 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. She remained in bilateral wrist restraints. - On 08/19/25 at 7:43 AM and 7:37 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/20/25 at 7:28 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/21/25 at 7:00 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/23/25 at 7:00 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - At 5:16 PM, a telephone order for bilateral mittens was obtained for a duration of seven days. She remained in bilateral wrist restraints. - At 7:00 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/24/25 at 9:50 AM, bilateral secured mittens were applied. A new order was not obtained. - On 08/26/25 at 3:35 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. The order was initially verified by a provider on 08/26/25 at 9:11 PM but then rejected by a provider on 08/31/25 at 10:00 PM. She remained in bilateral wrist restraints and bilateral secured mittens. - On 08/27/25 at 7:25 AM, the bilateral secured mittens were removed. - On 08/29/25 at 7:05 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 08/30/25 from 7:43 AM, bilateral secured mittens were applied. A new order was not obtained. - On 08/31/25 at 6:12 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. No new restraint orders were placed prior to the expiration of the order. She remained in bilateral wrist restraints and bilateral secured mittens. - On 09/01/25 at 8:01, bilateral wrist restraints and bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/04/25 at 7:24 AM, bilateral ankle restraints were applied, and the bilateral secured mittens were removed, meaning she was in four-point restraints. A new order was not obtained. - At 7:00 P, bilateral secured mittens were applied, and bilateral ankle restraints were removed. A new order was not obtained. - On 09/05/25 at 7:08 AM, the bilateral wrist restraints were removed. - At 7:00 PM, bilateral wrist restraints were applied. A new order was not obtained. - On 09/06/25 at 7:02 AM, the bilateral wrist restraints were removed. - On 09/07/25 at 7:35 PM and 7:45 PM, bilateral wrist restraints and bilateral secured mittens were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/09/25 at 2:20 PM, a provider order for bilateral wrist restraints was obtained for a duration of seven days. She remained in bilateral wrist restraints and bilateral secured mittens. - On 09/10/25 at 7:30 AM, bilateral secured mittens were removed. - On 09/11/25 at 8:00 PM at 11:06 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/16/25 at 10:14 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. No new restraint orders were placed prior to the expiration of the order. She remained in bilateral wrist restraints. - On 09/17/25 at 7:17 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/18/25 at 7:35 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/19/25 at 7:51 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/21/25 at 7:46 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/24/25 at 7:30 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/25/25 at 3:38 AM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. She remained in bilateral wrist restraints. - On 09/28/25 at 7:22 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/02/25 at 2:42 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. The order was not verified by a provider until 10/06/25 at 10:36 AM. - On 10/05/25 at 7:16 AM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/06/25 at 7:27 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/07/25 at 7:21 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 10/08/25, all restraints were discontinued. Review of Patient #27’s medical record showed: - On 09/09/25 at 4:00 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. A right wrist restraint was initiated. - At 7:00 PM, a left wrist restraint was applied, and the right wrist restraint was removed. A new order was not obtained. - On 09/12/25 at 11:11 AM, bilateral wrist restraints were initiated. A new order was not obtained. - At 7:00 PM, the right wrist restraint was removed. - At 10:24 PM, all restraints were removed. - On 09/13/25 at 9:54 AM, a left wrist restraint was applied. A new order was not obtained. - At 7:00 PM, a left restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/14/25 at 11:45 PM, a telephone order for bilateral wrist restraints was obtained for a duration of seven days. He remained in only the left wrist restraint. The order was not electronically signed by a provider until 09/18/25 at 6:03 PM. He remained in a left wrist restraint. - On 09/16/25 at 7:31 PM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/18/25 at 7:36 PM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/19/25 at 7:53 PM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/21/25 at 12:50 PM, a telephone order for a left wrist restraint was obtained for a duration of seven days. He remained in a left wrist restraint. - At 7:47 PM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/24/25 at 7:00 PM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 09/27/25 at 7:16 AM, a posey vest (type of medical safety garment or physical restraint used to secure a patient to a bed or chair) was applied, and the left wrist restraint was removed. A new order was not obtained. - At 7:10 PM, a left wrist restraint was applied. A new order was not obtained. - On 09/28/25 at 12:50 PM, a telephone order for a left wrist restraint was obtained for a duration of seven days. The order was not electronically signed by a provider until 10/03/25 at 5:42 AM. He remained in a left wrist restraint. - At 7:28 PM, all restraints were removed. - On 09/29/25 at 7:30 AM, a left wrist restraint was applied. A new order was not obtained. - On 10/04/25 at 7:58 AM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - On 10/05/25 at 7:21 AM, a left wrist restraint was initiated. A new order was not obtained. There was no documentation to show the restraint had been removed prior to initiation. - At 4:40 PM, restraints were discontinued. Review of Patient #28’s medical record showed: - On 09/11/25 at 2:00PM, a telephone order for bilateral wrist restraints was placed for a duration of seven days. Bilateral wrist restraints were applied. - At 9:47 PM, all restraints were removed. - On 09/12/25 at 7:00 PM, bilateral wrist restraints were applied. A new order was not obtained. - On 09/13/25 at 4:15 AM, all restraints were removed. - At 7:42 PM, bilateral wrist restraints were applied. A new order was not obtained. - On 09/13/25 at 7:43 PM, bilateral wrist restraints were initiated. A new order was not obtained. There was no documentation to show restraints had been removed prior to initiation. - On 09/15/25 at 9:00 PM, all restraints were removed. During an interview on 11/25/25 at 11:53 AM Staff M, Chief Nursing Officer (CNO), stated that she expected an order to be obtained when restraints were applied. If the restraints were removed, she expected a new order to be obtained. Patients should be placed in the restraint the provider ordered. Orders should be authenticated per policy. During an interview on 11/19/25 at 12:00 PM, Staff F, Registered Nurse (RN), stated that restraint orders were placed by either the physician or the Nurse Practitioner (NP, a nurse with advanced clinical education and training). All restraint orders were typically placed for a duration of seven days. If the patient remained in the same restraint for longer than seven days, the physician or NP were to renew the restraint order. If a restraint were removed, a new order would need to be obtained. The restraint ordered should match the restraint used. If a different type of restraint was needed, she would obtain a new order. She felt many staff were unsure if a mitten was considered a restraint. A mitten was only considered a restraint if it were to be tied to the bed. If the medical record showed a “secured mitten” was in use, that was considered a restraint. She believed other staff may have documented “secured mitten” when it was not actually tied to the bed or may have documented “wrist restraint” and “secured mitten” at the same time when a secured mitten was tied and used as a restraint. 51264”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to ensure required restraint documentation was completed every-two hours for three current patients (#2, #7 and #12) and three discharged patients (#26, #27, and #28) of six restraints reviewed. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion,” revised 02/2025, showed the use of restraints requires documentation of observations, assessments and care completed as often as needed, but at least every two hours for restraints. Review of Patient #2’s medical record showed: - On 11/02/25 at 8:00 AM, he was placed in restraints. - On 11/15/25 from 1:00 AM through 7:00 AM, every two-hour documentation was not completed. - On 11/19/25 from 5:30 PM through 9:00 PM, every two-hour documentation was not completed. - On 11/20/25 from 5:00 PM through 9:00 PM, every two-hour documentation was not completed. - On 11/21/25 from 5:21 PM through 10:00 PM, every two-hour documentation was not completed. Review of Patient #7’s medical record showed: - On 10/26/25 at 4:30 PM, she was placed in restraints. - On 10/28/25 from 5:00 PM through 10/29/25 at 7:30 AM, every two-hour documentation was not completed. - On 10/29/25 from 7:30 AM through 7:00 PM, every two-hour documentation was not completed. - On 10/31/25 from 5:00 PM through 9:30 PM, every two-hour documentation was not completed. - On 11/02/25 from 5:17 PM through 9:30 PM, every two-hour documentation was not completed. - On 11/03/25 from 1:07 PM through 7:00 PM, every two-hour documentation was not completed. - On 11/06/25 from 10:00 PM through 11/07/25 at 12:53 AM, every two-hour documentation was not completed. - On 11/10/25 from 1:50 AM through 5:29 AM, every two-hour documentation was not completed. - On 11/14/25 from 5:09 PM through 8:24 PM, every two-hour documentation was not completed. - On 11/16/25 from 3:00 AM through 8:00 AM, every two-hour documentation was not completed. Review of Patient #12’ medical record showed: - On 10/10/25 at 8:24 PM, he was placed in restraints. - On 10/11/25 from 4:00 AM through 6:54 AM and from 9:01 AM through 11:56 AM, every two-hour documentation was not completed. - On 10/12/25 from 5:27 AM through 12:50 PM, every two-hour documentation was not completed. - On 10/17/25 from 5:43 AM through 7:00 PM, every two-hour documentation was not completed. - On 10/18/25 from 7:00 AM through 10:00 AM and from 6:00 PM through 9:00 PM, every two-hour documentation was not completed. - On 10/19/25 from 5:08 PM through 9:00 PM, every two-hour documentation was not completed. - On 10/20/25 from 9:00 AM through 7:14 PM, every two-hour documentation was not completed. - On 10/22/25 from 4:27 PM through 7:58 PM, every two-hour documentation was not completed. - On 10/23/25 from 9:00 AM through 8:00 PM, every two-hour documentation was not completed. - On 10/24/25 from 6:00 AM through 8:55 AM and from 3:24 PM through 6:31 PM, every two-hour documentation was not completed. - On 10/25/25 from 3:00 PM through 7:04 PM, every two-hour documentation was not completed. - On 10/27/25 from 9:00 AM through 11:55 AM, every two-hour documentation was not completed. - On 10/28/25 from 5:07 PM through 8:00 PM, every two-hour documentation was not completed. - On 10/29/25 from 6:50 AM through 7:00 PM, every two-hour documentation was not completed. - On 11/01/25 from 4:00 PM through 8:00 PM, every two-hour documentation was not completed. - On 11/02/25 from 2:00 PM through 4:58 PM, every two-hour documentation was not completed. - On 11/03/25 from 1:10 PM through 7:00 PM, every two-hour documentation was not completed. - On 11/04/25 from 11:00 AM through 2:00 PM, every two-hour documentation was not completed. - On 11/05/25 from 8:00 AM through 11:08 AM, every two-hour documentation was not completed. - On 11/06/25 from 5:00 AM through 7:50 AM, every two-hour documentation was not completed. - On 11/11/25 from 5:00 AM through 8:56 AM, every two-hour documentation was not completed. - On 11/13/25 from 3:05 AM through 7:42 AM, every two-hour documentation was not completed. Review of Patient #26’s medical record showed: - On 07/17/25 at 7:00 PM, she was placed in restraints. - On 07/20/25 from 6:16 AM through 8:00 PM, every two-hour documentation was not completed. - On 08/22/25 from 5:00 AM through 7:59 AM and from 7:44 PM through 08/23/25 at 7:00 AM, every two-hour documentation was not completed. - On 08/24/25 from 8:00 PM through 10:54 PM, every two-hour documentation was not completed. - On 08/27/25 from 11:00 PM through 7:21 PM, every two-hour documentation was not completed. - On 08/28/25 from 5:00 PM through 7:54 PM, every two-hour documentation was not completed. - On 08/30/25 from 3:08 PM through 7:52 PM, every two-hour documentation was not completed. - On 08/31/25 from 5:04 PM through 8:00 PM, every two-hour documentation was not completed. - On 09/02/25 from 5:00 PM through 8:00 PM, every two-hour documentation was not completed. - On 09/03/25 from 3:30 PM through 7:00 PM, every two-hour documentation was not completed. - On 09/05/25 from 3:07 PM through 7:00 PM, every two-hour documentation was not completed. - On 09/16/25 from 5:00 AM through 7:56 AM, every two-hour documentation was not completed. - On 09/17/25 from 3:00 AM through 7:00 AM, every two-hour documentation was not completed. - On 10/01/25 from 5:00 AM through 7:58 AM, every two-hour documentation was not completed. - On 10/03/25 from 3:15 PM through 7:00 PM, every two-hour documentation was not completed. Review of Patient #27’s medical record showed: - On 09/09/25 at 4:00 PM, he was placed in restraints. - On 09/10/25 from 1:00 PM through 4:25 PM and from 4:25 PM through 7:00 PM, every two-hour documentation was not completed. - On 09/13/25 at 9:54 AM, he was placed in restraints. - On 09/14/25 from 7:00 PM through 11:00 PM, every two-hour documentation was not completed. - On 09/17/25 from 1:00 AM through 7:30 AM and from 5:00 PM through 9:00 PM, every two-hour documentation was not completed. - On 09/29/25 at 7:30 AM, he was placed in restraints. - On 10/01/25 from 5:00 AM through 7:56 AM, every two-hour documentation was not completed. - On 10/03/25 from 1:05 PM through 7:00 PM, every two-hour documentation was not completed. - On 10/04/25 from 5:00 AM through 7:59 AM, every two-hour documentation was not completed. Review of Patient #28’s medical record showed, on 09/11/25 at 9:47 PM, he was placed in restraints. On 09/13/25 from 5:25 PM through 9:00 PM, every two-hour documentation was not completed. During an interview on 11/25/25 at 11:53 AM, Staff M, Chief Nursing Officer (CNO), stated that she expected documentation of restraint care every two hours. 51264”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 50321 Based on interview, personnel file review and policy review, the hospital failed to ensure staff received restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) training on a periodic basis for three staff (F, G and M) of six staff, whose personnel files were reviewed. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving),” revised 02/2025, showed all staff designated by the hospital as having direct patient care responsibilities, including contract or agency personnel, must demonstrate competency prior to participating in the application of restraints. Competency would be demonstrated initially as part of general hospital orientation and then during annual competencies. Training included the use of first aid techniques in the use of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped), including required periodic recertification. The hospital would document in the staff personnel records that the training and demonstration of competency were successfully completed. Review of the hospital’s undated document titled, “Order Report,” showed there had been patients at the hospital placed in restraints from 05/02/25 to 11/18/25. During concurrent interview and review of personnel records on 11/19/25 at 10:00 AM and 11:00 AM, Staff CC, Human Resources (HR) Assistant, was unable to provide proof of restraint training for Staff M, Chief Nursing Officer (CNO). Staff F, RN, completed restraint training through an online module that expired prior to 11/19/25. Staff G, RN, had a restraint competency checklist that was incomplete and missed a check off for restraint first aid training that was signed on 07/10/25. Staff CC stated that all staff members should have completed restraint training. At 11:00 AM, Staff CC provided the same restraint competency checklist for Staff G, signed on 07/10/25, with a check that was not present at 10:00 AM for restraint first aid training. Staff CC stated that she agreed the restraint competency checklist was incomplete at 10:00 AM, and Staff G completed the form on 11/19/25. There should have been a new restraint competency checklist completed on 11/19/25, and there should not have been a revision to the incomplete restraint competency checklist from 07/02/25. Staff CC also provided a restraint competency checklist for Staff M that was completed on 11/19/25. Review of the hospital’s document titled, “Restraint Competency Checklist,” dated 11/19/25, provided on 11/19/25 at 11:00 AM, showed Staff M, CNO, completed restraint training on 11/19/25. Review of the hospital’s document titled, “Restraint Competency Checklist,” dated 07/02/25, provided on 11/19/25 at 11:00 AM, showed all check marks completed for restraint training for Staff G, RN. On 11/19/25 at 10:00 AM, there was not a checkmark for the section titled, “patient restraint test.” During an interview on 11/25/25 at 11:53 AM, Staff M, CNO, stated that the previous CNO was responsible for restraint training and documentation. After Staff M took over the role in August, she had been unable to locate the documentation for restraint training. She expected all staff to complete restraint training and was expected to have documentation of such training.