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Based on observation, interview, record review and policy review, the hospital failed to:
- Implement physician orders for two discharged patients (#34 and #65) of two reviewed; (A-0395)
- Document fall risk assessments for five discharged patients (#65, #78, #80, #81, and #82) who experienced a fall during admission of six discharged patients reviewed; (A-0395)
- Assess patients every two hours while in violent restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving); (A-0395)
- Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the back of an employee badge for one current patient (#83) of two insulin medication administrations observed; (A-0405)
- Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#44 and #83) of two observed; (A-0405)
- Ensure insulin, a critical medication, was administered within the ordered time frame for one current patient (#44) of two observed and for 341 administrations of long-acting insulin of 1,687 administrations reviewed, and 2,875 administrations of short acting insulin of 6,835 administrations reviewed; (A-0405) and
- Ensure all medications were secure on three units with medication cabinets located in the nurses' station of four units observed. (A-0502)

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 03/27/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included insulin administration education to all nursing staff who were qualified to administer medications.

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-0395, A-0405 and A-0502.

Based on interview, record review and policy review, the hospital failed to:
- Implement physician orders for two discharged patients (#34 and #65) of two reviewed;
- Document fall risk assessments for five discharged patients (#65, #78, #80, #81, and #82) who experienced a fall during admission of six discharged patients reviewed; and
- Assess patients every two hours while in violent restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving).

Findings Included:

Review of the hospital's policy titled, "Enteral Nutrition (nutrition that is delivered into the digestive system as a liquid)," revised 01/2021, showed Registered Dieticians (RDs) Nutritionists monitored the nutritional care of all patients receiving enteral nutrition. Enteral nutrition was provided to patients upon receipt of a physician order. The physician would specify for the RD to manage, specify the type of product, the rate of feeding and plan for advancement. Nurses would process enteral tube feeding orders and follow the policy regarding positioning of the patient, medication administration, clogged tubes and tolerance monitoring.

Review of Patient #34's medical record showed:
- On 05/02/24, he was admitted to the hospital for stab wounds to the neck, lower chest, abdomen, and groin.
- On 05/06/24, the patient's documented weight was 76.6 kg.
- On 05/23/24, a gastrostomy tube (G-tube, soft flexible tube inserted through the skin of the abdomen and into the stomach) was placed due to the patient having difficulty tolerating sufficient oral feeding.
- The RD recommendation and the physician order showed the nurses were to supplement a bolus (large volume) G-tube feed of 400 milliliters (ml) if the patient ate 50% of his meal, 125 ml if he ate 75%, and 480 ml if he ate nothing.
- The patient successfully removed his G-tube twice.
- On 05/28/24, Patient #34 removed his G-tube. He did not receive supplemental feeding, due to the wait for verification of proper placement of the replacement G-tube.
- On 05/31/24, RD documentation indicated Patient #34's primary nurse the day before was not aware that he was receiving tube feedings and did not give any.
- On 06/07/24, RD documentation requested for nursing staff to document all tube feedings to better estimate the patient's nutritional intake.
- On 06/10/24, supplemental feedings were missed again, due to the wait for verification of proper placement of a replacement G-tube. RD documentation indicated that no supplemental feedings had been documented over the past 72 hours. Sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) documentation showed no oral intake that day due to replacement of his G-tube and poor overall intake.
- On 06/11/24, RD documentation indicated Patient #34's nurse did not administer any tube feedings because she believed the feeding tube had not yet been replaced. The RD informed the nurse that the tube was in place and ready for infusions.
- From 06/07/24 through 06/13/24, no oral supplements were documented. Patient #34's G-tube was removed at night on 06/09/24 but was replaced and functional on 06/10/24.
- On 06/16/24, no oral supplements were documented, and he only took in 220 ml by mouth.
- On 06/17/24, progress note documentation indicated Patient #34 received a supplemental feeding of 480 ml. It could not be determined if that was a late entry.
- On 06/18/24, Staff QQQQ's, Case Manager, documentation indicated that she voiced concerns to the unit manager about Patient #34 not receiving multiple tube feedings as ordered by the physician.
- On 06/19/24, his weight was 68.6 kg, a loss of 8 kg since admission.
- On 06/21/24, Patient #34 was transferred to hospice care.
- On 06/24/24, Patient #34 died.

