Pam Rehabilitation Hospital of Beaumont

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 10135 Based on observation, interview and record review, the facility failed to ensure there was an active infection control program which included surveillance and prevention in 3 of 3 areas (lab/blood room,dialysis treatment room, dialysis supply room). The facility failed to: A. Ensure expired supplies were discarded and sterile lab supplies were not stored in a soiled lab caddy in the lab/blood room. B. Ensure floors, cabinets, and dialysis equipment were kept sanitary and in a manner to prevent contamination in the dialysis treatment room /supply room. The facility failed to ensure expired dialysis supplies were discarded. Refer to tag A0750 for additional information.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 10135 Based on observation and interview, the facility failed to ensure sterile lab supplies and equipment were stored in a room that was temperature regulated in 1 of 1 lab/blood room. This deficient practice had the likelihood to cause harm to all patients requiring lab services. Findings include: During an observation on 11/03/2025 after 1:16 p.m. the lab/blood room was noted to not have any temperature gauges in it. The temperature in the room was warm and stuffy. The following was stored in the room: A box containing vials of Bact/Alert which had storage temperatures of 15-30 degrees Celsius on them (meaning 59-86 degrees Fahrenheit) written on the labels. Sterile injection needles with Luer-Lok syringes were stored in the room. Eight packages of sterile blood vacutainer blood collection tubes were stored on shelves in the room. The storage temperature written on the labels was 4-25 degrees Celsius (which is 39.2-77.0 degrees Fahrenheit). Two blood coolers were within their outer boxes and stored on the floor in the room. A PowerSpin HXV Centrifuge (lab equipment) which was being used was stored in the room. Staff #2 confirmed the observations and said that the room was not temperature regulated. Staff #2 confirmed that the room was where they stored blood when it came in. During an interview on 11/03/2025 at 2:29 p.m., Staff #3 said there was no centralized temperature regulation for the room. They were buying a thermometer now to place in the room. According to AIA(American Institute of Architects) ASHRAE (The American Society of Heating, Refrigerating and Air Conditioning Engineers) standard 170 gave the following hospital requirements for temperature and humidity: Lab (General Pathology) 70-75 degrees Fahrenheit and humidity of less than 60 percent.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 10135 Based on observation, interview and record review, the facility failed to ensure their infection control program included surveillance and prevention in 3 of 3 areas (lab/blood room,dialysis treatment room, dialysis supply room). The facility failed to: A. Ensure expired supplies were discarded and sterile lab supplies were not stored in a soiled lab caddy in the lab/blood room. B. Ensure floors, cabinets, and dialysis equipment were kept sanitary and in a manner to prevent contamination in the dialysis treatment room /supply room. The facility failed to ensure expired dialysis supplies were discarded. This deficient practice had the likelihood to cause harm to all patients requiring lab services and dialysis treatments. Findings include: Lab During an observation on 11/03/2025 after 1:16 p.m. the lab/blood room was noted with the following: Four packets of sterile injection needles with Luer-Lok syringes were found which expired 08/31/2025 (over 2 months ago). A lab caddy in the room that had sterile needles and lab supplies stored in it. The caddy was soiled with spills and dust. Staff #2 confirmed the observations. Dialysis room During an observation on 11/03/2025 after 3:00 p.m.the following was found: The tile flooring in the dialysis room had a buildup of wax. The original color of the tile was a light gray, but it had brown and black stains throughout the room. Some of the seams between the tile had a buildup of brown substance. Tubing and lines from the dialyzers and reverse osmosis water filtration systems were draped across the soiled tile floor. The walls in the room had white dried acid spills on them. The baseboards in the room had a buildup of white acid spill and debris. Two dialyzing wands were stored in a sink. They were not stored vertically or contained within anything to prevent contamination. One of the sinks in the room used as an area for water supply had a cabinet door missing. Inside the cabinet a hole had been cut in the drywall