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Based on interview and record review, the facility failed to ensure policy and procedure were followed for four (4) of 30 patients (1, 2, 3, 19) when:

1. Patient 1 was not accompanied (supervised, escorted) by nursing staff leaving the facility's premises against medical advice (AMA - when a patient leaves the hospital before the physician recommends discharge).

2. Patient 2's Potassium (K - supplement) was not administered (given) as ordered.

3. Patient 3's Clinical Institute Withdrawal Assessment (CIWA - method of treating alcohol withdrawal) score was not communicated to the physician. In addition, Patient 3's CIWA score reassessment was not done.

4. Patient 19's physician order for Ativan (medication used to treat alcohol withdrawal syndrome) was not followed.

These failures had the potential to affect the patients' care and well-being.

Findings:

1. Patient 1 was admitted to the facility's emergency department (ED) on 8/28/25 at 8:20 P.M. after a motor vehicle accident (MVA; car accident).

A review of Patient 1's clinical record was conducted on 10/13/25 at 9 A.M. A nursing narrative note dated 8/29/25 at 1:55 A.M., included documentation that Patient 1 refused to stay in the hospital for further work-up (assessment, evaluation, tests, treatment) to be completed. Per this record, Patient 1 was alert and oriented, and walked out of the hospital lobby on 8/29/25 at 12:46 A.M. Patient 1's record included a signed AMA form (document that a patient is required to sign when leaving the hospital against medical advice).

A concurrent interview, observation of security video footage, and record review was conducted with the Emergency Department Director (EDD) on 10/13/25 at 10:05 A.M. The EDD stated that per Patient 1's clinical record and security video footage dated 8/29/25 between 12:47 A.M. and 12:49 A.M., Patient 1 walked out of the hospital building and premises without staff accompaniment (supervision; escort), and towards the bus stop. The EDD acknowledged that Patient 1 should have been accompanied by a nursing staff when he left the ED/hospital, for safety, and per AMA policy.

The facility's policy titled Procedure: AMA, Patient Leaving Against Medical Advice, revised 1/8/25, indicated, " ...III. PROCEDURE: COMPLIANCE- KEY STEPS ...C. Nursing staff should accompany the patient off the unit/out of the hospital to help assure the patient's safety."

2. Patient 2 was admitted to the facility on 10/08/25 with diagnoses which included alcohol abuse, congestive heart failure (CHF - failure of the heart to pump out adequate blood) per the history and physical dated 10/8/25.

A review of Patient 2's physician order dated 10/09/25 at 2:36 A.M. indicated that if Patient 1's K level is:

"3.6 to 3.9 Give 20 milliequivalent (meq - unit of measurement) x 1 (one time) dose by mouth.

3 to 3.5 - Give 40 meq by mouth. Recheck K level one hour after dose completed.

Less than 3 - Give 40 meq through intravenous administration over four (4) hours plus 40 meq, call physician. Recheck K level one hour after administration."

A review of Patient 2's physician order dated 10/09/25 at 11 P.M. indicated to give Patient 1 Potassium 40 meq twice a day.

A concurrent interview and record review was conducted with the pharmacist on 10/14/25 at 10 A.M. The pharmacist stated that Patient 2's K level on 10/10/25 at 7:26 A.M was 3.3. The pharmacist stated that per Patient 2's electronic medication administration record (EMAR - list of medications given to a patient), Patient 2 received 40 meq on 10/10/25 at 9:20 A.M. The pharmacist stated that the licensed nurse (LN) should have given Patient 1 another dose of potassium 40 meq per physician order, to ensure Patient 1 received the appropriate potassium coverage.

A review of the hospital's policy and procedure, titled Adult Inpatient Standards last revised 2/25/25 indicated "Standard of Assessment: ...6. The Nurse will carry out the physician order ..."

3. Patient 3 was admitted to the facility's Intermediate (IMC - unit where stable patients require frequent observation) level of care on 10/5/25 with diagnoses which included alcohol withdrawal and bipolar disorder (mental condition from elevated energy to sadness exhibited by a patient) per the history and physical dated 10/6/25.