During a review of Patient #34's incident reports and concurrent interview, Staff H, Quality Vice President, stated that an anonymous incident report was filed on 06/18/24 related to missed tube feedings. The report showed the patient had orders for tube feedings to supplement his oral intake. Staff V, Medical/Surgical Director, investigated this incident. Staff V's review of Patient #34's record indicated a missed tube feeding occurred on 06/17/24, but the feedings were resumed on 06/18/24. He concluded this was a "human factor".

During an interview on 03/26/25 at 10:22 AM, Staff QQQQ, Case Manager, stated that she had been concerned about Patient #34's weight loss and noticed the missed tube feedings in his chart. She brought it to the attention of the nurse leaders in a multi-disciplinary meeting.

During an interview on 03/26/25 at 9:20 AM, Staff V, Medical/Surgical Director, stated that he vaguely recalled the issue with Patient #34's missed feeds. He confirmed that there were missed supplemental feedings when the patient did not eat by mouth sufficiently.

During an interview on 03/26/25 at 2:30 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that there were nursing errors related to Patient #34's tube feedings.

Review of the hospital's policy titled, "Organization Wide Patient Assessment," revised 08/2024, showed the checking of vital signs (VS, measurements of the body's most basic functions: blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80] and heart rate [HR, normal 60 to 100 per minute]) was considered a part of the assessment/reassessment process. Patient reassessment on medical/surgical and telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) units was to be performed every shift. Physician orders served as mechanisms for the medical staff to communicate the patient's care, treatment needs, and continued care requirements.

Although requested there was no policy related to the obtention of orthostatic VS (VS measurements of BP and HR while a patient is lying down, sitting, and then standing, to assess how the body responds to changes in position).

Review of Patient #65's medical record showed:
- On 06/11/24 at 3:12 PM, a 39-year-old male was admitted to the hospital for nausea, vomiting, and generalized weakness with recurrent episodes of dizziness following a kidney transplant on 05/13/24.
- At 3:26 PM, a physician order was placed to obtain orthostatic VS once per shift.
- On 06/12/24 at 9:23 AM; 06/13/24 at 12:21 PM; 06/14/24 at 9:30 AM; 06/20/24 at 9:48 AM; 06/23/24 at 5:00 AM; and 06/25/24 at 12:31 PM, orthostatic VS were obtained.
- On 06/17/24 at 6:03 PM, orthostatic VS were attempted, and Patient #65 experienced a fall.
- On 06/20/24 at 3:18 AM, nursing documentation showed orthostatic VS could not be obtained due to Patient #65's weakness and syncopal (to faint) episodes.
- Orthostatic VS were not documented for any other nursing shift assessments. At a minimum, 26 sets of VS were missed.
- On 06/27/24 at 5:04 PM, Patient #65 was discharged.

During a review of Patient #65's incident reports on 03/26/25 at 1:31 PM, Staff H, Quality Vice President, stated that nursing staff had failed to obtain orthostatic VS after Patient #65 had sustained three falls between 06/15/24 and 06/17/25. She expected nursing staff to obtain VS as ordered by the medical team.

During an interview on 03/27/25 at 9:29 AM, Staff N, ACNO, stated that it was the responsibility of nursing staff to ensure physician orders were followed. If a physician ordered orthostatic VS every shift, they were to be obtained every shift. She expected nursing staff to follow physician orders as written.

Review of the hospital's policy titled, "Patient Fall Prevention Program Requirements and Performance Monitoring," revised 02/2024, showed a patient fall was a sudden, unintentional descent, with or without sustained injury, that resulted in the patient coming to rest on the floor, on or against some other surface, on another person, or an object. All patients would be evaluated for fall potential through completion of the appropriate Fall Risk Assessment. This would occur during the admission process; initial, daily nursing assessment; at minimum once per shift; following a change in medical condition and/or level of care; and post fall. After each patient fall, the nurse would document in the post fall assessment intervention within the medical record. At a minimum, the nurse would notify the attending physician, nurse leader, and the patient's legal representative as soon as possible. All notifications would be documented in the medical record.

Review of the hospital's undated document titled, "Event Reports," showed Patient #65, #78, #80, #81, and #82 sustained falls with harm that required intervention or prolonged hospitalization. Patient #65 experienced two additional falls with no harm.