and the piping inside the wall was exposed. The floor inside the cabinet was soiled with a buildup of white and black particles. The one cabinet door that was still in place was covered in white dried spills and there was a brown rusted screw holding the cabinet closed. A nursing supply cart in the room was opened and the following was found: One drawer was soiled with dust and brown dry stains. Inside the drawer was a bottle of sterile water, oxygen trees which were not contained in a bag, and a bag which had lab vacutainer tubes in it. Another drawer was soiled with black particles had loose sterile needles stored in it. Another drawer had 4- 100 milliliter bags of Sodium chloride stored in it. Two of the bags expired 09/2025 and the other two expired 10/2025. Dialysis supply room The room where containers of dialysate solution was stored had floor tile which had a buildup of wax. The baseboards in the room were soiled with a buildup of brown, black and white debris. Staff #’s 10 and 11 confirmed the observations. Staff #10 said they had reported the broken cabinet door to the facility a while ago, but nothing had been done. No specific time could be given. Staff #10 said that they clean their room daily when in use and the facility staff mop their floor for them. Dialysis treatment room On 11/04/2025 after 8:50 a.m. the following was found in the dialysis room: Dialyzer (PRO 552) was found sitting on a base which was soiled with debris and the bottom of the equipment had a black and brown buildup caked on it. RO (reverse osmosis)548 water filtration system had dry white spills on the gauges, the base it was sitting in and on the wheels. The base had areas of brown rust on it. Inside the base was a buildup of black debris in the inside corners. RO (reverse osmosis)708 water filtration system had a build of dried spills on it and the the base it was sitting in had a buildup of black and brown debris in the inside corners. The frame the equipment was housed in was covered in white dried spills and brown rust. Staff #1 and 10 confirmed the observations. During an interview on 11/04/2025 after 9:03 a.m., Staff #3 (chief nursing officer) said that dialysis staff had to verbally report issues to them. She had spoken to Staff #1(chief executive officer) and they do quarterly meetings with dialysis and there had been no issues reported. Maintenance had no reports of issues. During an interview on 11/04/2025 after 9:03 a.m. Staff #1(chief executive officer) confirmed there had been no reports of issues from dialysis. During an interview on 11/04/2025 after 9:05 a.m., Staff #2 said she was over infection control and the dialysis area was not apart of her rounding. The facility provided a Core Dialysis policy named “Section 07:Infection Control Policy 736 Cleaning and Disinfecting-Delivery System which was revised 02/17/2020 which read: “PURPOSE: To provide an environment that prevents the transmission of infectious agents.” .The exterior surface cleaning had a frequency of being “After Every Treatment. The exterior surface of the machine and any laminated information hanging on the machine should be wiped down using a cloth and a disinfecting cleaner or bleach wipes ...””

“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: 32143 Based on review and interview the governing board (GB) failed to ensure the facility governing bylaws were clear on the definition of the “Company Managers” and the process in which the governing board reports to the cooperation’s company managers. A. The governing board bylaws failed to address how the Chief Executive Officer (CEO) would be held accountable as a CEO if he/she was also appointed as the chairperson of the governing body. The Chairman of the Governing Board/CEO failed to speak to the process of reporting to the company managers. B. The governing board bylaws failed to address how the Medical Director would be objective and report issues with Medical Staff while a member of the governing board. Findings: A review of the Governing Body (GB) bylaws was approved on 6/1/22 and an addendum was found on 12-12-22 to appoint the following members to the governing board of the hospital, Staff # 2 Chief Executive Officer (CEO) as Chairperson, Staff #6, Div. President as Secretary, and Staff #11 Medical Director with no title documented. A review of the GB bylaws revealed under Article I- Adoption, Ownership, and Authority stated, “The Governing Body is legally responsible for the operations of the hospital and such duties conferred to it herein and as further required by the Laws and Accreditation Standards. The Governing Board shall report to the manager