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 51509 Based on interview, record review, personnel file review and policy review, the hospital failed to ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel, when the hospital failed to ensure qualified hospital staff members provided care to patients with percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tubes and to ensure wound care staff were qualified for one Staff (Z) of two wound care Registered Nurse (RN) personnel files reviewed. Findings included: Although requested, a policy that stated who was authorized to re-insert PEG tubes and what to do in the event one was dislodged, was not provided. Review of the hospital’s policy titled, “Gastric (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach) Tube Placement and Maintenance,” revised 10/2025, showed a contrast study should be completed if a feeding tube was accidentally removed, or placement was in doubt. Review of Staff EE, RN’s, personnel record showed an enteral feeding (nutrition that is delivered into the digestive system as a liquid) quiz was completed on 07/05/23. No other training or competencies related to G-tubes or PEG tubes were provided, and the quiz did not show evidence of PEG tube insertion training. Review of Patient #10’s medical record showed on 11/16/25 at 2:55 AM, Staff EE, RN, documented that her PEG tube was found dislodged and in her bed. Staff EE inserted a new PEG tube, obtained imaging to confirm placement and notified the provider. Although requested, PEG tube insertion training or competencies were not provided. Review of the hospital’s undated Wound Specialist job description showed a wound care specialist was identified as a Registered Nurse (RN) who was responsible for assessing, planning, delivering and evaluating each level of nursing care provided. Required experience was five years in wound care. Wound certification was to be obtained within 90 days of the start date. Review of the hospital’s undated document titled, “Competency Based Orientation (CBO) Wound Care Nurse - Addendum to RN/Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) CBO,” showed Staff Z, RN, was an orientee. There was no date of employment listed. The preceptor was to initial and date all competencies completed. A preceptor did not date completed competencies for Staff Z. The preceptor was to sign their full name on the identification line. A preceptors full name was not signed or identified on the form for Staff Z. Review of the hospital’s RN job description for Staff Z, RN, showed on 11/19/25, a RN job description was completed. Staff Z did not sign the job description. The job description was not initially provided when personnel files were reviewed on 11/19/25 at 10:00 AM. Review of Staff Z, RN’s, personnel filed showed an initial hire date of 06/09/25. During an interview on 11/20/25 at 12:40 PM, Staff M, Chief Nursing Officer, CNO, stated that PEG tube reinsertion should be completed by an Advanced Practice Registered Nurse (APRN) or a nurse with demonstrated competency. The hospital did not provide such a competency. There was not a job description given to Staff Z initially and she signed the RN job description on 11/19/25. She stated that Staff Z was not qualified to take the wound care certification test yet due to a lack of experience in wound care. She received training from the wound care specialist who was certified. She was unaware that the wound specialist job description stated they must be certified within 90 days of employment. During an interview on 11/17/25 at 3:10 PM, Staff F, RN, stated that she and some other nurses were trained to reinsert PEG tubes. During an interview on 11/19/25 at 11:00 AM, Staff CC, Human Resources (HR) Manager, stated the RN job description for Staff Z, RN, was completed after the surveyor requested personnel files. Staff Z was hired to fill the wound specialist job and started on 06/09/25. She did not have five years of wound care experience and had not obtained the wound certification within 90 days.”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to ensure that staff: - Appropriately turned and repositioned four current patients (#2, #6, #7 and #14) and one discharged patient (#12) of five patients reviewed; - Provided appropriate hygiene for four current patients (#2, #6, #7 and #14) and one discharged patient (#12) of five patients reviewed; - Appropriately labeled tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube) formula containers, accompanying water bag and tubing for three current patients (#4, #5 and #14) of five patients observed; - Appropriately labeled all peripheral inserted venous catheter (PIV, a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg, or foot] or in a vein in the scalp) sites and peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) line dressings for eight current patients (#3, #5, #6, #8, #9, #15, #16 and #21) of 17 patients observed; - Appropriately labeled wound dressings for six current patients (#2 #3, #5, #6, #8 and #23) of nine patients observed; - Completed PICC line dressing changes per policy for one current patient (#3) of two patients observed; - Received and implemented wound care orders for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; - Documented wound care consistently and clearly for two current patients (#3 and #6) and one discharged patient (#12) of four patients reviewed; - Documented wound care in a timely fashion for one current patient (#30) and one discharged patient (#12) of four patients reviewed; and - Completed incident reports for three current patients (#6, #7 and #8) of four patients reviewed with reportable events. Findings included: Review of the hospital’s policy titled, “Personal Care and Hygiene,” reviewed 10/2025, showed: - Patients were encouraged to turn frequently and not stay in place for long periods of time. Patients dependent on a caregiver would be turned every two hours and on an as needed basis. If assistance was needed, appropriate personnel would be requested. - If a patient refused personal care, that would be recorded in the medical record and reported to the attending nurse as it might be necessary to revise the plan of care. - Documentation should include the reason for the patient’s decision and the potential concerns. - Personal hygiene was expected and encouraged daily and staff were to ensure that certain aspects of a patient’s personal care hygiene were completed on each shift. Review of Patient #2’s medical record showed he was admitted on 09/23/25. He received 22 baths during 57 days of hospitalization. He was to be turned and/or repositioned in his bed or chair every two hours. Repositioning or Patient #2’s refusal to be turned were not documented on: - 09/24/25 from 11:30 AM through 5:12 PM; - 09/25/25 from 5:00 AM through 12:00 PM on 09/26/25; - 09/26/25 from 2:15 PM through 8:40 PM; - 10/01/25 from 5:31 AM through 10:13 AM and from 2:07 PM through 8:03 PM; - 10/02/25 from 8:24 AM through 3:28 PM; - 10/08/25 from 6:32 AM through 8:30 PM; - 10/17/25 from 2:44 PM through 8:30 PM; - 10/21/25 from 2:11 PM through 7:38 PM; - 10/24/25 from 8:00 AM through 6:33 PM; - 10/30/25 from 10:32 AM through 6:00 PM; - 10/31/25 from 7:07 AM to 12:22 PM; - 11/06/25 from 3:27 PM through 8:34 PM; - 11/08/25 from 3:00 PM through 9:52 PM; - 11/12/25 from 8:18 AM through 10:41 PM; - 11/14/25 from 10:34 AM through 3:23 PM; and - 11/18/25 from 4:00 AM through 8:00 PM. Review patient #6’s medical record showed he was admitted on 10/06/25. He received 12 baths and eight refused baths during 43 days of hospitalization. He was to be turned and/or repositioned in his bed or chair every two hours. Repositioning or Patient #6’s refusal to be turned were not documented on: - 10/07/25 from 5:34 AM through 4:38 PM; - 10/08/25 from 12:35 AM through 4:45 AM and from 5:00 PM through 8:35 PM; - 10/09/25 from 4:30 AM through 8:00 AM; - 10/10/25 from 1:00 PM through 4:00 PM and from 6:08 PM through 10:00 PM; - 10/11/25 from 2:00 AM through 5:00 AM; - 10/13/25 from 6:11 AM through 10:30 PM; - 10/14/25 from 2:30 AM through 8:54 AM and from 2:35 PM through 10/15/25 at 7:39 AM; - 10/16/25 from 3:00 AM through 6:00 AM and from 2:13 PM through 6:59 PM; - 10/17/25 from 7:59 PM through 11:30 PM; - 10/18/25 from 5:21 AM through 10:08 AM, from 10:08 AM through 1:00 PM and from 5:04 PM through 10:47 PM; - 10/19/25 from 12:48 AM through 5:00 AM and from 8:41 AM through 2:00 PM; - 10/20/25 from 12:23 PM through 4:13 PM, from 4:13 PM through 9:36 PM and from 11:36 PM through 10/21/25 at 2:47 AM; - 10/21/25 from 3:00 AM through 9:30 AM, from 9:30 AM through 2:15 PM and from 11:00 PM through 10/22/25 at 3:00 AM; - 10/22/25 from 5:00 AM through 9:00 PM and from 10:07 PM through 10/23/25 at 1:10 AM; - 10/23/25 from 2:48 PM through 6:00 PM; - 10/27/25 from 8:30 AM through 1:00 PM and from 5:42 PM through 8:57 PM; - 10/28/25 from 2:00 AM through 7:00 AM and from 9:00 AM through 8:00 PM; - 10/29/25 from 1:15 AM through 4:56 AM and from 4:56 AM through 10/30/25 at 2:39 AM; - 10/30/25 from 4:26 AM through 10:33 AM and from 10:33 AM through 8:00 PM; - 10/31/25 from 4:00 PM through 7:06 AM and from 7:06 AM through 10:30 PM; - 11/02/25 from 1:00 AM through 7:00 AM and from 7:00 Pm through 10:00 PM; - 11/04/25 from 4:14 AM through 9:18 AM, from 10:24 AM through 1:58 PM, from 2:26 PM through 8:14 PM and from 8:14 PM through 10/05/25 at 7:20 AM; - 11/05/25 from 7:20 AM through 1:01 PM, from 1:01 PM through 4:03 PM and from 4:03 PM through 11/06/25 at 2:47 PM; - 11/06/25 from 4:03 PM through 8:11 PM and from 8:13 PM through 11/07/25 at 3:00 AM; - 11/07/25 from 3:00 AM through 9:33 AM and from 2:19 PM through 6:00 PM; - 11/08/25 from 4:51 AM through 8:00 AM and from 8:00 AM through 3:00 PM and from 3:00 PM through 6:24 PM; - 11/09/25 from 12:00 AM through 3:00 AM and from 9:00 AM through 12:00 PM and from 6:00 PM through 10:53 PM; - 11/10/25 from 4:50 AM through 2:04 PM and from 4:30 PM through 11/11/25 at 6:00 AM; - 11/11/25 from 8:06 AM through 12:00 PM and from 4:21 PM through 11/12/25 at 9:00 PM; - 11/13/25 from 12:33 AM through 3:33 PM and from 3:33 PM through 6:00 PM; - 11/14/25 from 4:07 AM through 1:29 PM; and - 11/16/25 from 5:23 PM through 11/17/25 at 6:39 AM. Review patient #7’s medical record showed she was admitted on 10/26/25. She received seven baths during 24 days of hospitalization. She was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #7’s refusal to be turned were not documented on: - 10/27/25 from 11:00 AM through 2:14 PM; - 10/28/25 from 8:30 AM though 11:00 AM and from 1:46 PM through 5:32 PM; - 10/29/25 from 6:00 AM through 9:00 PM; - 10/30/25 from 11:00 AM through 7:00 PM; - 10/31/25 from 9:17 AM through 8:30 PM; - 11/02/25 from 4:00 AM through 7:30 PM; - 11/03/25 from 11:48 AM through 4:38 PM and from 8:05 PM through 12:15 AM on 11/04/25; - 11/04/25 from 2:15 PM through 4:13 AM, from 11:00 AM through 2:12 PM, from 4:12 PM through 7:00 PM on 11/04/25 and from 9:00 PM through 1:00 AM on 11/05/25; - 11/05/25 from 1:26 PM through 5:28 PM; - 11/06/25 from 2:00 AM through 7:00 PM and from 7:00 PM through 10:00 PM; - 11/07/25 from 11:00 AM through 4:00 PM; - 11/08/25 from 1:00 AM through 4:00 AM, from 8:00 AM through 10:58 AM and from 10:20 PM through 1:30 AM on 11/09/25; - 11/09/25 from 4:35 PM through 8:08 PM and from 10:10 PM through 1:30 AM on 11/10/25; - 11/10/25 from 5:00 PM through 9:30 PM; - 11/11/25 from 1:00 AM through 4:22 AM, from 12:12 PM through 4:01 PM and from 6:01 PM through 9:19 PM; - 11/12/25 from 12:30 AM through 4:00 AM, from 6:00 AM through 8:42 AM and from 10:42 AM through 9:00 PM; - 11/13/25 from 1:00 AM through 4:03 PM, from 6:00 AM through 8:57 AM and from 2:03 PM through 8:49 PM; - 11/14/25 from 11:16 AM through 2:00 PM; - 11/15/25 from 1:41 AM through 4:58 AM, from 4:09 PM through 8:00 PM and from 11:00 PM through 2:00 AM; - 11/16/25 from 4:45 AM through 10:21 AM, from 12:07 PM through 3:30 PM and from 7:00 PM through 10:00 PM; - 11/17/25 from 2:16 AM through 4:51 AM, from 6:30 AM through 9:15 AM and from 2:31 PM through 8:30 PM; and - 11/18/25 from 5:00 AM through 8:41 AM. Review of patient #12’s medical record showed he was admitted on 10/10/25. He received eight baths during 39 days of hospitalization. He was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #12’s refusal to be turned were not documented on: - 11/09/25 from 7:00 PM through 11:00 PM on 11/10/25; - 11/11/25 from 3:00 AM through 11:00 PM; - 11/12/25 from 1:00 AM through 6:00 AM and from 8:00 AM though 7:00 PM; - 11/13/25 from 6:00 AM through 9:06 PM; - 11/14/25 from 4:30 AM through 1:00 PM; - 11/15/25 from 12:06 PM through 7:00 PM; - 11/16/25 from 4:00 AM through 9:00 AM and from 1:47 PM though 7:00 PM; and - 11/17/25 from 9:17 AM through 7:31 PM. Review of Patient #14’s medical record showed she was admitted on 11/14/25. She received three baths during five days of hospitalization. She was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #14’s refusal to be turned were not documented on: - 11/15/25 from 2:21 AM through 11:35 AM and from 1:04 PM through 8:00 PM; - 11/16/25 from 7:05 PM through 10:54 PM; and - 11/17/25 from 3:03 AM through 2:08 PM and from 4:14 PM through 10:41 PM. During an interview on 11/25/25 at 11:54 AM, Staff M, Chief Nursing Officer (CNO), stated that she expected staff to turn patients who required assistance to do so. Nurses were responsible to assess their patient’s neurological (neuro, relating to or affecting the nervous system) and musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection and movement) ability to determine which patient’s needed assistance; an order was not required to turn patients. She expected baths to be offered at least once a day, though she preferred once per shift. If a patient refused hygiene, she expected staff to document the refusal. Review of the hospital’s policy titled, “Clinical Practice Guidelines,” revised 07/2025, showed tube feeding formula containers, bags, bottles and tubing were to be changed every 24 hours and were to be dated, timed and initialed when hung. All central, PICC and PIV sites would be labeled with date and time when changed along with the nurse’s initials. PICC line dressings were to be changed every seven days. Wound dressings should be labeled with a date, time and initial when changed. Review of Patient #3’s medical record showed he was admitted to the hospital on 10/23/25, although requested, no PICC line dressing changes were included in the medical record provided for Patient #3. During concurrent interview and observation on 11/17/25 at 4:20 PM, showed Patient #3’s PICC line dressing was not labeled with a date, time, or initials. Staff C, RN, stated that the patient refused his dressing change the week prior. Observation on 11/17/25 at 2:14 PM, showed Patient #6’s PIV and wound dressing was not labeled with a date, time, or initials. Observation on 11/17/25 at 3:30 PM, showed Patient #8’s PIV was not labeled with a date, time, or initials. Observation on 11/17/25 at 4:09 PM, showed Patient #9’s PIV was not labeled with a date, time, or initials. Observation on 11/17/25 at 2:41 PM, showed Patient #15’s PIV was not labeled with a date, time, or initials. Observation on 11/17/25 at 2:45 PM, showed Patient #16’s PIV was not labeled with a date, time, or initials. Observation on 11/18/25 at 9:15 AM, showed Patient #21’s PIV was not labeled with a date, time, or initials. Observation on 11/18/25 at 2:00 PM, showed Patient #5’s formula container and PIV were not labeled with a date, time, or initials. Observation on 11/17/25 at 2:45 PM, showed Patient #4’s formula container was not labeled with a date, time, or initials. Observation on 11/18/25 at 8:30 AM, showed Patient #14’s water flush bag was dated 11/16/25. Observation on 11/18/25 at 10:19 AM, showed Patient #2’s wound dressings were not labeled with a date, time, or initials. Observation on 11/18/25 at 9:30 AM, showed Patient #3’s wound dressings were not labeled with a date or initials. Observation on 11/17/25 at 2:30 PM, showed Patient #5’s wound dressings were not labeled with a date or initials. Observation on 11/18/25 at 10:53 AM, showed Patient #8’s wound dressings were not labeled with a date or initials. Observation on 11/18/25 at 09:23 AM, showed Patient #23’s wound dressings were not labeled with a date or initials. During an interview on 11/25/25 at 11:54 AM, Staff M, CNO, stated that tube feeding containers, tubing and water flush bags should be labeled accurately with a date, time and initial. She expected PIV’s and PICC’s to be labeled with the date of insertion and the nurse’s initials. She expected PICC dressing changes to be completed weekly. Wound care dressings were to be labeled with the nurse’s initials and the date it was changed. Review of the hospital’s policy titled, “Wound Care Scope of Practice,” revised 02/2024, showed: - Nursing staff were responsible to evaluate and document patient outcomes. - Physicians and wound care providers were responsible to complete orders for wound treatment. Wound care orders would be implemented upon admission. - The wound care practitioner or trained wound care designee (RN) completed a comprehensive wound assessment on admission for patients with wounds or pressure injuries (injury to the skin and/or underlying tissue, usually over a bony area). Wound documentation included photographs of wounds and pressure injuries that became a part of the permanent medical record. - The wound care RN assessment would be documented in the medical record at the time of the assessment. - Subsequent routine integumentary assessments, to include wound assessments and routine wound care treatment, were provided by the assigned nursing staff per wound care treatment orders. - Nursing staff were required to complete an incident report immediately if wound dressings were not changed as ordered and report their findings to the CNO and the Director of Quality Management (DQM). Review of Patient #3’s medical record showed: - On 10/23/25, he was admitted. - On 10/24/25, he received a wound team evaluation. Four wounds were identified. - He had a wound to his right lateral malleolus (the side of the ankle) labeled #1, gluteal cleft (groove between the buttocks) labeled #2, scrotum labeled #3 and left heel labeled #4. - On 11/05/25 wound team documentation showed no location for wound #4. Review of Patient #6’s medical record showed: - On 10/06/25, he received a wound team evaluation. 