Review of Patient #65's medical record showed:
- On 06/14/24 at 7:50 PM, a Morse Fall Risk Assessment (a method of assessing a patient's likelihood of falling) was completed with a score of 65, high risk. A Morse Fall Risk Assessment was not completed the following shift.
- On 06/15/24 at 10:12 AM, nursing documentation showed a physician was notified that Patient #65 experienced a fall.
- At 10:30 AM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed.
- At 1:13 PM, nursing documentation showed a physician was notified that Patient #65 experienced a fall.
- At 1:30 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed.
- At 8:30 PM, a Morse Fall Risk Assessment was completed with a score of 80, high risk. A Morse Fall Risk Assessment was not completed the following shift.
- On 06/16/24 at 12:19 PM, nursing documentation showed a physician was notified that Patient #65 experienced a fall.
- At 12:30 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift.

Review of Patient #78's medical record showed:
- On 07/30/24 at 11:22 AM, a 50-year-old male was admitted following a fall from a bicycle.
- On 09/29/24 at 10:45 AM, a Morse Fall Risk Assessment was completed with a score of 80, high risk.
- At 4:42 PM, nursing documentation showed a physician was notified that Patient #78 experienced a fall. No post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift.

Review of Patient #80's medical record showed:
- On 11/24/24 at 11:13 AM, a 65-year-old male was admitted for a gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) workup.
- On 12/11/24 at 8:00 PM, a Morse Fall Risk Assessment was completed with a score of 40, moderate risk.
- At 4:20 AM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift.
- At 4:22 AM, nursing documentation showed a physician was notified that Patient #80 experienced a fall.

Review of Patient #81's medical record showed:
- On 11/25/24 at 1:39 PM, a 63-year-old male was admitted for bilateral lower leg swelling.
- On 11/26/24 at 9:00 AM, a Morse Fall Risk Assessment was completed with a score of 20, low risk.
- At 9:18 PM, nursing documentation showed a physician was notified that Patient #81 experienced a fall.
- At 10:26 PM, one hour and eight minutes later, a post fall assessment and Morse Fall Risk Assessment were completed with a score of 70, high risk.

Review of Patient #82's medical record showed:
- On 08/13/24 at 12:18 AM, a 39-year-old female was admitted for burns sustained to her face, abdomen, and arms.
- On 09/17/24 at 8:00 AM, a Morse Fall Risk Assessment was completed with a score of 60, high risk.
- At 2:00 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift. No provider notification was documented.

During an interview on 03/26/25 at 2:35 PM, Staff IIII, ACNO, stated that she expected a Morse Fall Risk Assessment to be completed per policy. This included a post fall assessment and a reassessment of the Morse Fall Risk Assessment to be completed immediately after a patient fall. Over one hour or the next shift was not immediate. She expected nursing staff to notify the medical team of a patient fall and document the communication in the medical record.

During an interview on 03/26/25 at 1:31 PM, Staff H, Quality Vice President, stated that patient safety had identified a failure to complete nursing assessments as a contributing factor of patient falls.

Review of the hospital's policy titled, "Patient Restraint/Seclusion," dated 07/01/23, showed patients are assessed by a RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion. An RN would assess the patient at least every two hours. The assessment would include: signs of injury associated with restraint, including circulation of affected extremities; respiratory and cardiac status; psychological state, including level of distress or agitation, mental status and cognitive functioning; needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met; hydration/nutritional needs are being met; hygiene, toileting/elimination needs are being met; the patient's rights, dignity, and safety are maintained; patient's understanding of reasons for restraint and criteria for release from restraint; and consideration of less restrictive alternatives to restraint.