or managers of the company (the “Company Managers”). A review of the GB bylaws stated, “Article II Governing Board Members. Appointment of Governing Board. The company managers shall appoint the members of the Governing Board ...” Review of the bylaws revealed there was no information on who the “Company Managers” were, how the GB reports to the company managers, or how often. An interview was conducted with Staff #2 CEO on 2-6-24. Staff #2 stated that he was on the GB was not a voting member. The surveyor revealed the minutes to the CEO and stated that the minutes and the appointment addendum on 12-12-22 revealed he was a voting member. Staff #2 then stated, “Oh, yeah. I do vote.” Staff #2 was asked how he reports to the company managers. Staff # 2 stated that one of the GB members, staff #6 was one of the company managers, and reported to corporate. Staff #2 was not able to provide a list of the company managers and any information, meeting minutes, or bylaws that provided information on the chain of command from GB to company managers. Staff #2 was asked if he is the chair of the GB, how would he report to himself, and how was he held accountable for hospital actions as the CEO if he was also the chair of the GB. Staff #2 was unable to provide an answer or speak to the process. Staff #2 stated, “I see what you are saying.” Staff #2 was asked how Staff #11 (Medical Director) approved medical staff issues through the governing body when Staff #2 and Staff #11 were 2/3 of the voting members. Staff #2 was unable to speak to the process. Staff #2 shrugged his shoulders and stated, “That was how the company had set it up.” A review of the Governing Body (GB) bylaws approved on 6/1/22 revealed, “Article VII Chief Executive Officer Section 1. Appointment. The process for selection, qualifications, authority, and duties of the Chief Executive Officer are as defined in these Bylaws, the Operating Agreement of the Company, and subject to Laws and Accreditation Standards. The Governing Board shall appoint a Chief Executive Officer approved by the Company Managers to be responsible for managing the Hospital. Such appointment shall be documented in the Governing Board minutes. Section 2. Qualifications. The Chief Executive Officer shall have the education, knowledge, experience, skills, judgment, and demonstrated current competence necessary to manage the Hospital. Section 3. Responsibilities. The Chief Executive Officer shall represent the Hospital in all aspects of its operations. He/she shall make periodic reports to the Governing Board on the overall activities, developments, and inspections affecting the Hospital, but his/her line of authority shall derive from the Company Managers. The duties of the Chief Executive Officer shall include but not be limited to the following: Implementation of policies of the Governing Board as approved by the Company Managers and those of the Company, especially those relating to the physical and financial resources of the Hospital. Liaison among the Company Managers, Governing Board, administrative staff, and the Medical Staff and between the Hospital and the local community. Organization and management of the Hospital and its services, departments, and subdivisions, delegation of duties, and establishment of formal means of accountability of subordinates. Identification of a nurse leader at the executive level who participates in decision-making pursuant to Joint Commission accreditation standards. Monitor Hospital’s compliance with applicable state and federal laws.” An interview was conducted with Staff #2 on 2-6-24. Staff #2 was asked if the facility followed joint commission standards. Staff #2 stated that the facility was not deemed and that the State of Texas was their accreditation entity. Staff #2 was made aware of the GB bylaws that stated, “Identification of a nurse leader at the executive level who participates in decision-making pursuant to Joint Commission accreditation standards.” Staff #2 stated that they were not involved with joint commission. A review of the GB and Medical Executive Committee Ad-Hoc meeting minutes dated 12-29-23 revealed Staff # 2,6, and 11 approved the meeting minutes and voted by email. The meeting was performed as one meeting. Staff #11 (Medical Director) approved the medical staff bylaws and hospital annual plans as the Medical Executive Director (MEC) and then again as a voting GB member by email. The governing body must ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The facility failed to show how the CEO and MEC would be held accountable by the GB when they are 2/3 majority of the voting GB members.”