21 wounds were identified. - He had a wound to his left forearm labeled #1, left second finger labeled #2, left medial knee labeled #3, left lateral lower leg labeled #4, left lateral interior leg labeled #5, left interior foot labeled #6, left metatarsal (bones of the foot) head labeled #7, right lateral second toe labeled #8, right lateral heel labeled #9, right interior ankle labeled #10, right ankle labeled #11, right interior lower leg labeled #12, right medial knee labeled #13, right elbow labeled #14, right medial back labeled #15, right hip labeled #16, gluteal cleft labeled #17, left superior buttock labeled #18, right buttock labeled #19, left ischium (lower, back part of the hip bone) labeled #20, and right posterior lower leg labeled #21. - On 10/10/25 wound team documentation showed wound #2 was noted to be the left first finger instead of the left second finger and wound #5 was noted to be the left lateral interior lower leg instead of the left lateral lower leg, as they were originally labeled. - Wounds were identified on the paper measurement tape however there were pictures that were not clear and could not identify the wound number or wound location. - On 10/16/25 wound team documentation showed wound #1 was noted to be the left lateral lower leg instead of the left forearm, wound #2 was noted to be the left lateral interior lower leg instead of the left first finger, wound #3 was noted to be the left interior foot instead of the left medial knee, wound #4 was noted to be the left metatarsal head instead of the left lateral lower leg, wound #5 was noted to be the right lateral second toe instead of the left lateral interior leg, wound #6 was noted to be the right lateral heel instead of the left interior foot, wound #7 was noted to be the right interior ankle instead of the left metatarsal head, wound #8 was noted to be the right ankle instead of the right lateral second toe, wound #9 was noted to be the right interior lower leg instead of the right lateral heel, wound #10 was noted to be the right posterior lower leg instead of the right interior ankle, as they were originally labeled. - There were inconsistencies in wound care provided by nursing staff. Some wounds had orders to be changed daily and there was no documentation to show it was completed. Some wounds had orders to be changed every three days and there was no documentation to show it was completed. - On 11/11/25, wound team documentation showed a wound to his left ischium was found and labeled wound #22. A note showed skin prep (a liquid, film-forming product used to create a protective barrier on the skin) was to be applied daily, however, there were no wound care orders placed. During concurrent interview and review of Patient #6’s medical record on 11/18/25 at 3:30 PM, showed he did not receive daily wound care for his wound labeled wound #18 on eight out of 18 days as ordered. Staff F, RN, stated that he had many wounds that were difficult to keep track of. She agreed wound care was not completed as ordered. Review of Patient #12’s medical record showed: - On 10/11/25, he received a wound team evaluation. Nine wounds were identified. - He had a wound to his left forearm labeled #1, right thigh skin graft site labeled #2, right medial hand with two external fixator pins (a stabilizing fame to hold broken bones in position) labeled #3, right hand labeled #4, right dorsal (back side of) wrist labeled #5, right forearm skin graft site labeled #6, right inner elbow labeled #7, right scalp (the skin that covers the top of the head) labeled #8 and coccyx (tailbone area) labeled #9. - On 10/14/25, wound team documentation showed a wound to his right upper chest was found and labeled #10. - On 10/15/25, wound team documentation showed wound #9 was noted to be the right upper chest instead of the coccyx, as it had originally been labeled. - A wound dressing change was completed but was not documented until 10/16/25 at 11:51 AM. - On 11/06/25, wound team documentation showed wound #9 was noted to be the resolved coccyx wound instead of the right upper chest, as it had previously been labeled. - On 11/10/25, wound #3 was resolved, however, the external fixator pins remained inserted to his right wrist. There were no wound care orders continued after the wound around the external fixator pins was resolved. External fixator pin care was documented only twice during his admission. - On 11/13/25, wound team documentation showed a second wound #4 was labeled left clavicle (collarbone). Review of Patient #30’s medical record showed on 11/05/25, a wound dressing change was completed but not documented until 11/12/25 at 9:47 PM. On 11/07/25, a wound dressing change was completed but was not documented until 11/10/25 at 7:11 PM. During an interview on 11/25/25, at 11:54 AM, Staff M, CNO, stated that nurses were not to delay documentation. She expected wounds to have wound care orders, and for those orders to be completed and documented properly and consistently. The medical record should clearly show when wound care was performed. She was surprised external fixator pin care was not completed for Patient #12. She expected documentation to be completed when patient care was administered. It was not acceptable to document wound care several days after a wound dressing was changed. During an interview on 11/18/25 at 3:30 PM, Staff L, RN, stated that it was difficult for nurses to identify what wounds needed to be changed and when, due to inconsistent labeling. Patient #6’s wound identification was a “hot mess” and she, “could not determine which wound needed what.” During an interview on 11/19/25 at 3:11 PM, Staff H, Wound Team RN, stated that wounds were to be labeled the same way consistently. There was not a policy to state that, but it was the standard they followed. If there were more than 10 wounds, the electronic health record (EHR) would require staff to create a second note labeled one through 10 again, but each subsequent wound would be labeled with a number in the note section. There should not be two wounds labeled with the same number at any point. If a wound was resolved, it would still retain the same number that would not be assigned to a new wound. During an interview on 11/18/25 at 11:30 AM, Staff F, RN, stated all wound care should be documented on the day the wound care was performed. Review of the hospital’s policy titled, “Incident Reporting,” revised 06/2024, showed: - An incident was defined as an unusual event or circumstance not consistent with quality and safe patient care or hospital standards. It included situations that may potentially or actually result in injury, harm or loss to any patient, visitor, employee or any event that results in damage or potential damage of hospital property, patient property or specified employee property. - It was the responsibility of any employee who identified or became aware of a potential or actual problem, error, adverse outcome or injury (regardless of severity) to notify risk management and complete an incident report. In the event that the incident caused harm or caused a patient an adverse outcome, the employee was to notify the Administrator on Call (AOC), Chief Executive Officer (CEO) and DQM immediately. - Examples of events which required an incident report included, but was not limited to, a good catch, near misses, medical treatment problems or complications, procedural treatment problems or complications, equipment or device problems that involved a patient, medication errors, adverse medication events; falls and other patient injuries; diagnostic or testing problems; admission, discharge or transfer problems; leaving against medical advice; fire or environmental hazards; behavioral problems; intravenous (IV, in the vein) transfusion problems (including blood and blood products); sentinel events; damage or loss to patient, hospital or employee property and other incidents that were considered unusual or problem prone. Review of Patient #7’s medical record showed on 10/31/25, she was transported to Hospital D, Acute Care Hospital, for an outpatient procedure without an identification bracelet and a PEG tube that was dislodged and found lying in the sheets. The incident became controversial, and management was called for assistance. Observation on 11/18/25 at 10:53 AM, showed Patient #8 swallowed an unidentified medication found in the bed by the nurse during a wound care dressing change. A second unidentified medication was found under his bed and was discarded in the trash by the nurse. An attempt to identify the medications was not made, a patient assessment was not completed, the physician wasn’t notified, and no incident report was completed. Although requested, no incident reports were provided for Patient #6, #7 or #8 when requested by the survey team on 11/19/25. During an interview on 11/25/25, at 11:54 AM, Staff M, CNO, stated that incident reports should be filed if wound care was not administered as ordered, if there was a patient injury, or if something out of the ordinary occurred. She would have expected an incident report to be completed for Patient #7 and Patient #8. She was unsure what kind of education staff received about how and when to report incidents, but they did receive access to the incident reporting computer application on hire. During an interview on 11/20/25 at 10:18 AM, Staff F, RN, stated that she knew how to complete an incident report, however, it was cumbersome. Staff were often hesitant to complete them. She recalled a coworker that had so much difficulty when they attempted to submit an incident report that they instead emailed Staff M, CNO, directly. An incident report should have been completed for Patient #6 and #7. 50321 51264 51509”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Safely secure medications in patient rooms for four current patients (#8, #10 #14 and #21) and one discharged patient (#12) of 10 patients observed. - Ensure medications were administered at the time they were documented for three current patients (#3, #6 and #8) and one discharged patient (#34) of 10 patients observed or reviewed; - Administer insulin (medication that regulates the amount of sugar in the blood) using a double-check system per policy for one discharged patient (#33) of three patients observed or reviewed; - Administer Time Critical Medications (medications that when administered early or late may cause harm or have a negative impact to the intended therapeutic effect) within 30 of the scheduled time due for three current patients (#2, #3 and #33) and one discharged patient (#34) of six patients observed or reviewed; and - Administer Humalog (a rapid-acting blood-glucose-lowering medication) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for two current patients (#7 and #33) and one discharged patient (#34) of three patients reviewed. Findings included: Review of the hospital’s policy titled, “Drug Storage General,” dated 04/2020, showed all medications were to be stored in a secure area locked in a room, container, or under surveillance. Any patient-specific multiple-dose medications previously dispensed were to be stored in a locked box inside the patient’s room to be accessed only by authorized personnel. Observation on 11/18/25 at 10:53 AM, showed Patient #8 swallowed an unidentified medication found in the bed during a wound care dressing change. During concurrent observation and interview on 11/17/25 at 2:30 PM, showed 10 milliliters (mL) of an unidentified red liquid in a paper medication cup was found unattended near the sink in Patient #10’s room. Patient #10’s mother stated she was unsure what the liquid was, but it had been there for a while. Observation on 11/17/25 at 2:55 PM, showed a needleless syringe labeled Heparin (a medication used as a blood thinner or to prevent blood clots from forming) contained five mL of liquid and was found unattended near the sink in Patient #12’s room. During concurrent interview and observation on 11/18/25 at 8:30 AM, showed insulin was stored in an unlocked cabinet in Patient #14’s room and 30 mL of an unidentified red liquid in a paper medication cup was found unattended on top of the soap dispenser in Patient #14’s room. Staff G, RN, was unsure what the liquid was, or how long it had been there. She planned to ask someone else for help with what to do. Staff G left medications unattended in the hallway on the computer and in the patient’s room on multiple occasions while she gathered supplies. Observation on 11/18/25 at 9:15 AM, showed Staff G, RN, left Patient #21’s medications in a zip lock bag unattended on the computer in the hallway while she gathered supplies. During an interview on 11/25/25 at 11:54 AM, Staff M, Chief Nursing Officer (CNO), stated that any ordered medications were to always be in locked boxes in patient rooms, the locked medication room or with the nurse. Review of the hospital’s policy titled, “Drug Administration General,” dated 06/2024, showed staff were to administer drugs as soon as possible after the dose was prepared. After positively identifying the patient and medication order, the drug should be administered, and staff should observe the patient take the drug. Review of the hospital’s policy titled, “Medication Safety High-Alert Medications,” dated 07/2020, showed a double-check system should be implemented for the nursing service of preparing a dose of insulin. Observation on 11/18/25 at 9:30 AM, showed Staff L, RN, documented the administration of medications to Patient #3 at 9:42 AM, but did not administer the medications until 10:15 AM. Review of Patient #3’s medical record showed on 11/18/25 at 9:42 AM, medications due at 9:00 AM were administered. Observation on 11/18/25 at 9:00 AM, showed Staff L, RN, documented the administration of medications to Patient #6 at 9:05 AM, but did not administer the medications until 9:25 AM. Review of Patient #6’s medical record showed on 11/18/25 at 9:05 AM, medications due at 9:00 AM were administered. Observation on 11/18/25 at 10:53 AM, showed Patient #8 swallowed an unidentified medication found in the bed during a wound care dressing change. Review of Patient #8’s medical record showed on 11/18/25 at 8:38 AM, medications due at 9:00 AM were administered. Review of Patient #34’s medical record showed on 10/30/25 at 1:58 PM, insulin was administered that was due at 12:00 PM. A comment documented, “given on time, no cosigner,” acknowledging the medication was given at a time other than what was documented without a cosigner. During an interview on 11/25/25 at 11:54 AM, Staff M, CNO, stated that medications should be given at the time documented in the medical record. She expected staff to document in the medical record if there was a change in the time the medication was given. The nurse who administered the medication Patient #8 found in his bedding and then swallowed should have ensured he took the medication at the time it was documented. It was not possible to determine what medication was found in Patient #8’s bedding as he swallowed it when he found it during a dressing change, however, it was likely a blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) medication administered earlier that morning. During an interview on 11/20/25 at 3:00 PM, Staff HH, RN, stated that two nurses were required to cosign all insulin administrations. Review of the hospital’s policy titled, “Drug Administration Timing of Administration of Medications,” dated 10/2024, showed Time Critical Medications were medications that might cause harm or have significant negative impacts on the intended therapeutic or pharmacologic effect if not administered within 30 minutes of the scheduled administration time. Examples of time-critical medications included antibiotics administered every six hours or more frequently and mealtime insulin (fast acting insulin taken at mealtimes to manage the rise in blood sugar that occurs after eating). Review of hospital’s incident log, dated 06/01/25 through 11/17/25, showed a total of 162 incidents with 112 documented as medication errors. Review of the hospital’s document titled, “Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) Committee Report,” dated 10/2025, showed: - The goal for antibiotics administered on time was 90%, and the current result was 68.6%. - The goal to administer insulin on time was 90% and the current result was 76%. - The goal for overall time critical medications administered on time was 90%, and the current result was 68.4%. Review of the hospital’s undated document titled, “Pharmacy and Therapeutics Committee Meeting,” showed: - The percentage of antibiotics administered on time was between 61% through 77.6% from quarter four of 2023 to present. - The percentage of fast-acting insulin administered on time was between 70.5% through 82% from quarter four of 2023 to present. - The total percentage of medications given on time over total opportunities was between 67.6% through 76.4% from quarter four of 2023 to present. Review of Patient #2’s medical record showed on 11/18/25 at 9:00 AM, intravenous (IV, in the vein) antibiotic medication was due to be administered. The medication was administered at 11:00 AM. From 09/24/25 through 11/18/25, IV antibiotics were administered more than 30 minutes before or after the scheduled time due five additional times. Review of Patient #3’s medical record showed on 11/18/25 at 9:00 AM, IV antibiotic medication was due to be administered. The medication was administered at 9:42 AM. From 10/29/25 through 11/18/25, IV antibiotics were administered more than 30 minutes before or after the scheduled time due eight additional times. Review of patient #33’s medical record from 10/11/25 through 11/14/25 showed, mealtime insulin was administered more than 30 minutes before or after the scheduled time due 32 times, and IV antibiotics were administered more than 30 minutes before or after the scheduled time due six times. There were six late insulin administrations with comments to explain the late administration. Review of Patient #34’s medical record showed from 10/01/25 through 11/08/25, mealtime insulin was administered more than 30 minutes before or after the scheduled time due 25 times. There were four late insulin administrations with comments to explain the late administration. Observation on 11/18/25 at 9:30 AM, showed Staff L, documented the administration of an IV antibiotic at 9:42 AM for Patient #3. The medication was not administered until 10:15 AM. During concurrent observation and interview on 11/18/25 at 10:19 AM, showed Staff GG, RN, stated that Patient #2’s scheduled IV antibiotic would be late because she could not find an IV pump. She then left to locate an IV pump. During an interview on 11/24/25 at 9:00 AM, Staff V, Chief Executive Officer (CEO), stated that she was aware of the metrics for late Time Critical Medications. The metrics for late medications remained unaddressed and under the goal of 90% for the last two years due to leadership changes. The hospital was working to gather root causes to address the problem. She believed a lack of equipment and delivery of medications to multiple medications rooms contributed to the problem. During an interview on 11/17/25 at 4:30 PM and 11/25/25 at 11:54 AM, Staff M, CNO, stated that medications should be given on time. The hospital was aware of an ongoing problem related to late Time Critical Medication administration. There were several factors that contributed to late antibiotic administration, to include a lack of computers to scan medications, unreasonable timing expectations and delivery of antibiotics to multiple medication rooms throughout the unit. If insulin administration needed to be delayed due to meal timing, she expected nursing staff to document the reason in the medical record. There had been many changes in administration which contributed to the lack of follow through to address the problem. There had also been a recent change to the pharmacy team at the hospital. The previous pharmacist used to provide and follow up on reports for late medications, but she recently left the hospital. The medication errors listed on the incident report were late medications. Although requested, there was no policy related to how soon a blood glucose measurement should be obtained prior to Humalog administration. Review of Patient #7’s medical record showed: - On 11/02/25 at 1:02 AM, three units of Humalog were administered using a blood glucose measurement of 177 obtained on 11/01/25 at 11:05 PM, one hour and 52 minutes prior to administration. - At 12:56 PM, three units of Humalog were administered using a blood glucose of level 160. A blood glucose measurement of 161 was obtained at 12:14 PM, 42 minutes prior to administration. - On 11/04/25 at 6:12 AM, three units of Humalog were administered using a blood glucose of level 167 obtained at 5:39 AM, 33 minutes prior to administration. - On 11/08/25 at 6:13 PM, three units of Humalog were administered using a blood glucose of level 155 obtained at 5:12 PM, one hour and one minute prior to administration. - On 11/09/25 at 5:57 PM, three units of Humalog were administered using a blood glucose of level 155 obtained at 4:58 PM, 59 minutes prior to administration. - On 11/11/25 at 12:53 PM, three units of Humalog were administered using a blood glucose of level 191 obtained at 11:32 M, one hour and 21 minutes prior to administration. - On 11/13/25 at 7:29 PM, three units of Humalog were administered using a blood glucose of level 173 obtained at 4:54 PM, two hours and 35 minutes prior to administration - On 11/14/25 at 12:51 AM, three units of Humalog were administered using a blood glucose of level 177 obtained 12:13 AM, 38 minutes prior to administration. Review of patient #33’s medical record showed: - On 10/12/25 at 11:49 PM, 41 total units of Humalog were administered using a blood glucose measurement of 433 obtained at 11:02 AM, 47 minutes prior to administration. - On 