Review of Patient #25's medical record showed:
- On 03/14/25, a 62-year-old male was admitted to the Research Psychiatric Center (RPC).
- On 03/15/25 at 7:20 PM, he was placed in seclusion.
- At 7:46 PM, a face-to-face assessment and a seclusion assessment were documented. An order was placed for seclusion.
- At 9:23 PM, nursing noted that the patient had been in seclusion since the start of the shift.
- At 11:57 PM, an order for seclusion was placed.
- On 03/16/25 at 3:42 AM, an order for seclusion was placed.
- At 6:48 AM, nursing noted that the patient remained in seclusion.
- At 7:34 AM, seclusion was discontinued. There was an 11 hour and 48-minute gap with no seclusion assessment documentation. A new order was placed for seclusion.
- At 7:35 AM, seclusion was restarted.
- At 11:19 AM, an order was placed for seclusion.
- At 11:20 AM, seclusion was discontinued. There was a three hour and 45-minute gap with no seclusion assessment documentation.
- At 11:21 AM, seclusion was restarted.
- At 3:58 PM, seclusion was discontinued. There was a four hour and 37-minute gap with no seclusion assessment documentation.
- At 3:59 PM, an order was placed for seclusion, and seclusion was restarted.
- At 7:40 PM, an order was placed for seclusion.
- At 11:38 PM, an order was placed for seclusion.
- On 03/17/25 at 1:50 AM, seclusion was discontinued. There was a nine hour and 51-minute gap with no seclusion assessment documentation.
- At 6:55 AM, seclusion was restarted.
- At 6:57 AM, an order for seclusion was placed.
- At 10:08 AM, a seclusion reassessment and face-to face assessment were documented, three hours and 13 minutes after seclusion was started.
- At 10:09 AM, seclusion was discontinued.
- Patient #25's Patient Monitoring Form, dated 03/16/25, showed he was in seclusion from 7:45 AM to 11:46 PM. The nurse signed the form hourly from 8:00 AM to 6:01 PM. From 7:00 PM to 11:46 PM, there were no nurse signatures.

Review of Patient #89's medical record showed:
- On 02/28/25, a 36-year-old male was admitted to RPC.
- On 03/01/25 at 9:35 PM, he was placed in seclusion and an order entered.
- At 9:37 PM, nursing documented that seclusion was discontinued, and four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were applied. An order was placed for four-point restraints.
- At 9:38 PM, nursing documented that his restraints were assessed.
- On 03/02/25 at 1:48 AM, an order for four-point restraints was placed.
- At 5:44 AM, an order for four-point restraints was placed.
- At 7:40 AM, nursing documented that restraints were discontinued. There was a ten hour and two-minute gap with no restraint assessment documentation.
- Patient #89's Patient Monitoring Form, dated 03/01/25 and 03/02/25, showed the nurse initialed the form every one hour and fifteen minutes, from 03/01/25 at 9:45 PM to 03/02/25 at 7:36 AM, while Patient #89 was in restraints. There was no additional documentation regarding circulation, toileting or alternatives attempted.

During an interview on 03/26/25 at 12:20 PM, Staff HHHH, RPC House Supervisor, stated that if a patient was let out of seclusion for one minute and then placed back in seclusion, a new order was needed.

During an interview on 03/26/25 at 12:00 PM, Staff BBB, VP of Operations and RPC ACNO, stated that for violent restraint or seclusion documentation, there was no option for continuation documentation. The only options available for documenting violent restraints or seclusion were to start, restart, and discontinue. Staff had to document that restraints or seclusion were discontinued, and then document that restraint or seclusion was restarted. If it was restarted, there was no need for a face-to-face assessment. Her expectation was for staff to document every two hours while a patient was in physical violent restraints, and every four hours for patients in seclusion.

During an interview at 03/27/25 10:00 AM, Staff IIII, ACNO, stated that the hospital's policy was for nursing to assess patients in restraints or seclusion every two hours.

During an interview on 03/27/25 at 11:50 AM, Staff YYYY, Quality Manager, stated that nursing documented every two hours on the Patient Monitoring Form while a patient was in restraints or seclusion.

During an interview on 03/27/25 at 12:12 AM, Staff IIII, ACNO, stated that the Patient Monitoring Form documentation every two hours did not meet her expectation for nursing restraint or seclusion documentation every two hours.


46856




49489

Based on observation, interview, record review and policy review, the hospital failed to:
- Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the back of an employee badge for one current patient (#83) of two insulin medication administrations observed;
- Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#44 and #83) of two observed; and
- Ensure insulin, a critical medication, was administered within the ordered time frame for one current patient (#44) of two observed, for 341 administrations of long-acting insulin of 1,687 administrations reviewed, and 2,875 administrations of short acting insulin of 6,835 administrations reviewed. These failures had the potential of affecting all patients that required insulin. Late administration and failing to label insulins could cause harm or have a significant, negative impact on all patients receiving insulin.