“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: 40989 The hospital failed to have an organized nursing service that ensured there was safe staffing for patient care. The facility failed to have a staffing matrix that clearly delineated the Licensed Vocational Nurse (LVN) from the Registered Nurse (RN), a safe staffing matrix, a patient acuity tool to adjust staffing when needed, and RN supervision of the LVN on 1 of 1 unit. Refer to Tag A0392”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to follow its policy and procedure “Grievance Resolution Process” to ensure patient complaints, grievances, or allegations of abuse or neglect were documented and processed in a timely fashion in 1 of 1 (# 2) chart reviewed. A review of patient #2’s chart revealed she was admitted to the facility on 1/7/24 for Gait impairment-multifactorial, generalized osteoarthritis, and obesity. The patient was an 81 y/o female and was transferred from the local hospital. Patient #2 was admitted to the hospital with a urinary infection and was treated with antibiotics. A review of the history and physical done on 1-7-24 the physician stated, “Cognition: seems grossly intact although she tends to elaborate on tangential subjects and needs to be redirected to answer questions.” A review of patient #2’s chart revealed a nurse’s note dated 1/9/24 at 17:45. The nurse’s note stated, “Pt screaming in room stating that no one will help her move and has not been in room. Offered to help patient multiple times during the day to help turn and reposition. Pt continues to refuse help. Pt proceeded to call BMT PD. BMT PD arrived and spoke with staff and patient. Officer in room with nurses to attempt to reposition patient and still complains of not being assisted by staff.” There was no incident report, or a complaint or grievance entered for patient #2 concerning her complaints and the phone call to the police department. Staff #2 stated in her complaint that she was being held against her will and requested to go home. Patient #2 stated that the CEO had come in to speak with her on multiple occasions. A review of patient #2’s chart revealed a nurse’s note dated 1/10/24 at 6:30 am stated, “This Nurse knocked and entered pt room to perform initial assessment. Pt told this Nurse “Don’t you touch me, you are with them. I’ve already called Beaumont Police Department but yall got to them before they come in here. That man was going to bring me home, but they got to him. They wouldn’t help me, and neither will you. Pt appeared to be crying but this nurse did not observe any tears. You’re just going to go out there and laugh with the rest of them”. This Nurse attempted to reassure pt that I was here to help if she would allow. This Nurse asked pt if I could reposition her or help her get comfortable. Pt. stated “I just want to sit on side of the bed and hang my legs off. I sat in the ER 31 hours with my legs hanging off of the bed. I won’t fall”. This Nurse agreed to reposition pt to let her legs hang off of the side of the bed while I was in the room if she would allow me to grab her medicine first. Pt agreed. This nurse left the room to pull pt medicine and once Nurse arrived back to the room pt began yelling angrily at Nurse” Oh you think you’re so smart. You think because you talk in a calm voice you’re fooling anyone? Well, you’re not dummy. You’re just like the rest of them.” At this time the aide came into the room to check pt vitals, Pt began yelling at aide “Oh no! Get her out of here. Get out now! You will not touch me! She’s not touching me and they just recruited you on to do their dirty work. I don’t trust you either”. “The big one from earlier came in and lied to me just like you’re doing and I know yall are all working together against me.” This nurse asked pt if she would like to still be repositioned and allow this nurse to change her to which she responded “you’re not touching me”. Pt did agree to take her meds but did not allow this Nurse to change or reposition her. Pt continued to tell this nurse “This is against the law. this is illegal to hold me here against my will. I want to go home. Randy and the nurse with the light skin and light hair lied to me. He said that he would be back and fix this. They turned him too. He said that those people laughing in the hallway was the tv. I know what I heard and I seen them laughing with my own eyes. They stood right there and laughed. This Nurse attempted to redirect pt unsuccessfully. Pt continued to yell at this nurse. This Nurse turned on pt bed alarm placed call light within reach and reassured pt that I would return momentarily to check on her.” An interview was conducted with Staff #2 (CEO) on 2-6-24. Staff #2 stated that he had spoken with patient #2 on numerous occasions and had come to her room after hours to speak with her. I asked staff #2 if there was a complaint or grievance for patient #2 with her continued complaints of poor care and wanting to be discharged. Staff #2 stated, “There should be.” Staff #2 was informed that there were no complaints or grievances for patient #2 and no incident reports. Staff #2 stated that they had put a new employee in that position, and he would have to do some more training. Staff # 1 and Staff # 4 confirmed there were no incident reports, complaints, or