10/13/25 at 8:04 AM, 38 total units of Humalog were administered using a blood glucose measurement of 316 obtained at 6:58 AM, one hour and 6 minutes prior to administration. - At 5:10 PM, 36 total units of Humalog were administered using a blood glucose measurement of 252 obtained at 4:37 PM, 33 minutes prior to administration. - On 10/14/25 at 8:52 AM, six total units of Humalog were administered using a blood glucose measurement of 151 obtained at 7:17 AM, one hour and 35 minutes prior to administration. - On 10/16/25 at 8:31 AM, six total units of Humalog were administered using a blood glucose measurement of 151 obtained at 6:48 AM, one hour and 43 minutes prior to administration. - On 10/18/25 at 8:11 AM, 25 total units of Humalog were administered using a blood glucose measurement of 290 obtained at 7:37 AM, one hour and 34 minutes prior to administration. - At 12:29 PM, 31 total units of Humalog were administered using a blood glucose measurement of 240 obtained at 11:52 AM, one hour and 37 minutes prior to administration. - On 10/20/25 at 1:20 PM, 40 total units of Humalog were administered using a blood glucose measurement of 152 obtained at 11:02 AM, two hours and 18 minutes prior to administration. - At 5:19 PM, 42 total units of Humalog were administered using a blood glucose measurement of 241 obtained at 4:31 PM, 48 minutes prior to administration. - On 10/21/25 at 8:20 AM, 48 total units of Humalog were administered using a blood glucose measurement of 350 obtained at 7:25 AM, 55 minutes prior to administration. - On 10/22/25 at 12:09 PM, 42 total units of Humalog were administered using a blood glucose measurement of 240 obtained at 11:11 AM, 58 minutes prior to administration. - On 10/23/25 at 8:31 AM, 40 total units of Humalog were administered using a blood glucose measurement of 240 obtained at 7:28 AM, one hour and three minutes prior to administration. - At 12:29 PM, 40 total units of Humalog were administered using a blood glucose measurement of 240 obtained at 11:39 AM, one hour and 50 minutes prior to administration. - On 10/24/25 at 9:18 PM, 48 total units of Humalog were administered using a blood glucose measurement of 305 obtained at 8:08 AM, one hour and 10 minutes prior to administration. - On 10/27/25 at 8:15 AM, 10 total units of Humalog were administered using a blood glucose measurement of 223 obtained at 7:44 AM, 31 minutes prior to administration. - On 10/28/25 at 9:33 AM, 36 total units of Humalog were administered using a blood glucose measurement of 142 obtained at 8:15 AM, one hour and 18 minutes prior to administration. - At 6:29 PM, 30 total units of Humalog were administered using a blood glucose measurement of 80 obtained at 4:21 PM, two hours and eight minutes prior to administration. - On 10/29/25 at 8:43 AM, 10 total units of Humalog were administered using a blood glucose measurement of 288 obtained at 7:04 AM, one hour and 39 minutes prior to administration. - On 10/31/25 at 12:14 PM, 40 total units of Humalog were administered using a blood glucose measurement of 187 obtained at 11:14 AM, one hour prior to administration. - On 11/01/25 at 8:27 AM, 46 total units of Humalog were administered using a blood glucose measurement of 265 obtained at 7:47 AM, 40 minutes prior to administration. - On 11/03/25 at 9:03 AM, 40 total units of Humalog were administered using a blood glucose measurement of 165 obtained at 6:33 AM, two hours and 30 minutes prior to administration. - At 5:08 PM, 30 total units of Humalog were administered using a blood glucose of 112 obtained at 4:17 PM, 51 minutes prior to administration. - On 11/04/25 at 8:43 AM, 34 total units of Humalog were administered using a blood glucose measurement of 171 obtained at 7:11 AM, one hour and 32 minutes prior to administration. - At 2:10 PM, she had a blood glucose measurement of 59. A recheck blood glucose measurement at 2:51 PM was 107. - At 5:56 PM, 34 total units of Humalog were administered using a blood glucose of 165 obtained at 4:17 PM, one hour and 39 minutes prior to administration. - On 11/05/25 at 8:57 AM, 34 total units of Humalog were administered using a blood glucose measurement of 186 obtained at 7:05 AM, one hour and 52 minutes prior to administration. - At 12:04 PM, 29 total units of Humalog were administered using a blood glucose measurement of 182 obtained at 11:22 AM, 42 minutes prior to administration. - On 11/06/25 at 8:10 AM, 29 total units of Humalog were administered using a blood glucose of 186 obtained at 6:55 AM, one hour and 15 minutes prior to administration. - At 12:38 PM, 25 total units of Humalog were administered using a blood glucose of 166 obtained at 11:39 AM, 50 minutes prior to administration. - At 5:48 PM, 31 total units of Humalog were administered using a blood glucose measurement of 156 obtained at 4:34 PM, one hour and 14 minutes prior to administration. - On 11/07/25 at 8:18 AM, four total units of Humalog were administered using a blood glucose measurement of 190 obtained at 7:45 AM, 33 minutes prior to administration. - At 8:23 AM, 29 total units of Humalog were administered using a blood glucose measurement of 190 obtained at 7:45 AM, 38 minutes prior to administration. - At 5:36 PM, 35 total units of Humalog were administered using a blood glucose measurement of 229 obtained at 4:32 PM, one hour and four minutes prior to administration. - On 11/08/25 at 9:10 AM, 29 total units of Humalog were administered using a blood glucose measurement of 190 obtained at 7:42 AM, one hour and 28 minutes prior to administration. - At 5:34 PM, 25 total units of Humalog were administered using a blood glucose measurement of 105 obtained at 5:00 PM, 34 minutes prior to administration. - On 11/09/25 at 9:14 AM, 4 total units of Humalog were administered using a blood glucose measurement of 196 obtained at 7:52 AM, one hour and 22 minutes prior to administration. - At 9:21 AM, 25 total units of Humalog were administered using a blood glucose measurement of 196 obtained at 7:52 AM, one hour and 29 minutes prior to administration. - On 11/10/25 at 9:00 AM, 31 total units of Humalog were administered using a blood glucose measurement of 223 obtained at 7:37 AM, one hour and 23 minutes prior to administration. - At 12:41 PM, 29 total units of Humalog were administered using a blood glucose measurement of 157 obtained at 11:50 AM, 51 minutes prior to administration. - On 11/12/25 at 8:16 AM, 29 total units of Humalog were administered using a blood glucose measurement of 187 obtained at 7:45 AM, 31 minutes prior to administration. - On 11/13/25 at 8:40 AM, four total units of Humalog were administered using a blood glucose measurement of 169 obtained at 7:59 AM, 41 minutes prior to administration. - At 9:32 AM, 40 total units of Humalog were administered using a blood glucose measurement of 169 obtained at 7:59 AM, one hour and 33 minutes prior to administration. Review of Patient #34’s medical record showed: - On 11/02/25 at 10:04 AM, six total units of Humalog were administered using a blood glucose measurement of 120 obtained at 7:28 AM, two hours and 36 minutes prior to administration. - At 1:05 PM, six total units of Humalog were administered using a blood glucose measurement of 150 obtained at 11:49 AM, one hour and 16 minutes prior to administration. - On 11/03/25 at 8:36 AM, six total units of Humalog were administered using a blood glucose measurement of 113 obtained at 6:23 AM, two hours and 13 minutes prior to administration. - At 11:43 AM, six total units of Humalog were administered using a blood glucose measurement of 148 obtained at 11:09 AM, 34 minutes prior to administration. - On 11/04/25 at 9:00 AM, six total units of Humalog were administered using a blood glucose measurement of 104 obtained at 7:03 AM, one hour and 57 minutes prior to administration. - On 11/05/25 at 8:33 AM, six total units of Humalog were administered using a blood glucose measurement of 100 obtained at 7:00 AM, one hour and 33 minutes prior to administration. - At 12:01 PM, eight total units of Humalog were administered using a blood glucose measurement of 238 obtained at 11:19 AM, 49 minutes prior to administration. - On 11/06/25 at 9:14 AM, six total units of Humalog were administered using a blood glucose measurement of 115 obtained at 7:03 AM, two hours and 11 minutes prior to administration. - At 5:48 PM, five total units of Humalog were administered using a blood glucose measurement of 101 obtained at 4:36 PM, one hour and 12 minutes prior to administration. - On 11/07/25 at 12:22 PM, seven total units of Humalog were administered using a blood glucose measurement of 216 obtained at 11:47 AM, 35 minutes prior to administration. - At 5:18 PM, five total units of Humalog were administered using a blood glucose measurement of 170 obtained at 4:35 PM, 43 minutes prior to administration. During an interview on 11/25/25 at 11:54 AM, Staff M, CNO, stated that she was unsure what the policy stated, but she expected a glucose measurement to be checked within 30 minutes of Humalog administration. She found it disappointing and unacceptable for blood glucose measurements taken multiple hours prior to the administration of Humalog to be used. That was a nursing responsibility, and she was working on education for all staff related to insulin administration timing. She was aware Patient #33 received large amounts of Humalog but was sure she had never been hypoglycemic (low blood sugar). During an interview on 11/20/25 at 3:00 PM, Staff HH, RN, stated that she would ensure a blood glucose measurement was obtained within 30 minutes of the administration of Humalog. She was unsure what the policy stated, but it would not be safe to administer Humalog using a blood glucose measurement obtained hours earlier. She would check a blood glucose measurement again if a nurse technician obtained the blood glucose measurement too early. 50321 51509”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44536 Based on interview, record review and policy review, the hospital failed to protect and promote patient’s rights when the hospital failed to: - Follow their policy to keep a log of patient complaints/grievances for one current patient (#12) and one discharged patient (#14) of two patients reviewed; - Provide a timely written response to patients and patient representatives after submission of a grievance for one current patient (#12) and one discharged patient (#14) of two patients reviewed; - Investigate multiple medication errors including controlled substances (drugs or medications that are high risk for personal consumption or abuse) for seven patients (#10, #12, #19, #25, #26, #27, and #28) of 12 patients reviewed; - Recognize, report, and investigate patient complaints of possible injury/incidents for three patients (#1, #10, and #15) of three patients reviewed; and - Safeguard Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) for five patients (#1, #6, #8, #16, and #22) out of eight patients observed. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). The hospital submitted a document to abate the IJ on 11/18/24 to provide an acceptable plan of correction to prevent further risk to patients. A second IJ was identified and the hospital submitted a second document to abate the IJ on 11/20/24 to provide an acceptable plan of correction to prevent further risk to patients. Please refer to A-0122, A-0123, A-0144, A-0145 and A-0146.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 44536 Based on interview, record review and policy review, the hospital failed to adequately analyze the causes, investigate, and implement actions as part of their Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program, to prevent potential patient injury and address multiple medication errors and prevent potential diversion and misuse of controlled substances. These failures had the potential to adversely affect the quality of care, safety, and care outcomes of all patients in the hospital. The severity and cumulative effects of these systemic practices resulted in the hospital’s non-compliance with 42 CFR 482.21 Condition of Participation: QAPI Program and resulted in the hospital’s failure to ensure quality health care and safety. Please refer to A-0286.”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to ensure that staff followed the hospital policies when they failed to: - Provide appropriate hygiene for five current patients (#1, #2, #15, #17, and #18) out of six patients reviewed; - Appropriately turn and reposition six current patients (#1, #2, #5, #12, #16, and #17) out of 10 patients reviewed; - Appropriately provide and document pain assessments for two current patients (#12 and #15) and two discharged patients (#25 and #28) out of 11 patients reviewed; - Appropriately provide and document nursing assessments for two current patients (#12 and #16) and one discharged patient (#25) out of 13 patients reviewed; - Appropriately date, time and initial all intravenous (IV, in the vein) catheters sites and lines for six current patients (#1, #2, #5, #8, and #11) out of 13 patients reviewed; and - Ensure two nursing personnel (Staff J and Staff Z) of four nursing personnel records reviewed, completed orientation and education prior to providing patient care. - Administer and document medications appropriately for seven patients (#10, #12, #19, #25, #26, #27 and #28) of 12 patients reviewed. The severity and cumulative effects of these failures resulted in the hospitals non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services and resulted in the hospital’s failure to ensure quality healthcare and safety. Please refer to A-0395, A-0398, and A-0405.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 44536 Based on observation, interview, record review and policy review, the hospital failed to ensure patient medications were properly secured and labeled with a patient identifier. Due to the potential risk and harm to all patients this resulted in the non-compliance with §42 CFR 482.25 Condition of Participation: Pharmaceutical Services. Please refer to A-0502.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 44536 Based on interview, document review and policy review, the hospital failed to follow their policy to keep a log of patient complaints/grievances for one current patient (#12) and one discharged patient (#14) of two patients reviewed. These failures had the potential for harm when care or safety concerns from patients or patients’ representatives were not addressed after brought to the attention of hospital staff. Finding included: Review of hospital policy titled, “Patient Complaints and Grievances,” reviewed 02/2023, showed the following: - The purpose of the policy was to provide a consistent process for addressing patient and/or patient’s representatives complaints and grievances. - A complaint was an expression of dissatisfaction brought to the attention of personnel. A grievance was a formal or informal written or verbal grievance that is made to the hospital by a patient, or the patient’s representative regarding the patient’s care. A complaint is considered a grievance if received in writing or if the patient’s representative requests their complaint handled as a formal grievance. - All complaints and grievances will be logged for tracking purposes. The hospital keeps and maintains a grievance log and written documentation and all responses and correspondences. On 11/12/24 the survey team requested items for investigation including a list of all complaints and grievances submitted to the hospital from 11/01/23 through 12/31/23 and from 05/01/24 through 11/12/24. The hospital could not provide a list of complaints and grievances from 2023. On 11/18/24 the hospital submitted a document titled, “Landmark Hospital 2024 Grievance/Complaint Log,”. The log consisted of one hand-written page and one typed page. Patient #12’s complaint was listed on both pages of the documents. The typed page showed Patient #12 submitted a verbal complaint on 09/13/24. A hand-written page showed Patient #12 submitted a written grievance on 09/13/24. The hand-written page also showed a verbal grievance submitted by Patient #14 on 06/11/24. Review of the hospital’s document titled, “Quality Assessment and Process Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety),” dated 10/31/24, showed there were no complaints or grievances submitted during the third quarter of 2024. Review of the hospital’s document titled, “QAPI,” dated 07/31/24, showed there were no complaints or grievances submitted in June 2024. During an interview on 11/18/24 at 1:15 PM, Staff C, CEO, stated that he was not able to locate the list of patient grievances/complaints previously recorded.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44536 Based on interview, document review and policy review, the hospital failed to provide a timely written response to patients and patient representatives after submission of a grievance for one current patient (#12) and one discharged patient (#14) of two patients reviewed. These failures had the potential for Patients and Patients’ Representatives perception their concerns were not investigated or fairly evaluated. Findings included: Review of hospital policy titled, “Patient Complaints and Grievances,” revised 02/2023, showed the following: - A complaint was an expression of dissatisfaction brought to the attention of personnel. A grievance was a formal or informal written or verbal grievance that is made to the hospital by a patient, or the patient’s representative regarding the patient’s care. A complaint is considered a grievance if received in writing or if the patient’s representative requests their complaint handled as a formal grievance. - Within seven days of receipt of a grievance, the hospital will review, investigate, and reconcile the issue or provide an acknowledgement letter to the patient or patient’s representative. If more than 30 days is needed to investigate the grievance, a letter will be sent notifying the patient or patient’s representative of the delay and include an anticipated date of completion. Unless complex issues were involved in investigation of the grievance, patient grievances should be resolved within 30 days of notification to the Risk Management. - Letters will be sent from the Directory of Quality and Risk Management and will include confirmation of receipt of the grievance; steps taken to investigate; results of the grievance process, date of 30 days completion; or if additional time is needed, an expected timeframe of the next response from the hospital; and the name and contact information for risk management. On 11/12/24 the survey team provided the hospital with a list of requested items including a list of all complaints and grievances submitted to the hospital from 05/01/24 through 11/12/24. On 11/18/24 the hospital submitted a document titled, “Landmark Hospital 2024 Grievance/Complaint Log,”. The log showed Patient #12 submitted a verbal complaint on 09/13/24 with no written response required marked on the form and the complaint was resolved on 09/13/24 after a meeting with Patient #12’s spouse. The log also showed Patient #12 submitted a written grievance on 09/13/24 and that a written response was required. The hand-written page also showed a verbal grievance was submitted by Patient #14 on 06/11/24. Review of the hospital-provided documents associated with a grievance submitted by Patient #12’s spouse showed a document marked “Received via Fax 09/13 and meeting occurred on 09/13.” The document was a letter with three grievances presented to hospital administration from Patient #12’s husband. A letter on Landmark Hospital Letterhead, dated 11/18/24, showed Staff C, Chief Executive Officer (CEO) wrote a final response to Patient #12’s husband summarizing a meeting held on 09/13/24 with the husband; Staff C; Case Management; Staff E, Chief Clinical Officer (CCO); and Staff F in attendance. Review of a hospital-provided letter on Landmark Hospital Letterhead, dated 11/18/24, showed Staff C, CEO wrote to Patient #14 summarizing a meeting held on 06/11/24 with the patient, his wife, the CEO, and Case Management in attendance regarding the patient’s displeasure with being discharged from the hospital on that date. During an interview on 11/18/24 at 1:15 PM, Staff C, CEO, stated meetings with Patient #12 and #14 had occurred immediately after their grievances were voiced, but written documentation of the investigation or outcome was not mailed to the patients or families until 11/18/24.”