Findings included:

Review of the hospital's policy titled, "Medication Administration," revised 02/2024, showed a work around was the intentional or purposeful use of a function or process which would result in the bypass of critical functions of the systems intended to promote patient safety. The verification for correct medication, dosage, route and time was accomplished by comparing the label on the medication, scanning the medication bar code and the patient's armband. The steps in the administration process included the verification that the medication selected matched the medication label and the scanning of all medications.

Review of the hospital's undated policy titled, "Addendum One," showed patient specific vials should be labeled and stored in the patient specific medication bins.

Observation on 03/25/25 at 9:31 AM, showed:
- Staff XXX, Registered Nurse (RN), removed insulin from the automatic dispensing machine (ADM). She withdrew lantus (long-acting blood-glucose-lowering medication) and Lispro (a short-acting insulin) into separate syringes from multi-dose vials. She returned the insulin vials to the ADM, closed the door and laid the two syringes down on the counter beside the ADM without affixing a barcode label. She then withdrew a pre-filled syringe of Lovenox (a medication used to help prevent the formation of blood clots) and laid it down next to the two unlabeled syringes.
- Staff XXX stated "I guess I need to put labels on them with you observing me" and proceeded to reopen the ADM. She became confused with which syringe was lantus and which syringe was Lispro. She was comparing dosages of insulin and trying to label them appropriately, decided to discard them. She then re-withdrew the insulin and labeled the syringes with the appropriate labels located in the bin of the ADM for each insulin type.
- At 9:31 AM, Staff XXX entered Patient #44's room and administered the insulin. She stated, "I am late giving this today. I just got busy." She did not re-check Patient #44's blood sugar at that time.

Review of Patient # 44's medical record showed on 03/25/25 at 9:31 AM, Staff XXX, RN, administered 30 units of lantus and 20 units of Lispro.

Observation on 03/26/25 at 11:24 AM, showed:
- Staff TTTT, RN, removed insulin from the ADM, withdrew the insulin into a syringe from a multi-dose vial and returned the vial to the ADM. A roll of orange labels was in the ADM bin, next to the insulin.
- Staff TTTT entered Patient #83's room, scanned his identification bracelet, returned to the computer and scanned a barcode taped on the backside of her employee badge to complete the medication administration documentation. She did not scan the barcode on the insulin vial.
- Two different types of insulin barcodes were taped on the backside of Staff TTTT's employee badge.

Review of Patient #83's medical record, showed on 03/26/25 at 11:26 AM, Staff TTTT, RN, administered three units of insulin.

During an interview on 03/26/25 at 2:35 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that it was not appropriate for nursing staff to scan a barcode label located on the back of their employee badge. Insulin was to be labeled at the time of preparation when withdrawn from a multi-dose vial. The label attached during preparation should be used for scanning during medication administration. She expected staff to use the labels available in the ADM. The orange labels located in the bin next to the insulin, within the ADM, were the correct labels. Each label contains the correct barcode for that insulin. Labels should be used during the preparation and administration of insulin. There was no shortage of labels.

During an interview on 03/26/25 at 11:31 AM, Staff UU, Nurse Manager (NM), stated that her expectation was to label insulin syringes only if staff were to administer more than one type of insulin, or prepare insulin for more than one patient at a time. She was aware staff were using barcode labels located on the backside of their employee badges and that was her expectation for staff. She stated there was no policy related to the labeling of insulin syringes.

During an interview on 03/26/25 at 11:30 AM, Staff TTTT, RN, stated that she was not expected to label insulin syringes if she only gave one type of insulin to one patient at a time. Currently, there was a shortage of insulin labels with a barcode so the work around was to use a label on the backside of her employee badge.

Review of the hospital's policy titled, "Medication Administration," revised 02/2024, showed time critical medications are medications that should be given within 30 minutes of their scheduled times. Early or late administration could cause harm or have significant, negative impact on the intended effects. Lispro insulin should be administered at 8:00 AM and 5:00 PM if ordered two times per day and administered at 8:00 AM, 12:00 PM and 5:00 PM if ordered three times per day. Other insulins should be administered at breakfast 7:30 AM, lunch at 11:30 AM, and dinner at 4:30 PM. Addendum One identifies that insulin is a high risk and high alert medication.