grievances for patient #2. A review of the policy and procedure “Grievance Resolution Process” stated, “POLICY All patients have the right to initiate the grievance resolution process. Patients who file a grievance will not be retaliated against by any employee or any other representative of the hospital. If the patient care complaint cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance ... A. Grievance- Written or verbal complaint made to the hospital by a patient or representative related to: a. Patient care (when not resolved at the time) b. Abuse or Neglect c. Noncompliance with CoP’s d. Medicare beneficiary complaint Any complaint asked to be treated as a grievance. e. AMA ... The Director of Quality Management or designee will meet with the patient to discuss their complaint and resolve the issue if possible. If the complaint is unable to be resolved, the grievance process will be initiated. Should the grievance involve more than one specific concern, each concern will be addressed individually within the written response.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40989 Based on observation, document review, and interview the facility failed to ensure there was safe staffing for patient care. The facility failed to have a staffing matrix that clearly delineated the Licensed Vocational Nurse (LVN) from the Registered Nurse (RN), a safe staffing matrix, patient acuity tool to adjust staffing when needed, and RN supervision of the LVN on 1 of 1 unit. Findings: A tour of the nursing unit was conducted on 2/6/2024 at 11:00 AM with Assistant Chief Nursing Officer (ACNO) RN Staff #4. RN Staff #4 confirmed the patient census was 27. It was observed there was 1 Registered Nurse (RN) Charge Nurse, 4 Licensed Vocational Nurses (LVN), and 2 Nurse Aides (NA) scheduled to care for 27 patients. The hospital patient care unit was located on one floor and considered to be one unit with a centralized nursing station for all inpatients. A review of the daily assignment sheets revealed that RNs, LVNs, and NAs were scheduled. There was no defined LVN per patient census schedule or acuity tool. The acuity tool allows the scheduler to determine when staffing should be increased or decreased for safe patient care. The acuity tool determines the level of care required for the patient’s needs. The acuity tool is used to determine the level of care for the patient’s needs and allows the scheduler to determine when staffing should be increased or decreased for the patient’s needs. On 2/06/2024, RN Staff #4 confirmed there was no patient acuity tool used to determine the daily nurse staffing schedules. During an interview on 2/06/2024 at 3:50 PM with the Administrator, Staff #2, he stated, “We are just a Rehab Hospital. Our patient acuities are different than a regular hospital.” Staff #2 was not aware that the facility admitted patients with different medical needs and required the facility to staff according to the patient’s acuity needs. Staff #2 was asked how the nursing staff knew to increase or decrease the nurse staffing to adjust to the patient care needs without an acuity tool. He replied that the staff would call RN Staff #4 for guidance if they needed additional staff. An interview was conducted with RN Staff #4 on 2/6/2024 at 11:00 AM. She was asked if she was responsible for daily nurse staffing for the patient care unit. She confirmed yes, she was. She was also asked if she was the interim Chief Nursing Officer (CNO) since CNO Staff #7 was on FMLA. She replied, “I would assume that I am”. Staff # 4 stated that she started the job in May of 2023. A review of the Staffing Grid revealed 4 columns for day and night shifts for a census of 1-58 patients. The 4 columns were titled: Census, Charge, RN/LVN, and CNA. During an interview with RN Staff #4 on 2/6/2024 at 11:15 AM it was confirmed the RN/LVN column could be a combination of RNs and LVNs or could be all RNs or all LVNs because they used RNs and LVNs interchangeably. RN Staff #4 confirmed there was no specific nursing discipline required except for the RN Charge. She confirmed that one (1) RN Charge was the only required RN on the matrix for 1-58 patients and all other nursing staff could be LVNs or RN’s. Staff #4 stated, “The plan is to be able to staff 2 RNs and 2 LVNs but right now can’t do that.” Administrator Staff #2 confirmed he was not aware the staffing matrix/grid was the bare minimal nurse staffing allowed to maintain patient and staff safety. A request for the nurse staffing plan was made on 2/06/2024. RN Staff #4 presented the nurse staffing plan to include the matrix/grid for review. A review of the document presented by RN Staff #4 titled; “Plan for the Provision of Patient Care 2024” was as follows: “ ...Nursing The nursing department’s plan for providing nursing care is designed to support improvement and innovation in nursing practice and is based on both the needs of the patients to be served and the hospital’s mission and vision. The plan is reviewed annually and as warranted by changing patient care needs and/or outcomes identified through performance improvement activities, risk management, utilization review, and/or staffing plan variances. Registered nurses hold professional accountability for the provision of nursing care to patients in the