“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: 44536 Based on interview, record review and policy review, the hospital failed to investigate multiple medication errors including controlled substances (drugs or medications that are high risk for personal consumption or abuse) for seven patients (#10, #12, #19, #25, #26, #27, and #28) of 12 patients reviewed. These failures had the potential to affect all patients receiving care in the hospital. Findings included: Review of the hospital’s policy titled “Controlled Drugs Administration,” effective 10/2021, showed the following: - Administration of controlled drugs should be recorded on the MAR. - The medical record must include the date and time of administration to the patient; quantity of the drug issued, administered, wasted, or returned; signature of the person who administered the drug; and signature of a witness to waste. - The disposition of the remainder of a controlled drug must be documented as wasted or destroyed and cosigned by a licensed person. - The pharmacist should reconcile the amount of controlled substance on hand and compare with the patient records. - The pharmacy should review a daily report of all controlled substance transactions from the automated dispensing machine (ADM) and confirm that all discrepancies have been resolved, overrides approved, and documentation completed. - The person responsible for the incorrect or incomplete entry of drug administration should be required to make an entry or correction. If necessary, the supervisor-in-charge should make the MAR available to the responsible person. Review of hospital’s document titled, “Incident and Accidents,” dated 05/01/24 through 11/12/24, showed from 08/01/24 through 11/12/24 a total of 98 incidents with 84 of the incidents documented as medication errors. Review of the hospital-provided incident report, dated 11/11/24, showed Staff F, Pharmacy Director, documented a medication error where Tramadol (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg was removed from the ADM for Patient #10 on 11/09/24 at 4:51 PM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the hospital-provided incident report dated 09/03/24 showed Staff F, Pharmacy Director, documented a medication error where lorazepam (a medication used to treat anxiety or sleep difficulty) one mg tablet was removed for Patient #12 from the ADM on 09/02/24 at 5:19 PM. The medication was not documented as administered on the Patient #12’s MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of an incident report dated 11/07/24 showed Staff F, Pharmacy Director, documented a medication error where oxycodone-acetaminophen (synthetic pain medication with a high risk for misuse) 5/325 mg tablet for Patient #12 from the ADM on 11/05/24 at 6:18 PM. The medication was documented as administered at 6:15 PM and the administration signed at 6:35 PM. Review of the hospital-provided incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error where lorazepam two mg was removed and administered to Patient #19 on 10/19/24 at 7:06 AM. There was not an active order for the medication for Patient #19, however staff were able to remove the medication without an over-ride because a previous one-time order from the previous day was still active. Review of the hospital-provided incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error where oxycodone five mg was removed from the ADM for Patient #25 on 10/17/24 at 10:29 AM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the hospital-provided incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error where methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction) tablets were removed from the ADM for Patient #26 on 10/16/24 at 10:23 AM. The medication was documented as administered in the MAR at 9:25 AM. Review of the hospital-provided incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error where methadone tablets were removed from the ADM for Patient #26 on 10/17/24 at 11:09 AM. The medication was documented as administered in the MAR at 9:13 AM and signed by the nurse at 11:14 AM. The incident report also showed Patient #26 was given a hydromorphone (a potent opioid analgesic drug) injection at 11:13 AM, the administration was signed at 11:56 AM and the hydromorphone was removed from the ADM at 11:20 AM. Review of the incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed hydromorphone two mg from the ADM for Patient #26 on 10/18/24 at 12:30 PM. The medication was not documented as administered in the MAR. A waste for one mg of hydromorphone was completed at 1:10 PM, leaving one mg of the hydromorphone unaccounted for. Review of the incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed morphine 4 mg from the ADM for Patient #27 on 10/16/24 at 2:17 PM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the hospital-provided incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error where lorazepam two mg was removed and administered to Patient #28 on 10/20/24 at 7:48 AM. There was not an active order for the medication for Patient #28. During an interview on 11/19/24 at 4:05 PM and on 11/21/24 at 8:15 AM, Staff F, Pharmacy Director, stated that she did not believe that the hospital was addressing medication errors. She did not believe that the errors were related to diversion of controlled substances, but a result of negligent documentation by nursing personnel. Medication errors were presented to the Chief Clinical Officer (CCO) in the form of incident reports and for the past month she had also included the Director of Quality Management (DQM) from the hospital’s corporate office. Over the previous six months the number of patients, as well as the number of new staff had increased; and the number of medication errors also increased. During interviews on 11/20/24 at 8:55 AM and 11/21/24 at 11:55 AM, Staff E, CCO, stated that he was aware of the number of medication errors identified and had developed a document to track the reports to identify trends. Staff E stated that some errors showed controlled substances pulled from the ADMs and were never documented as given to the patient. He did not follow-up the investigation of an unaccounted controlled substance with patient interview or review of pain documentation; but did not believe that the medications were being diverted by the nurses. He felt that the number of medication errors would improve because he talked with each nurse face-to-face. During an interview on 11/20/24 at 10:00 AM, Staff C, Chief Executive Officer (CEO), stated that he was aware of a problem with medication errors, but not the volume of the errors. The corporate office saw and signed off on all incident reports and therefore they were also aware of the number of incident reports identified as medication errors. The medication errors were presented during a weekly meeting of audits by each department because of incident reports and the categorization of the event being identified as medication errors. Staff C was not aware if nursing staff were aware of the number of medication errors identified. 47504”

“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: 44536 Based on interview, record review and policy review, the hospital failed to recognize, report, and investigate patient complaints of possible injury/incidents for three patients (#1, #10, and #15) of three patients reviewed. This failure had the potential to affect the safety of all patients in the hospital. Findings included: Review of the hospital’s policy titled, “Patient Rights and Responsibilities,” revised 08/2019, showed the following: - Patients have the right to receive safe, quality care delivered by skilled staff with high professional standards. - Patients have the right to receive care in a setting that is safe and free from any form of abuse or neglect. - Patients have the right to receive proper assessment and management of pain. - Patients have a right to expect a timely response from the hospital related to any complaint. Review of hospital policy titled, “Incident Reporting,” revised 06/24, showed: - An incident was defined as an unusual event or circumstance not consistent with quality and safe patient care or hospital standards. - Situations were included that may potentially or actually result in injury, harm, or loss to any patient. - Events for incident reporting include a medical treatment problem or complication, an equipment/device problem involving a patient, falls and other patient injuries, and other incidents that are considered unusual or problem prone. Review of hospital policy titled, “Patient Events,” revised on 06/2024, showed upon receipt of an incident report or knowledge of an adverse event, the risk manager would review and investigate the incident to determine if a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) is indicated. The gathering of information, data collecting, investigation and interviews should be started within 72-96 hours after notification of the event. On 11/13/24 at 10:30 AM, incident and investigation reports were requested for Patient #1 and Patient #10 regarding safety concerns reported to hospital staff by the patients and their families. No incident reports were available. On 11/14/24 at 8:15 AM, the survey team was presented with incident reports dated 11/13/24 regarding the reported events. Review of the medical record for Patient #1, showed: - She was admitted on 10/15/24 for acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) and acute chronic physical (a condition of the body) debility (physical weakness as a result of illness) requiring therapy for rehabilitation (the action of restoring someone to health or normal life through training and therapy.) - On 11/09/24 at 11:11 AM the primary care physician documented a progress note. Patient #1 was awake, alert, and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) with mild pitting edema (swelling caused by fluid building up in the body’s tissues and organs, which can leave a temporary dent in the skin when pressure is applied) to extremities and ace wraps on both legs. - On 11/10/24 at 9:24 a nursing assessment showed Patient #1 reported pain in her left foot and stated that her toe was broken during a transfer the previous day. The nurse reported no bruising, redness or swelling. Her psychosocial assessment showed the patient’s memory was intact. Her musculoskeletal assessment showed patient transfers were completed by a patient lift. - On 11/10/24 at 9:37 AM a primary care physician progress note showed Patient #1 reported pain in her left big toe and she thought she hit the toe against metal while lifted with the patient lift. She did not want to get out of her bed and into the chair because of the pain. The physician documented that he ordered x-rays of the left foot. - On 11/10/24 at 12:42 PM a nursing note showed the patient reported that her pain was in her right foot and not in her left foot and that there was obvious injury to her right foot. The nurse documented that both feet were swollen, red and that the left toe looked worse than the right. - On 11/10/24 at 9:28 AM the primary care physician entered an order for x-rays of the left foot but then changed the order to the right foot on 11/10/24 at 1:50 PM. - A radiology report showed an x-ray was completed of Patient #1’s left foot on 11/10/24 at 9:45 AM, but the findings were documented for the right foot and showed degenerative changes of the first toe, demineralization of bones and degenerative changes of the midfoot. No fracture was identified. - On 11/10/24 at 1:30 PM, a pain scale assessment was documented for right foot pain rated at seven on a pain scale of zero to 10. - On 11/11/24 at 12:29 AM, a nursing assessment showed Patient #1 reported pain in her right toe following a patient lift transfer two days prior. Assessment of the toe did not show redness or bruising but was tender to the touch. An x-ray had been ordered and completed and the patient was started on pain medication. - On 11/11/24 at 10:37 PM, a pain scale assessment was documented for right foot pain rated at eight on a pain scale of zero to 10. - There was no other documentation in nursing notes regarding an incident involving a patient lift. - There was no incident report or investigation that occurred until identified by the survey team. Review of the incident report for Patient #1, dated 11/13/24, showed a complaint regarding an event that occurred on 11/09/24 at approximately 12:00 PM. The incident description showed Patient #1 told the nurse that she thought she broke a toe on her left foot, and later reported the injury occurred to her right foot, the previous day while being transferred using a patient lift. The patient care technician (PCT) who cared for the patient on 11/09/24 reported that the patient was not transferred using the patient lift during that shift. The incident report showed that the physician ordered x-rays (a test that creates pictures of the structures inside the body-particularly bones) of the foot following the patient’s reported injury and no injury was identified. During an interview on 11/12/24 at 3:30 PM, Patient #1, stated that on 11/09/24, the PCTs were using the patient lift to transfer her and did not have her correctly in the sling. Her feet were swinging around when her right foot hit the metal piece of the patient lift. She complained of pain and reported it to the nurse. The following day she reported it to the physician. She stated that her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) had been at an eight to nine on a pain scale of zero to ten consistently since it happened. An x-ray was done on her foot with no findings. No one from hospital administration came to discuss the incident with her. Record review of Patient #10’s medical record, showed: - She was a 78-year-old admitted on 11/07/24 for methicillin-susceptible staphylococcus aureus, (MSSA, a type of bacterial infection caused by staph bacteria.) bacteremia (bacteria in the bloodstream) with multi valve endocarditis (infection to the heart’s inner lining) requiring intravenous (IV, in the vein) antibiotic therapy. - On 11/08/24 at 10:00 AM, a nursing assessment showed Patient #10 was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time), complained of sternal pain and back pain. The patient had mild intermittent confusion at times. She was incontinent with use of an external urinary suction catheter. Her mobility was limited and was chairfast. - On 11/10/24 at 8:30 PM, a nursing assessment by Staff HH, Registered Nurse (RN), showed Patient #10 was A&Ox3 and her behavior was appropriate to situation. She was incontinent with use of external urinary suction catheter and requested to use the bed pan only to void. - On 11/10/24 at 10:00 PM, Staff HH documented Patient #10 was A&Ox3, and needed assistance with toileting. - On 11/11/24 at 2:34 PM, documentation showed that Staff NN, Physician, documented Patient #10 had a bad experience last night when she was on the bedpan and had suctioning from the external urinary suction catheter which irritated her buttocks/perianal region. She thought the nurse did not listen to her complaints. She was awake, alert, and cooperative with examination and answered questions appropriately. - There was no documentation on 11/10/24 of a problem with the external urinary suction catheter. Review of the incident report for Patient #10, dated 11/13/24, showed a complaint regarding an event that occurred on 11/10/24 at 11:00 PM. The incident description showed Patient #10 complained of irritation caused by an external urinary suction catheter. Staff K, Advanced Practice Registered Nurse (APRN, a nurse with advanced clinical education and training), met with the patient on 11/13/24. Patient #10 stated that she needed to urinate and did not want to use the bedside commode due to pain from her recent surgeries. She stated that the nurse placed a “suction tube” in her perianal region and that she was also placed on the bedpan. She stated that it felt like the bedpan formed a suction seal to her buttocks but realized that she could feel the suction tube applying suction to her perianal area while she was urinating. She stated this caused her irritation. Per nursing documentation, the patient did not have any perianal wounds and did not complain of pain in the area since that incident. It was unknown if the nurse in question placed the external urinary suction catheter incorrectly. Education of proper external urinary suction catheter would be provided to the nurse. During an interview on 11/13/24 at 10:30 AM, Staff A, Quality Management Director (DQM), stated she did not have an incident report for Patient #10 regarding an external urinary suction catheter. During an interview on 11/13/24 at 10:50 AM, Staff E, Chief Clinical Officer (CCO), stated that he was not aware of any incident regarding the use of an external urinary suction catheter with Patient #10. During an interview on 11/13/24 at 11:40 AM, Staff K, APRN, was not aware of any incident and asked for details regarding the external urinary suction catheter incident that was reported to the survey team. During an interview on 11/13/24 at 12:30 PM, Staff C, Chief Executive Officer (CEO), stated that he was not aware of any incident regarding an external urinary suction catheter. During an interview on 11/25/24 at 7:00 PM, Staff HH, RN, stated she did not put an external urinary suction catheter on Patient #10. She stated “That is not my job, that is the tech’s job. I have no idea how to even put one on.” She stated that Patient #10 never made any complaint to her regarding the use of the external urinary suction catheter. She stated that Patient #10 was confused most of the time. Staff HH stated that she had not received any education regarding the use of the external urinary suction catheter. She was not aware of the incident reporting policy. She stated that the PCT had to be the one to put the external urinary suction catheter on Patient #10. She stated that she had an assigned PCT that night but did not recall who it was. Review of Patient #15’s medical record showed the following: - He was admitted on 10/21/24 for hypoxic respiratory failure, tracheostomy (an opening created in the neck in order to place a tube into a person’s windpipe that allows air to enter the lungs) care/weaning and oxygen titration, and underlying tetraplegia (a medical condition that causes partial or total loss of function in the