Observation on 03/25/25 at 9:31 AM, showed Staff XXX, RN, enter Patient #44's room and administer insulin at 9:31 AM. She stated "I am late giving this today. I just got busy." She did not re-check Patient #44's blood sugar, his last documented blood sugar was at 7:00 AM.

During an interview on 03/26/25 at 9:00 AM, Staff UUU, NM, stated the Patient Care Technician (PCT) normally checked blood sugars around 7:00 AM. All floors use multi-dose vials of insulin. Each of the nurses have their own preferred way of drawing up insulins and administering them. Some nurses place their insulin syringes in a baggie and place a label on the baggie. All syringes and baggies should have a label attached to them. The labels are in the bins next to the multi-dose insulin vials in every ADM. Critical medication administrations were not monitored. An application on the charge nurse phone alerts when a nurse is late administering a medication.

During an interview on 03/26/25 at 2:35 PM, Staff IIII, ACNO, stated that it was not appropriate for nursing staff to administer insulins late or to use a blood sugar that was obtained at two hours before the administration. She expects the nursing staff to re-check a blood sugar if they were obtained over an hour before administering the insulin.

During an interview on 03/27/25 at 9:15 AM and 11:30 AM, Staff WWWW, Pharmacy Director, stated the administrations of critical timed medication insulins were not routinely monitored. Insulins should be administered within 30 minutes of the scheduled administration times. She reviewed an untitled, handwritten document labeled with Lantus (long-acting) and stated that out of 1,687 administrations reviewed, from 02/12/25 to 03/27/25, 62 of the administrations were greater than 120 minutes late. 279 administrations were greater than 60 minutes late. She reviewed a second untitled, handwritten document labeled Humalog (short-acting) insulin and stated that out of a total of 6,835 administrations reviewed, from 02/12/25 to 03/27/25, 2,245 were administered greater than 60 minutes late and 630 administrations were administered greater than 120 minutes late.

The overall totals of short-acting insulin administrations that were late was 2,875 out of 6,835. The overall totals of long-acting insulin administrations that were late was 341 out of 1,685.





47504

Based on observation, interview and policy review, the hospital failed to ensure all medications were secure on three units with medication cabinets located in the nurses' station of four units observed. This failure had the potential to allow unauthorized access of medications by personnel, visitors, and patients.

Findings included:

Review of the hospital's policy titled, "Storage of Medications," revised 08/2024, showed lockable medication carts, automated dispensing cabinets (ADCs), and drawers were used to store medications. These storage areas/units would be locked when unattended.

Observation with concurrent interview on 03/24/25 at 3:28 PM, on the Progressive Care Unit (PCU), showed a cabinet in the center of the nurses' station. The cabinet doors were visibly ajar with the doorknob lock turned to the right with no staff present. Upon stepping toward the cabinet Staff M, Nurse Manager (NM), was seen twisting the doorknob lock counterclockwise while attempting to close the doors. She then moved the numbered dial locking mechanism on the doorknob lock to lock the cabinet. Staff M stated that the cabinet was locked, and it contained patient medications in plastic bins labeled with room numbers.

Observation on 03/25/25 at 9:16 AM, on the PCU, showed the doors to the cabinet with patient medications were open with no staff present. The cabinet contained patient medications in plastic bins labeled with room numbers.

Observation on 03/25/25 at 2:47 PM, on the fourth-floor central telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) unit, showed a cabinet in the center of the nurses' station. The cabinet doors were open with no staff present. The cabinet contained patient medications in plastic bins labeled with room numbers.

Observation with concurrent interview on 03/25/25 at 2:50 PM, on the fourth-floor north telemetry unit, showed a cabinet in the center of the nurses' station with no staff present. The doorknob lock was turned to the right. Staff OO, Nursing Director, opened the cabinet door without turning the doorknob lock or moving the numbered dial locking mechanism on the doorknob lock. Staff OO stated that the cabinet door was not locked. The cabinet contained patient medications in plastic bins labeled with room numbers.

During an interview on 03/26/25 at 2:35 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that she expected cabinets containing patient medications located in the center of the nurses' stations to be locked. The cabinets not located behind locked doors could be accessible to the any person who walked on the unit.

During an interview on 03/24/25 at 3:10 PM, Staff L, Registered Nurse (RN), stated that the patient medication cabinet located in the middle of the nurses' station on the PCU was not kept locked.