hospital. Job descriptions and policies and procedures provide written evidence that clearly identifies registered nurses’ responsibility and accountability for delegating and coordinating all nursing care provided. Delegation of nursing care activities to licensed vocational nurses, nursing assistants, and other staff members based on the registered nurse’s evaluation of the person’s qualifications and competence to safely and effectively carry out the delegated responsibilities. Registered nurses will provide timely and adequate supervision, as required. The LVN provides nursing care in accordance with educational background and State practice acts under the direction of the registered nurse and physician. In the core staffing matrix, the number, mix and qualifications of nursing personnel required to meet the usual and projected patient requirements for nursing care are explicitly stated in actual numbers of persons. Annually during the budget preparation process and more frequently as determined by patient needs, the plan for core staffing is evaluated for efficacy and efficiency. Data from the patient classification system is utilized in this evaluation in addition to information from quality improvement activities, nursing [practice monitoring, degree of patient satisfaction (as measured by responses on patient questionnaires and number of patient complaints), and judgment of charge nurses...” Staff #3 presented an additional policy for review. A review of the policy and procedure titled, “Texas Nurse Staffing Plan and Nurse Staffing Advisory Committee”, Policy Number: NSG52 was as follows: “ ...POLICY Staffing Plan The governing body of the hospital shall adopt, implement, and enforce a written staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The policy must include a process for: ... The official nurse services staffing plan adopted must: *Reflect current standards established by private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations *Set minimum staffing levels for patient care units that are: *based on multiple nurse and patient considerations; and *determined by the nursing assessment and in accordance with evidence¿based safe nursing standards *Include a method for adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs; and *Include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources. Attachment A Each hospital will attach their staffing plan to the policy ...” RN Staff #4 and Staff #3 confirmed there was no attachments to the above policy. RN Staff #4 was asked if she was knowledgeable about policy, NSG52. Staff #4 confirmed she was not aware that a policy existed regarding the nurse staffing plan/nurse staffing committee. She stated, “I gave you the Provision of Care Plan and that is the only staffing plan that I am aware of and that is the one that I use daily.” A review of the staffing schedules revealed the following: On 1/08/2024 the census was 26 patients. There was only 1 RN for the day shift and 1 RN for the night shift. On 1/20/2024 the census was 28 patients. There was 1 RN scheduled for the night shift. On 2/01/2023 the census was 23 patients. There was only 1 RN for the day shift and 1 RN for the night shift. On 2/03/2023 the census was 26 patients. There was only 1 RN assigned to the night shift. On 2/04/2023 the census was 28 patients. There was only 1 RN assigned to the night shift. On 2/05/2023 the census was 28 patients. There was only 1 RN assigned to the day shift. On 2/06/2023 the census was 27 patients. There was only 1 RN assigned to the day shift. If the RN was involved with a patient in a medical crisis, there would not be an RN to assist and/or supervise the LVNs and/or unlicensed personnel. An interview with LVN Staff #8 and LVN Staff #9 was conducted on 2/6/2024 at 2:40 PM. Staff #8 and Staff #9 were asked who completed the 24-hour assessments on the patients. Staff #8 stated, “We do them every 12 hours here and I do them on the patients that I am assigned, and the RN signs behind me.” Staff #9 stated, “I do my own assessments and the RN signs behind me. The RN can’t do all of them because there’s not enough time and sometimes, she is the only RN scheduled. Sometimes she has her own patient assignments. She is also responsible for all the admissions and discharges.” A review of the facility policy titled, “Nursing Documentation” Policy Number NSG 36 was as follows: “ ...Purpose The Nursing Plan of Care is reviewed for effectiveness in meeting departmental and hospital goals and objectives. The Hospital’s Nursing Policies and the Clinical Policy Manual Lippincotts, Manual of Nursing Practice will serve as the standard for nursing and clinical procedures and provided tools for hospital-specific practice. ... Daily Nursing Assessment: RN assessment will be completed on each patient every 24 hours. This is documented via the daily nursing assessment form and corresponding daily patient care record ...” RN Staff #4 confirmed the RN would sign behind the LVNs on their shift assessments. Staff #4 stated, “I thought the only assessment the LVN could not do was the admission assessment and after that was complete, they could do the shift assessments.” RN Staff #4 was then asked how the hospital made sure that all patients were assessed by an RN every 24 hours. She stated, “We