torso and all four limbs). - On 10/26/24 at 8:44 AM, documentation showed the tracheostomy was secured in place. - On 10/26/24 at 10:16 AM, nursing documentation showed a respiratory therapist (RT) responded to Patient #15’s room around 9:15 AM due to oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%) alarms showing a low value. RT called out for assistance because the patient had been decannulated (the process by which a tracheostomy tube is removed). - Staff GG, RN, responded to Patient #15’s room. His eyes were open, but he was not responding to voice or pain stimulation. His pupils appeared to be unequal with sluggish response and he was not following commands, tracking, or speaking. Vital signs were normal. The charge nurse (CN) was notified. The on-call APRN ordered Patient #15 transferred to Hospital B (nearby acute care hospital) for evaluation. RT notified family that he was being sent to Hospital B. The CN called Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and report was called to Hospital B’s Emergency Department (ED). - Patient returned to Landmark Hospital on 11/05/24 for continued care. Review of Patient #15’s medical record from Hospital B, dated 10/26/24, showed he was a 33-year-old who presented to the ED on 10/26/24 after being found unresponsive at Landmark Hospital. He was reportedly found on the ground, decannulated, and his oxygen saturation was in the 80s. The trach was put back in place and he was transported to the ED. He was admitted to the Medical Intensive Care Unit (MICU) for further care. On 11/18/24 at 11:30 AM, incident and investigation reports were requested for Patient #15 regarding a safety concern reported to hospital staff by his family on 10/27/24. No incident report was available. During an interview on 11/14/24 at 9:50 AM, Patient #15’s family stated that when he was transferred to Hospital B, the documentation showed he was found on the floor at Landmark Hospital. She returned to Landmark Hospital the day after Patient #15 was transferred to get some of his belongings. She spoke with a nurse and made a complaint that she was not notified that her brother had fell and was found on the floor. She stated that the nurse told her that he was not found on the floor and that the documentation from Hospital B’s ED was incorrect. She asked if the survey team could investigate the fall. She stated that no one from Landmark had contacted her regarding the incident after she told the nurse her concern. During an interview on 11/19/24 at 2:00 PM, Staff GG, RN, stated that Patient #15 was not found on the floor. He was found unresponsive, it happened very fast, he decannulated. RT responded to an alarm and called for the nurse. She went in to assist. She notified the physician of the incident and then called EMS to transfer the patient to the ED at Hospital B for an evaluation. She did call the ED and gave report but did not report he was found on the floor. She stated Patient #15’s sister approached her the day following his transfer and asked her how he ended up on the floor. She told her that it was not a true statement, and that Patient #15 could not move himself out of a bed. She did call the hospital and attempted to get the note taken out of the medical record. She did not fill out an incident report as she thought she had taken care of the problem. “If I can take care of a complaint, I will just take care of it. If I can’t, I would call the CN to come to speak with the patient.” During an interview on 11/19/24 at 2:30 PM, Staff EE, RT, responded to an alarm for Patient #15. She stated his oxygen level was 88-89% and that his tracheostomy was laying on his chest. He was unresponsive and she called the nurse. He was found laying in his bed on his back. The CN called Staff K, APRN, and a decision was made to send him to the ED at Hospital B for an evaluation. She stated that Staff K did come and ask if he was found on the floor, and she told her that he was found in the bed. During an interview on 11/19/24 at 3:30 PM, Staff K, APRN, stated she was on-call the night Patient #15 was sent to the ED at Hospital B. He was not on the floor, there was no way he could get there on his own. She had heard that his sister asked if he fell out of the bed so she reviewed his chart and asked the staff that was on duty that night if he was found on the floor. She stated that the information Hospital B documented was incorrect. During an interview on 11/19/24 at 2:35 PM, Staff CC, CN, stated that over the previous six months there had been several new clinical staff added and new leadership. Nursing had received recent training regarding the process of patient and family complaints and incident reports. During interviews on 11/20/24 at 8:55 AM and on 11/21/24 at 11:55 AM, Staff E, CCO, stated his expectation from staff was to follow the policy for patient complaints and it was the nurse’s responsibility to ensure that an incident report was entered. He stated that it was his expectation that staff forwarded patient and family complaints and all incidents to administration.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 47504 Based upon observation, interview and policy review, the hospital failed to safeguard Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) for five patients (#1, #6, #8, #16, and #22) out of eight patients observed. This failure had the potential to affect the confidentiality of all patients in the hospital. Findings included: Review of the hospital’s policy titled, “Patient Rights and Responsibilities,” revised 08/2019, showed patients have a right to every consideration of privacy, including personal needs. This also means that care discussion, consultation, examination, and treatment will be conducted to protect the patient’s privacy. Patients have a right to expect all written communications and records about treatment be treated as strictly confidential except in certain cases permitted or required by law (i.e. suspected abuse, public health hazards). This includes written notices that explains how personal health information will be used and shared with other health care professionals involved in the patients care. Review of the hospital’s policy titled, “Confidentiality of Patient Information,” revised 11/2022, showed patient specific medical information should not appear anywhere that can be accessed by other patients or visitors. Patients have the right to have their medical record read only by individuals directly involved in their treatment or the monitoring of quality and by other individuals only on their written authorization. Observation on 11/13/24 at 11:43 AM, showed Staff R, Patient Care Technician (PCT), left a computer monitor unattended outside of Patient #1’s room. The computer monitor faced the hallway and left patient information (names, medications, diagnosis) visible to staff and visitors not involved in the patient’s care. Observation on 11/13/24 at 12:05 PM, showed Staff MM, Registered Nurse (RN), left a computer monitor unattended outside of Patient #1’s room. The computer monitor faced the hallway and left patient information visible to staff and visitors not involved in the patient’s care. Observation on 11/14/24 at 9:15 AM, showed Staff L, RN, left a computer monitor unattended outside of Patient #6’s room. The computer monitor faced the hallway and left patient information visible to staff and visitors not involved in the patient’s care. Observation on 11/13/24 at 9:10 AM, showed Staff M, RN, left a computer monitor unattended in the hallway outside of Patient #8’s room. The computer monitor faced the hallway and left patient information visible to staff and visitors not involved in the patient’s care. Observation on 11/14/24 at 9:28 AM, showed Staff Y, RN, left a computer monitor unattended outside of Patient #16’s room. The computer monitor faced the hallway and left patient information visible to staff and visitors not involved in the patient’s care. Observation on 11/14/24 at 08:15 AM, showed Staff W, RN, left a computer monitor unattended outside of Patient #22’s room. The computer monitor faced the hallway and left patient information visible to staff and visitors not involved in the patient’s care. During an interview on 11/20/24 at 8:55 AM, Staff E, Chief of Clinical Operations (CCO) stated that computer monitors should not be open and left in the hall with patient information visible. All medical records should be kept confidential at all times.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44536 Based on interview, record review and policy review, the hospital failed to adequately analyze the causes and implement actions to prevent potential medication errors and prevent potential diversion and misuse of controlled substances for seven incident reports of medication errors with seven patients (#10, #12, #19, #25, #26, #27 and #28) of 12 patients reviewed involving controlled substances (drugs or medications that are high risk for personal consumption or abuse). These failures had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes. Findings included: Review of the hospital’s policy titled, “Patient Safety Risk Management Plan,” reviewed 01/2024, showed that the patient safety risk management goals are to continuously improve patient safety and minimize and/or prevent the occurrence of errors, events and system breakdowns leading to harm to patients, staff and visitors through proactive risk management and patient safety activities. The patient safety and risk management functional responsibilities included the following: - Developing systems for and overseeing the reporting of adverse events, near misses and potentially unsafe conditions. - Ensuring the collection and analysis of data to monitor the performance of processes that involve risk or that may result in serious safety events (SSE). - Overseeing the organizational incident reporting process for data collection and processing, information analysis and generation of statistical trend reports for the identification and monitoring of SSE’s. -Analyzing data collected on SSE, near misses and potentially unsafe conditions. Providing feedback to providers and staff and using this data to facilitate system improvements to reduce the probability of future occurrence. - Facilitating and ensuring the implementation of patient safety initiatives and provider and staff participation in education programs on patient safety and risk management. Review of the hospital’s policy titled, “Quality Assessment Performance Improvement Plan (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety),” reviewed 01/2024, showed the following: - QAPI provided continuous process improvement, education, and training to achieve excellent clinical outcomes and patient safety. - Pharmacy and Therapeutics review provided ongoing monitoring and evaluation of selected medications of high risk, high volume, or problem prone activities, and was designed to improve processes including medication administration. Review of the hospital’s policy titled, “Incident Reporting,” revised 04/06/21, showed the following: - The objective of incident reporting was to ensure immediate management of an incident when required and that every incident is appropriately prioritized, investigated and managed, and to mitigate risk and prevent future incidents through development of appropriate action plans, recommendations and ongoing review. - Quarterly reports are provided to the Risk Management Committee, QAPI Committee, Medical Executive Committee and Governing Body that show trended data by category of events. Trends are reviewed and ad hoc process improvement and patient safety initiatives implemented as indicated with follow-up through the QAPI committee. If trends are identified or increases in incidents are noted, leadership should have monthly Risk Management meetings until the trends decrease. Incidents, complaints, grievances, employee injuries, and safety events are all brought through Risk Management for open discussion and problem solving. Review of the hospital’s policy titled, “Controlled Drugs (drugs or medications that are high risk for personal consumption or abuse) Drug Diversion Prevention, Detection and Response,” effective 10/2021, showed the following: - The prevention, detection, and reporting of drug diversion should be interdisciplinary and the responsibility of all personnel. - The hospital should routinely audit relevant data and ensure trends and variances are acted on in a timely manner and that corrective action plans are implemented. - Pharmacy audits could include full tracing audits on opioids routinely; audit nursing removal, administration, and wasting records; audit pain medication administered to patient response documentation, review reports of high-volume users from the automated dispensing machine (ADM) and tracking trends of poor documentation practices. - A quality improvement review should be initiated by the pharmacy director, including a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred to find the root cause) to prevent future occurrences. Review of the document titled, “Landmark Hospital - The Governing Board (Body) Bylaws,” reviewed 09/2024, showed responsibilities of the Board included the review, approval, and periodic reassessment of improving performance; maintaining quality patient care; and assuring continuous performance improvement by regularly receiving and acting on reports and requests from the administrative staff and clinical staff. Review of hospital’s document titled, “Incident and Accidents,” dated 05/01/24 through 11/12/24, showed a total of 98 incidents from 08/01/24 through 11/12/24 with 84 of the incidents documented as medication errors. Review of the hospital’s document titled, “QAPI,” dated 09/30/24, showed the QAPI committee discussed an increase in unaccounted for narcotics. There was no documentation of medication error trending, analysis, investigation or determination of root causes. The document showed audits and education were planned. Review of the incident report dated 11/11/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff KK, RN, removed Tramadol (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg from the automated dispenser machine (ADM) for Patient #10 on 11/09/24 at 4:51 PM. The medication was not documented as administered in the medication administration record (MAR), nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the incident report dated 09/03/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, Registered Nurse (RN) (a nurse employed by a business that provides nursing staff to hospitals and other health care institutions), removed lorazepam (a medication used to treat anxiety or sleep difficulty) one mg for Patient #12 from the ADM on 09/02/24 at 5:19 PM. The medication was not documented as administered on Patient #12’s MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of an incident report dated 11/07/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff Y, RN, removed oxycodone-acetaminophen (synthetic pain medication with a high risk for misuse) 5/325 mg tablet for Patient #12 from the ADM on 11/05/24 at 6:18 PM. The medication was documented as administered at 6:15 PM and the administration signed at 6:35 PM. Review of the incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff LL, APRN, removed and administered lorazepam two mg to Patient #19 on 10/19/24 at 7:06 AM. There was not an active order for the medication at that time; however, staff were able to remove the medication from the ADM without an over-ride because a previous one-time order from the previous day was still active. Review of the incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed Oxycodone five mg from the ADM for Patient #25 on 10/17/24 at 10:29 AM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction) 10 mg from the ADM for Patient #26 on 10/16/24 at 10:23 AM. The medication was documented as administered in the MAR at 9:25 AM. Review of the incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed methadone tablets from the ADM for Patient #26 on 10/17/24 at 11:09 AM. The medication was documented as administered in the MAR at 9:13 AM and signed by the nurse at 11:14 AM. The incident report also showed Staff J documented Patient #26 was given a hydromorphone (a potent opioid analgesic drug) injection at 11:13 AM, signed the medication administration at 11:56 AM and withdrew the hydromorphone from the ADM at 11:20 AM. Review of the incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed hydromorphone two mg from the ADM for Patient #26 on 10/18/24 at 12:30 PM. The medication was not documented as administered in the MAR. A waste for one mg of hydromorphone was completed at 1:10 PM, leaving one mg of the hydromorphone unaccounted for. Review of the incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff J, RN, removed morphine (opioid pain medication) 4 mg from the ADM for Patient #27 on 10/16/24 at 2:17 PM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff Z, Agency RN, removed and administered lorazepam two mg to Patient #28 on 10/20/24 at 7:48 AM. There was not an active order for the medication. During interviews on 11/19/24 at 4:05 PM and 11/21/24 at 8:15 AM, Staff F, Pharmacy Director, stated that she did not believe the hospital was addressing medication errors. Medication errors were presented to the CCO in the form of incident reports and for the past month she had also included the DQM. She completed an incident report for medication “unaccounted for” when the medication was not reconciled as given or wasted or when the time withdrawn from the ADM did not coincide with documented administration. Every medication error involving controlled substances or critically timed medications was presented during an administration meeting held monthly reviewing departmental audits. The medication errors were reported to QAPI by way of the incident reports completed. Some physicians were aware of the errors due to incident reports reviewed during the Pharmacy and Therapeutics meeting. During an interview on 11/20/24 at 8:55 AM, Staff E, CCO, stated that he was aware of the number of medication errors identified and had developed a document to track the reports to identify trends. He followed through and talked with each nurse involved in a medication error. He had not identified specific trends or worked on a solution. Staff E stated that some errors showed controlled substances pulled from the ADMs and were never documented as given to the patient. His investigation involved asking the nurse who pulled the medication if the medicine was given to the patient. When the nurse reported they had given the medication and neglected to document, the incident was resolved. He did not follow-up the investigation with patient interview, review of medical record or pain documentation. During an interview on 11/19/24 at 2:35 PM, Staff CC, Charge Nurse, stated that the hospital had a problem with medication errors last year. They developed and implemented extensive training and the number of medication errors decreased. Over the previous six months there had been changes with several new clinical staff and new leadership. Some of the progress with medication errors was lost. Nursing had not had recent education on reducing medication errors. During an interview on 11/20/24 at 10:00 AM, Staff C, Chief Executive Officer (CEO), stated that he was aware of a problem with medication errors, but not the volume of the errors.”