A review of Patient 3's physician order dated 10/6/25 at 12:20 A.M. indicated to give Patient 3 " ... Ativan (medication used to treat alcohol withdrawal syndrome) 1 milligram (mg - unit of measurement) for CIWA score 9-15. Give Patient 3, Ativan 2 mg for CIWA score 16 and above. Reassess CIWA score after an hour, medication was given. Call physician if patient had two consecutive CIWA scores more than 15."

A concurrent interview and record review was conducted with the nurse educator (NE) on 10/16/25 at 10 A.M. The NE stated that per Patient 3's CIWA score assessment flowsheet dated 10/6/25 at 8:41 A.M., Patient 3 had a CIWA score of 16. In addition, on 10/6/25 at 10:58 A.M., Patient 3 had a CIWA score of 16. The NE stated that the LN should have called and informed the physician that Patient 3's CIWA score was 16 and Patient 3 may have needed an intensive care unit (ICU - unit where constant, life sustaining interventions were provided) level of care. The NE further stated that a CIWA score reassessment should have been done by the LN on 10/16/25 at 9:41 A.M and 11:58 A.M. to further evaluate Patient 3's response to the medication and identify the need for a higher level of care.

A review of the hospital's Adult Inpatient Standards, (undated) indicated, "RN should reassess CIWA 60 minutes post Ativan and re-medicate if indicated. Notify provider if CIWA greater than 15 ..."





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4. Patient 19 was admitted to the facility on 9/21/25 with diagnoses which included alcohol abuse (habitual misuse of alcohol) per the history and physical dated 9/21/25.

A review of Patient 19's physician order dated 9/21/25 was conducted. This record included an order for a Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar; tool used to assess alcohol withdrawal) assessment. Further, the order included direction for the following medication to be administered based on the CIWA assessment score: "Lorazepam (Ativan) ... : CIWA-Ar less than 8: No PRN (as needed) Ativan; CIWA-Ar 8-15: Ativan 0.5 mg (milligrams)) ... q (every) 1 hr (hour); CIWA- Ar greater than 15: Ativan 1 mg ... q 1 hr ..."

A review of Patient 19's Medication Administration Record (MAR) indicated that Patient 19 was administered Ativan 0.5 mg tablet PO (oral) on 9/21/25 at 1:26 P.M.

A review of Patient 19's medical record indicated a CIWA-Ar assessment score of 4 on 9/21/25 at 10:59 A.M. It further indicated that there was no CIWA-Ar assessment documented when the Ativan was administered on 9/21/25 at 1:26 P.M.

A concurrent interview and record review was conducted on 10/14/25 at 2:34 P.M. with the Director of Regulatory (DR). The DR stated that Patient 19's MAR indicated Ativan 0.5 mg PRN for CIWA-Ar score of 8-15 was administered on 9/21/25 at 1:26 P.M. The DR further stated that Patient 19's CIWA-Ar assessment and documentation did not support the indication for the administration of Ativan. The DR acknowledged that physician orders were not followed when the "as needed" Ativan tablet was administered without an indication.

A review of hospital's policy and procedure titled Adult Inpatient Standards last revised 2/25/25 indicated "Standard of Assessment: ...6. The Nurse will carry out the physician order ..."

Based on interview and record review, the facility failed to ensure Clinical Resource Management Initial Assessments (CRM IA- assessment tool used to identify a patient's relevant background/history related to post-discharge needs) were completed for four (4) of 30 sampled patients (Patient 24, 26, 27 and 28).

This failure had the potential to affect patient care and well-being.

Findings:

1. Patient 24 was admitted to the facility on 10/9/25 with diagnoses which included encephalopathy (disturbance of brain function) and urinary tract infection (bacterial infection of the urinary system) per the history and physical dated 10/9/25.

A review of Patient 24's medical record was conducted. A CRM IA was not completed.