do shift assessments and the LVNs do them, and the RN signs behind them but we do not look at the records to make sure that an RN has seen them every 24 hours. The RNs do complete some of the assessments but not all of them.” A review of the document titled; “Daily Staffing Log” revealed a statement that read; “RN to assess patients assigned to LVN”. During an interview with RN Staff #10 on 2/06/2024 RN Staff #10 confirmed the LVNs complete their own assessments and we sign behind them. Unless the patient is having problems, we will not do a shift assessment on them. The LVNs can care for the patient.” LVN Staff #9 was asked when the RN goes to lunch who supervises the LVNs. She stated, “She never leaves the hospital she is always here somewhere. She is usually in one of the break rooms and we just go and get her if we need to.” An interview was conducted with RN Staff #10 on 2/06/2024 at 3:00 PM. RN Staff #10 was asked if she was the only RN on the schedule. RN Staff #10 confirmed she was the RN Charge scheduled for 6:00 AM- 6:00 PM and the only RN on the schedule. RN Staff #10 was asked who relieves her for her lunch break. She stated, “There is no one to relieve me for a lunch break most days. We just take lunch and go to one of the break rooms and the nurses know where we are, and they will come and get me if they need to. We usually are not gone very long, and we will just eat and come back”. This surveyor was unable to determine from the employee timecards if the RN was on break or not. The facility was not aware the staff were not taking a lunch breaks. RN Staff #4 confirmed the RNs were not completing a missed lunch form but were taking a lunch break in one of the employee break rooms on the unit. RN Staff #10 confirmed she would eat in the break room but not leave the hospital so she did not fill out a missed lunch form. She stated, “I may not get the full 30 minutes but I do get to go and eat in the breakroom.” An interview was conducted with RN Staff #4 on 2/06/2024 at 3:30 PM. Staff #4 was asked who relieves the RNs for a lunch break when there is only one RN on the schedule. Staff #4 stated, “They usually eat their lunch right there in a break room.” She was then asked who supervised the LVNs when she was off the floor for lunch. She stated, “Well she is not leaving the hospital, she is there on the floor in one of the break rooms, so she is always available if needed”. RN Staff #4 confirmed the lunch period was an automatic deduction and the nurses were supposed to fill out a form if they were not able to take a lunch. An interview was conducted with Staff #14, HR Director/Payroll on 2/06/2023 at 4:00 PM. Staff #14 stated that the employee should be clocking in and out for a lunch break and it was not an automatic deduction. If the employee does not take a lunch break, they must fill out the Missed Lunch Form.” Staff #14 was asked if she had received any missed lunch forms for the year. She confirmed she had not received any forms for the year but also confirmed the ACNO could adjust the employee time. A review of a partial policy provided for review by Staff #14 was as follows: “ ...Meals Each employee will be allowed one (1) unpaid uninterrupted meal break per eight (8) hour or twelve (12) hour shift, unless otherwise noted. Each meal break is 30 minutes uninterrupted total time away from the workstation. Employees may not take a lunch break at their workstations or anyone else’s workstation as we would like you to step away and enjoy your free time without interruption. The company complies with applicable federal and/or state laws. Supervisor approval is needed if employee works through their meal break. The employee must advise their supervisor in the event they cannot take an uninterrupted break and complete a Missed Lunch Form (FIN P11#2) form in such circumstances ...” A review of the BON for LVNs was as follows: “ ...15.27 The Licensed Vocational Nurse Scope of Practice The Texas Nursing Practice Act (NPA) and the Board’s Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN). The LVN scope of practice is a directed scope of practice and requires appropriate supervision ... The LVN Scope of Practice The LVN serves as an advocate for the patient and the patient’s family and promotes safety by practicing in accordance with the NPA and the BON Rules and Regulations. LVN’s scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.4 The practice of vocational nursing must be performed under the supervision of an RN, advanced practice registered nurse (APRN), physician, physician assistant, podiatrist, or dentist.5 Supervision is defined as the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity.6 The LVN is precluded from practicing in a completely independent manner; however, direct and on-site supervision may not be required in all settings or patient care situations. Determining the proximity of an appropriate clinical supervisor, whether available by phone or physical presence, should be made by the LVN and the LVN’s clinical supervisor by evaluating the specific situation, taking into consideration patient conditions and the level of skill, training, and competence of the LVN. An appropriate clinical supervisor may need to be physically available to assist the LVN should emergent situations arise ...””