“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: 44536 Based on observation, interview, policy review and record review, the hospital failed to ensure that staff: - Provided appropriate hygiene for five current patients (#1, #2, #15, #17, and #18) out of six patients reviewed; - Appropriately turned and repositioned six current patients (#1, #2, #5, #12, #16, and #17) out of 10 patients reviewed; - Appropriately provide and document pain assessments for two current patients (#12 and #15) and two discharged patients (#25 and #28) out of 11 patients reviewed; - Appropriately provide and document nursing assessments for two current patients (#12 and #16) and one discharged patient (#25) out of 13 patients reviewed; and - Appropriately date, time and initial all IV sites, PICC lines, and central lines for six current patients (#1, #2, #5, #8, and #11) out of 13 patients reviewed. These failures had the potential to result in increased infections, impaired skin integrity, and overall increase the risk of deterioration in health status. Findings included: Review of the medical record for Patient #1, showed she was admitted on 10/15/24. She received five baths during 28 days of hospitalization. Review of the medical record for Patient #2, showed he was admitted on 10/22/24. He received four baths during 21 days of hospitalization. Review of the medical record for Patient #15, showed he was admitted on 11/05/24. He received one bath during eight days of hospitalization. Review of the medical record for Patient #17, showed she was admitted on 10/24/24. She received five baths during 23 days of hospitalization. Review of the medical record for Patient #18, showed he was admitted on 11/07/24. He received one bath during six days of hospitalization. During an interview on 11/12/24 at 3:30 PM, Patient #1, stated the staff was very inconsistent in bathing and she has only received a few baths since her admission date of 10/15/24. When she asked the staff for a bath, she was told they were too busy or did not have enough staff. During an interview on 11/12/24 at 4:00 PM, Patient #2, stated that he had not received regular bathing due to not enough staff. During an interview on 11/13/24 at 12:00 PM, Staff N, Patient Care Tech (PCT), stated that management reduced staffing and that she was typically assigned 10 patients during her shift. All of the patients required a high level of assistance and she was unable to bathe patients regularly. During an interview on 11/20/24 at 11:52 AM, Staff E, Chief of Clinical Operations (CCO), stated his expectation was for all patients to receive daily hygiene and offered a bath or shower. Bathing should be documented daily; and if the patient refused, the PCT should document the refusal and report it to the nurse. The nurse was responsible to ensure that all hygiene needs are met. Review of the medical record for Patient #1 showed she was admitted on 10/15/24. She was to be turned and/or repositioned in bed or chair every two hours. Repositioning or Patient #1’s refusal to be turned were not documented: - From 6:19 PM on 10/15/24 through 7:27 AM on 10/16/24; - From 4:48 PM on 10/16/24 through 9:16 AM on 10/17/24; - From 4:27 PM on 10/17/24 through 9:58AM on 10/18/24; - From 4:25 PM on 10/18/24 through 3:05 PM on 10/19/24; - From 5:03 PM on 10/19/24 through 6:33 AM on 10/20/24; - From 2:19 PM on 10/20/24 through 8:00 AM on 10/21/24; - From 4:58 AM on 10/22/24 through 10:48 PM on 10/22/24; - From 10:48 PM on 10/22/24 through 6:35 AM on 10/23/24; - From 8:43 PM on 10/23/24 through 6:11 AM on 10/24/24; - From 1:55 PM on 10/27/24 through 7:16 PM on 10/29/24; and - From 3:39 PM on 10/31/24 through 3:16 AM on 11/01/24. Review of the medical record for Patient #2 showed he was admitted on 10/22/24. He was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #2’s refusal to be turned were not documented: - From 12:55 AM through 6:15 AM on 10/24/24; - From 7:27 PM on 10/24/24 through 5:24 AM on 10/25/24; - From 7:12 PM on 10/27/24 through 7:12 PM on 10/29/24; - From 7:12 PM on 10/29/24 through 4:58 AM on 10/30/24; - From 8:45 PM on 10/30/24 through 2:13 AM on 10/31/24; - From 5:39 PM on 10/31/24 through 12:00 AM on 11/01/24; - From 4:10 PM on 11/01/24 through 6:00 AM on 11/02/24; - From 2:20 PM on 11/03/24 through 6:00 AM on 11/04/24. Review of the medical record for Patient #5 showed they were admitted on 10/25/24. He was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #5’s refusal to be turned were not documented: - From 4:44 AM on 10/26/24 through 12:37 AM on 10/27/24; - From 4:19 AM on 10/27/24 through 12:00 AM on 10/29/24; - From 4:00 AM on 10/30/24 through 7:10 AM on 11/03/24; - From 6:44 PM om 11/03/24 through 6:43 PM on 11/04/24; - From 6:43 PM on 11/04/24 through 2:00 PM on 11/05/24; - From 5:47 AM on 11/10/24 through 8:32 AM on 11/12/24. Review of the medical record for Patient #12, showed they were admitted on 06/28/24. She was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #12’s refusal to be turned were not documented: - From 8:22 AM 09/02/24 through 7:23 AM on 09/04/24. - From 9:40 AM on 09/04/24 through 8:00 PM on 09/05/24. - From 2:25 AM on 09/07/24 through 9:05 AM on 09/09/24. - From 9:05 AM through 6:56 PM on 09/09/24. - From 4:37 AM through 7:00 PM on 09/10/24. - From 7:00 PM 09/10/24 through 3:16 AM on 09/11/24. - From 4:46 AM through 6:26 PM on 09/11/24. - From 4:41 AM through 8:30 PM on 09/12/24. - From 10:00 AM through 7:00 PM on 09/13/24. - From 5:42 AM through 6:00 PM on 09/14/24. - From 6:00 PM on 09/14/24 through 8:22 AM on 09/16/24. - From 8:22 AM on 09/16/24 through 8:19 AM on 09/18/24. - From 11:30 AM 09/20/24 through 9:19 AM on 09/23/24. - From 9:19 AM 09/23/24 through 10:46 PM on 09/24/24. - From 10:46 PM on 09/24/24 through 6:54 PM on 09/26/24. - From 4:30 AM on 10/01/24 through 6:39 AM on 10/02/24. - From 5:58 PM on 10/02/24 through 3:04 PM on 10/04/24. - From 7:00 PM on 10/04/24 through 6:30 PM on 10/06/24. - From 4:06 PM on 10/07/24 through 6:30 PM on 10/13/24. Review of the medical record for Patient #16, showed she was admitted on 10/31/24. She was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #16’s refusal to be turned were not documented: - From 5:30 AM on 11/04/24 through 12:23 PM on 11/05/24; - From 6:21 PM on 11/05/24 through 7:532 AM on 11/06/24; - From 6:17 PM on 11/06/24 through 12:23 AM on 11/07/24; - From 3:38 AM on 11/07/24 through 6:36 PM on 11/08/24; - From 4:29 AM on 11/09/24 through 12:30 AM on 11/10/24; - From 10:00 PM on 11/10/24 through 6:48 PM on 11/11/24; - From 4:00 AM on 11/12/24 through 7:06 PM on 11/12/24. Review of the medical record for Patient #17, showed she was admitted 10/21/24. She was to be turned and/or repositioned in the bed or chair every two hours. Repositioning or Patient #17’s refusal to be turned were not documented: From 10:43 PM on 10/21/24 through 6:30 PM on 10/22/24; From 8:30 PM on 10/22/24 through 12:30 AM on 10/23/24; From 12:31 AM on 10/23/24 through 10:18 AM on 10/23/24; From 10:18 AM on 10/23/24 through 12:32 PM on 10/25/24; From 4:50 PM 10/26/24 through 8:51 AM on 10/27/24, Patient #17 was documented on back; From 8:51 AM on 10/27/24 through 12:32 PM on 10/27/24, Patient #17 was documented on left side; From 12:32 PM on 10/27/24 through 4:58 PM on 10/27/24, Patient #17 was documented in bed on right side; From 8:30 PM on 10/27/24 through 12:19 PM on 10/28/24; From 12:30 AM on 10/29/24 through 6:30 PM on 10/29/24; and From 4:49 PM on 11/11/24 through 6:00 AM on 11/12/24. During an interview on 11/12/24 at 3:30 PM, Patient #1, stated she did not get repositioned at night. During an interview on 11/12/24 at 4:00 PM, Patient #2, stated he did not get repositioned every two hours at night. During an interview on 11/14/24 at 9:30 AM, Patient #15’s family stated that staff did not come in on a regular basis and turn the patient. During an interview on 11/13/24 at 11:30 AM, Staff N, PCT, stated that she was not able to turn patients every two hours. They have a minimum of 10-12 patients to care for, the patients had a lot of needs, and she did not have time to turn them. During an interview on 11/19/24 at 1:35 PM, Staff CC, Charge Nurse (CN), stated that every patient should be turned at a minimum of every two hours. It was part of the care plan, as well as part of wound care. During an interview on 11/19/24 at 10:05 AM, Staff K, Advanced Practice Nurse (APRN, a nurse with advanced clinical education and training), stated that it was considered the standard of care to turn patients every two hours. The physician does not order repositioning but it was expected on every patient and was part of their care plan and wound assessments. She stated that the PCT’s should have no excuse for not turning patients and that it was the responsibility of the nurse to ensure that their patients were being turned. If a patient refused to turn, the PCT should notify the nurse. During an interview on 11/20/24 at 11:00 AM, Staff I, Wound Care Nurse (WCN), stated that turning does not occur every two hours anywhere in the country. Turning was important to wound healing, deterioration of the wound could occur if a patient was not turned every two hours. Review of the medical record for Patient #12 showed pain assessments were not completed during the following dates of her admission: - 09/06/24 evening shift; - 09/07/24 evening shift; - 09/08/24 morning and night shift; - 09/10/24 morning shift; - 09/12/24 morning shift; - 09/14/24 morning and night shift; - 09/15/24 morning shift; - No pain assessments were completed on the evening shift of 09/18/24 until the morning shift of 09/22/24; - 09/23/24 morning shift; - No pain assessments were completed on 09/24/24 through the evening shift of 09/26/24; - No pain assessments were completed from 09/27/24 evening shift through 09/29/24; - No pain assessments were completed from evening shift 09/30/24 through 10/03/24; - No pain assessments were completed on 10/05/24 through the evening shift of 10/06/24; - No pain assessments were completed from 10/08/24 evening shift through 10/15/24; - No pain assessments were completed from 10/15/24 evening shift through 10/17/24 evening shift; - No pain assessments were completed on 10/18/24 through 10/19/24 evening shift; and - No pain assessments were completed 10/30/24 evening shift through 11/01/24. Review of the medical record for Patient #15 showed that pain assessments were not completed during the following dates of his admission: - 11/09/24 morning and night shift; - 11/12/24 morning and night shift; and - 11/13/24 morning shift. Review of the medical record for Patient #25 showed pain assessments were not completed on 10/17/24 during the day shift or 10/18/24 during the evening shift. Review of the medical record for Patient #28 showed that pain assessments were not completed from 10/15/24 at 1:06 AM through 10/25/24 at 11:47 AM and 10/25/24 at 12:46 PM through 10/28/24 at 10:26 PM during his admission. Review of hospital policy titled, “Clinical Practice Guidelines,” revised 11/2023, showed every patient would have a nursing history and comprehensive assessment completed within the first 24 hours of admission, before the end of the RN’s shift. A complete shift assessment would be done towards the first part of the shift and documented in the patient’s medical record. Any significant change in the patient’s condition would result in a focused re-assessment. Review of the medical record for Patient #12 showed nursing assessments were not completed for the evening/night shift of 09/30/24 or the morning/day shift of 10/01/24. Review of the medical record for Patient #16 showed nursing assessments were not completed for the following dates of admission: - No assessment on 11/02/24; - No assessment on night shift on 11/04/24; - No assessment on night shift on 11/06/24; and - No assessment on night shift on 11/12/24. Review of the medical record for Patient #25 showed nursing assessments were not completed on 10/16/24 during the day shift and on 10/18/24 during the evening shift. Review of hospital policy titled, “Clinical Practice Guidelines,” revised 11/2023, showed all central lines, PICC and peripheral IV sites will be labeled with date and time when changed along with the nurse’s initial. Peripheral IV sites are to be changed on a PRN basis but must be assessed per shift for signs and symptoms of infection and any inflammation. If the site is not changed, there should be documentation to why and the reasonably vigilant in changed the dressing labeling with the date, time, and the nurse initials for when it was changed. Peripheral IV’s started at another facility should be changed within 24 hours of admission. This should be documented in the patient’s medical record. The IV dressing should be dated, time and initialed for when they are to be changed next. Transparent semipermeable dressing should be changed minimally every seven days. The dressing should be date, timed and initialed for when the dressing is to be changed next. Central line and PICC line dressings should be changed within 24 hours of admission for any non-visible dressing or for those that do not have a date on them. Following the initial dressing change, the dressings should be changed every seven days and as needed. The dressing must be dated, timed, and initialed when they are to be changed. Observation on 11/12/24 at 3:30 PM, showed that Patient #1’s central line dressing was dated 11/02/24, did not have a time, and was not initialed. Observation on 11/12/24 at 4:00 PM, showed that Patient #2’s IV dressing was not dated, did not have a time, and was not initialed. Observation on 11/13/24 at 9:50 AM, showed that Patient #5’s IV dressing was not dated, did not have a time, and was not initialed. Observation on 11/13/24 at 9:10 AM, showed that Patient # 8’s central line dressing was not dated, did not have a time, and was not initialed. Observation on 11/13/24 at 11:45 AM, showed that Patient #11’s IV dressing was not dated, did not have a time, and was not initialed. During an interview on 11/19/24 at 11:52 AM, Staff E, Chief Clinical Officer (CCO), stated that all IV’s, Ports, and Central lines should be dated and initialed. They should be inspected every shift. If they are not clean, dry and intact the nurse should change that dressing. During an interview on 11/19/24 at 1:35 PM, Staff CC, CN, stated that all dressings should have a date, time and initials. 47504”

“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: 44536 Based on interview, record review and policy review, the hospital failed to ensure two nursing personnel (Staff J and Staff Z) of four nursing personnel records reviewed, completed orientation and education prior to providing patient care. This failure had the potential to cause harm to all patients in the hospital. Findings included: Review of the hospital’s policy titled, “Contract Personnel Orientation,” dated 11/2022, showed all clinical contract service personnel will receive orientation to the facility, roles and responsibilities, and they meet all provisions outlined. This includes Infection Prevention and Control and job specific orientation. Review of the personnel record for Staff J, Agency Registered Nurse (RN), showed no job specific orientation checklist, Infection Control training or restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) training. Review of the personnel record for Staff Z, Charge RN, showed no job specific orientation checklist, Infection Control training or restraint training. During an interview and concurrent personnel records review on 11/21/24 at 10:00 AM, Staff JJ, Human Resources Manager, stated that she could not find orientation, competency skills check-off, or restraint training for two contracted staff. She stated that the nurses were on their second assignment with the hospital. During an interview on 11/21/24 at 11:55 AM, Staff E, Chief Clinical Officer, stated that he was not aware that Staff J and Staff Z had not completed orientation. He was responsible to ensure they received a proper orientation. 47504”