An interview and record review was conducted with the Director of CRM (DCRM) on 10/16/25 at 11:07 A.M. The DCRM could not find a CRM IA in Patient 24's electronic health record. The DCRM stated that a CRM IA was not completed. The DCRM acknowledged that Patient 24's CRM IA should have been completed and documented because it contained important information that included the baseline information of the patient's post discharge needs.

A review of the hospital's policy and procedure titled Procedure: Documentation of Discharge Planning and Instructions last revised 10/13/25, indicated "III. Procedure: Compliance - Key Steps A. Standards of practice ...2. Discharge planning begins on admission as actual or potential needs are identified with the initiation/completion of the Admission Assessment by the attending RN. This assessment may be updated with changes in patient status by Clinical Resource Management (CRM) staff as indicated by referral or patient's needs in the Ad Hoc CRM Initial Assessment ..."

2. Patient 26 was admitted to the facility on 10/11/25 with diagnoses which included appendicitis (inflammation and infection of appendix) per the history and physical dated 10/11/25.

A review of Patient 26's medical record was conducted. A CRM IA was not completed.

An interview and record review was conducted with the Director of CRM (DCRM) on 10/16/25 at 11:07 A.M. The DCRM could not find a CRM IA in Patient 26's electronic health record. The DCRM stated that a CRM IA was not completed. The DCRM acknowledged that Patient 26's CRM IA should have been completed and documented because it contained important information that included the baseline information of patient's post discharge needs.

A review of hospital's policy and procedure titled Procedure: Documentation of Discharge Planning and Instructions last revised 10/13/25, indicated "III. Procedure: Compliance - Key Steps A. Standards of practice ...2. Discharge planning begins on admission as actual or potential needs are identified with the initiation/completion of the Admission Assessment by the attending RN. This assessment may be updated with changes in patient status by Clinical Resource Management (CRM) staff as indicated by referral or patient's needs in the Ad Hoc CRM Initial Assessment ..."

3. Patient 27 was admitted to the facility on 10/11/25 with diagnoses which included cholelithiasis (gallstones in the gallbladder or bile ducts) and abdominal pain per the history and physical dated 10/11/25.

A review of Patient 27's medical record was conducted. A CRM IA was not completed.

An interview and record review were conducted with the Director of CRM (DCRM) on 10/16/25 at 11:07 A.M. The DCRM could not find a CRM IA in Patient 27's electronic health record. The DCRM stated that a CRM IA was not completed. The DCRM acknowledged that Patient 27's CRM IA should have been completed and documented because it contained important information that included the baseline information of patient's post discharge needs.

A review of hospital's policy and procedure titled Procedure: Documentation of Discharge Planning and Instructions last revised 10/13/25, indicated "III. Procedure: Compliance - Key Steps A. Standards of practice ...2. Discharge planning begins on admission as actual or potential needs are identified with the initiation/completion of the Admission Assessment by the attending RN. This assessment may be updated with changes in patient status by Clinical Resource Management (CRM) staff as indicated by referral or patient's needs in the Ad Hoc CRM Initial Assessment ..."

4. Patient 28 was admitted to the facility on 10/12/25 with diagnoses which included chest pain per the history and physical dated 10/12/25.

A review of Patient 28's medical record was conducted. A CRM IA was not completed.

An interview and record review was conducted with the Director of CRM (DCRM) on 10/16/25 at 11:07 A.M. The DCRM could not find a CRM IA in Patient 28's electronic health record. The DCRM stated that a CRM IA was not completed. The DCRM acknowledged that Patient 28's CRM IA should have been completed and documented because it contained important information that included the baseline information of patient's post discharge needs.

A review of hospital's policy and procedure titled Procedure: Documentation of Discharge Planning and Instructions last revised 10/13/25, indicated "III. Procedure: Compliance - Key Steps A. Standards of practice ...2. Discharge planning begins on admission as actual or potential needs are identified with the initiation/completion of the Admission Assessment by the attending RN. This assessment may be updated with changes in patient status by Clinical Resource Management (CRM) staff as indicated by referral or patient's needs in the Ad Hoc CRM Initial Assessment ..."