“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: 44536 Based on interview, record review and policy review, the hospital failed to ensure that staff follow the medication administration policies for seven patients (#10, #12, #19, #25, #26, #27, and #28) of 12 patients reviewed. These failures had the potential to affect all patients with negative outcomes. Findings included: Review of hospital policy titled, “Clinical Practice Guidelines,” revised 11/2023, showed patient administration of medication to patients were documented with the appropriate time, route, dose, and injection site in the patient’s medical administration record (MAR). When the medication was not given, the nurse noted a brief explanation or documented in the MAR. When administering narcotic medications and the amount available exceeds the dose ordered, the partial dose must be wasted immediately and witnessed by a second nurse. Any full dose narcotic errors were returned directly to the pharmacy with a full explanation. Review of the hospital policy titled, “Drug Administration General,” effective 06/2022, showed: - Drugs should be administered to patients only upon the receipt of the order from a practitioner who has clinical privileges and is legally authorized to prescribe/order drugs. This includes protocols and pre-printed forms. Review of the hospital’s policy titled “Controlled Drugs (drugs or medications that are high risk for personal consumption or abuse) Storage, Distribution and Accountability,” effective 09/2014, showed the following: - The Director of the Pharmacy should ensure that the use and accountability of controlled drugs are legal and accurate; documentation satisfies all statutes; controlled substances are administered; and all records are properly documented and filed. - The Director of Pharmacy should ensure the distribution and administration of controlled drugs are documented adequately by nursing. Review of the hospital’s policy titled “Controlled Drugs Administration,” effective 10/2021, showed the following: - Administration of controlled drugs should be recorded on the MAR. - The medical record must include the date and time of administration to the patient; quantity of the drug issued, administered, wasted, or returned; signature of the person who administered the drug; and signature of a witness to waste. - The disposition of the remainder of a controlled drug must be documented as wasted or destroyed and cosigned by a licensed person. - The person responsible for the incorrect or incomplete entry of drug administration should be required to make an entry or correction. If necessary, the supervisor-in-charge should make the MAR available to the responsible person. Review of hospital’s document titled, “Incident and Accidents,” dated 05/01/24 through 11/12/24, showed from 08/01/24 through 11/12/24 a total of 98 incidents with 84 documented as medication errors. Review of the hospital-provided incident report dated 11/11/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff KK, Registered Nurse (RN), removed Tramadol (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg from the ADM for Patient #10 on 11/09/24 at 4:51 PM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of Patient #10’s orders showed an order for oral Tramadol 50 mg every six hours as needed for pain was entered on 11/07/24. Review of Patient #10’s MAR showed tramadol was administered on 11/09/24 at 10:26 AM only. No other doses were documented as administered on 11/09/24. Review of Patient #10’s pain assessment on 11/09/24 showed an assessment and reassessment both documented at 6:21 PM by Staff KK, RN, for an encounter at 11:21 AM. Patient #10 rated her pain level at 8/10 and 0/10. Review of the hospital-provided incident report dated 09/03/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed lorazepam (a medication used to treat anxiety or sleep difficulty) one mg tablet for Patient #12 from the ADM on 09/02/24 at 5:19 PM. The medication was not documented as administered on the Patient #12’s MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of the hospital-provided incident report dated 11/07/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff Y, RN, removed oxycodone-acetaminophen (synthetic pain medication with a high risk for misuse) 5/325 mg tablet for Patient #12 from the ADM on 11/05/24 at 6:18 PM. The medication was documented as administered at 6:15 PM and the administration signed at 6:35 PM. Review of Patient #12’s physician orders showed an order for lorazepam one mg tablet as needed for anxiety entered on 07/02/24 and an order for oxycodone-acetaminophen 5/325 mg as needed for pain every six hours entered on 09/17/24. Review of Patient #12’s MAR for 09/02/24 showed she was administered lorazepam one mg tablet at 5:54 AM. No other doses were administered. Her MAR for 11/05/24 showed the dose was administered at 6:15 PM. Review of the hospital-provided incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff LL, APRN, removed and administered lorazepam two mg to Patient #19 on 10/19/24 at 7:06 AM. There was not an active order for the medication for Patient #19, however staff were able to remove the medication without an over-ride because a previous one-time order from the previous day was still active. Staff F located a note in the patient’s medical record documenting the patient was agitated and pulled his trach out. Review of Patient #19’s physician orders showed a one-time order for lorazepam one mg IV ASAP entered by Staff LL, APRN, on 10/19/24 at 3:58 PM. Review of the hospital-provided incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed oxycodone five mg from the ADM for Patient #25 on 10/17/24 at 10:29 AM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of Patient #25’s physician orders showed an order for oral oxycodone five mg administered as needed for pain levels reported between seven and ten was entered on 10/03/24 at 9:16 PM. Review of Patient #25’s MAR showed the patient was administered oxycodone five mg at 8:34 PM by Staff II, Licensed Practical Nurse (LPN). There was no documentation that oxycodone was administered to Patient #25 at any other time on 10/17/24. Review of Patient #25’s pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) showed no pain level assessment from 10/16/24 at 9:33 PM until 10/17/24 at 8:34 PM. Review of the hospital-provided incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction) 10 mg from the ADM for Patient #26 on 10/16/24 at 10:23 AM. The medication was documented as administered in the MAR at 9:25 AM. Review of Patient #26’s MAR showed a scheduled dose of methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction) 95 mg at 9:00 AM, the dose was recorded as administered by Staff J, RN, on 10/16/24 at 9:25 AM and signed at 10:26 AM. Patient #26’s pain scale assessment was documented on the MAR as eight at 9:25 AM and was documented as reassessed at 10:25 AM without a pain level identified. Review of the hospital-provided incident report dated 10/18/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed methadone tablets from the ADM for Patient #26 on 10/17/24 at 11:09 AM. The medication was documented as administered in the MAR at 9:13 AM and signed by the nurse at 11:14 AM. The incident report also showed Staff J documented Patient #26 was given a hydromorphone (a potent opioid analgesic drug) injection at 11:13 AM, signed the administration at 11:56 AM and withdrew the hydromorphone from the ADM at 11:20 AM. Review of the hospital-provided incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed hydromorphone two mg from the ADM for Patient #26 on 10/18/24 at 12:30 PM. The medication was not documented as administered in the MAR. A waste for one mg of hydromorphone was completed at 1:10 PM, leaving one mg of the hydromorphone unaccounted for. Review of Patient #26’s physician orders showed an order for oral methadone 95 mg in 10 mg tablets administered once per day was entered on 10/09/24 at 4:50 PM and an order for hydromorphone two mg injection every four hours as needed for pain was entered on 10/09/24 at 6:44 PM. Review of Patient #26’s MAR showed hydromorphone was administered on 10/18/24 at 3:36 AM and 5:07 PM. Review of the hospital-provided incident report dated 10/17/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff J, RN, removed morphine (an opioid pain medication) four mg from the ADM for Patient #27 on 10/16/24 at 2:17 PM. The medication was not documented as administered in the MAR, nor was it returned to the ADM or wasted. The medication was unaccounted for. Review of Patient #27’s physician orders showed an order for intravenous (IV, to manually administer a dose of medication through a tube into a vein) morphine administered prior to wound dressing changes was entered on 10/01/24 at 3:05 PM. Review of Patient #27’s MAR showed she was not administered IV morphine between 10/14/24 and 10/20/24. Review of the hospital-provided incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error and showed Staff Z, RN, removed and administered lorazepam two mg to Patient #28 on 10/20/24 at 7:48 AM. There was not an active order for the medication for Patient #28. Staff F located a note in the patient’s medical record documenting the patient was having a seizure. Review of the incident report dated 10/22/24 showed Staff F, Pharmacy Director, documented a medication error which showed Staff Z, RN, removed and administered lorazepam two mg to Patient #28 on 10/20/24 at 7:48 AM. There was not an active order for the medication. Review of Patient #28’s medication orders showed a one-time order for lorazepam one mg IV for seizure activity entered by Staff LL, Advanced Practice Registered Nurse (APRN, a nurse with advanced clinical education and training), on 10/29/24 at 7:00 AM. Additional directions for the order showed “Order should have been for 10/20/24 at around 7:20. Not allowing me to back date the order given on 10/20/24.” During an interview on 11/19/24 at 4:05 PM and on 11/21/24 at 8:15 AM, Staff F, Pharmacy Director, stated that she did not believe that the hospital was addressing medication errors. She did not believe that the errors were related to diversion of controlled substances, but a result of negligent documentation by nursing personnel. Medication errors were presented to the Chief Clinical Officer (CCO) in the form of incident reports and for the past month she had also included the Director of Quality Management (DQM) from the hospital’s corporate office. Medication errors were a problem for the hospital last year, but the hospital provided education and the number of errors improved significantly. Over the previous six months the number of patients, as well as the number of new staff had increased; and the number of medication errors also increased. During interviews on 11/20/24 at 8:55 AM and 11/21/24 at 11:55 AM, Staff E, CCO, stated that he was aware of the number of medication errors identified and had developed a document to track the reports to identify trends. Staff E stated that some errors showed controlled substances pulled from the ADMs and were never documented as given to the patient. His resolution was to speak directly with the nurse who pulled the medication and ask if the medicine was given to the patient. He did not follow-up the investigation of an unaccounted controlled substance with patient interview or review of pain documentation; but did not believe that the medications were being diverted by the nurses. He felt that the number of medication errors would improve because he talked with each nurse face-to-face. All staff were aware of the importance of reducing the incidents of medication errors and repeated negligence could result in disciplinary action. During an interview on 11/21/24 at 10:25 AM, Staff Z, RN, stated that the hospital held a meeting with charge nurses on 11/20/24 and informed them of the concern with medication errors. Nursing staff were informed to adjust times to make consistent with the time the medication was administered to the patient. During an interview on 11/20/24 at 10:00 AM, Staff C, Chief Executive Officer (CEO), stated that he was aware of a problem with medication errors, but not the volume of the errors. The corporate office saw and signed off on all incident reports and therefore they were also aware of the number of incident reports identified as medication errors. The medication errors were presented during a weekly meeting of audits by each department because of incident reports and the categorization of the event being identified as medication errors. Staff C was not aware if nursing staff were aware of the number of medication errors identified.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 47504 Based on observation, interview, and policy review, the hospital failed to ensure patient medications were properly secured and labeled with a patient identifier for six patients (Pt #1, #2, #3, #6, #8, and #16) out of 12 patient rooms observed. These failed practices had the potential to cause harm for all patients receiving medications in the hospital. Findings included: Review of hospital policy titled, “Drug Storage General,” dated 04/2020, showed drugs will be stored with appropriate safeguards, so that unauthorized individuals do not have access to them. Review of hospital policy titled, “Drug Storage Floor Stock,” dated 08/2022, showed floor stock medications will be secured and/or locked as to prevent unauthorized access. Observation on 11/12/24 at 3:30 PM, showed three normal saline (solution made of salt and water) 10 cc syringes in an unlocked drawer of Patient #1’s room. The syringes were not labeled with a patient identifier and were not secured in the dedicated medication lock box. Observation on 11/12/24 at 4:00 PM, showed three normal saline 10 cc syringes and three heparin (a medication used as a blood thinner or to prevent blood clots from forming) 50u/3ml syringes in an unlocked drawer of Patient #2’s room. The syringes were not labeled with a patient identifier and were not secured in the dedicated medication lock box. Observation on 11/12/24 at 4:10 PM, showed one normal saline 10 cc syringe laying on the bedside table of Patient #3’s room. It was not labeled with a patient identifier and was not secured in the dedicated medication lock box. Observation on 11/13/24 at 9:10 AM, showed three normal saline 10 cc syringes and three heparin 50u/3ml syringes laying on the counter of Patient #8’s room. The syringes were not labeled with a patient identifier and were not secured in the dedicated medication lock box. Observation on 11/13/24 at 11:43 AM, showed a multi-dose insulin vial laying in the medication lock box of Patient #1’s room. The medication lock box was unlocked and not secure. Observation on 11/14/24 at 9:15 AM, showed Staff L, Registered Nurse (RN), left Patient #6’s medication unsecured and unattended on the top of a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient). Observation on 11/14/24 at 9:28 AM, showed that Staff Y, Registered Nurse (RN), left Patient #16’s medications unsecured and unattended on the top of a WOW. During an interview on 11/12/24 at 3:30 PM, Patient #1 stated that staff leave normal saline filled syringes in the drawer in her room all the time to have them readily available when they need them. She stated, “I could do it myself with them just lying in there.” During an interview on 11/12/24 at 4:00 PM, Patient #2 stated that medication filled syringes were kept in the top drawer. Staff always keep a supply in the drawer of her room. During an interview on 11/13/24 at 10:15 AM, Patient #2 stated that the previous night someone came and removed all of the medication filled syringes out of the drawer and told him that “State was here”, and they “had to put them away.” During an interview on 11/12/24 at 4:10 PM, Patient #3 stated that the nurses always keep extra syringes of normal saline flush in the room. The syringes were usually kept in a drawer or on the countertop by the sink. During an interview on 11/19/24 at 1:00 PM, Staff I, Director of Pharmacy, stated that patient medications were not to be kept in patient room drawers or on bedside tables. Each patient room had a lock box available for the storage of medications. During an interview on 11/20/24 at 8:55 AM, Staff E, Chief of Clinical Operations (CCO) stated that all patient medications should be properly secured and not kept in patient drawers or on bedside tables. They should be labeled with a patient identifier.”