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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, the group of individuals legally responsible for overseeing the hospital, including ensuring that policies are followed, resources are provided, and patient safety is protected) was met, as evidenced by:

1. The facility's Governing Body failed to ensure effective oversight of the hospital's quality and safety systems by not ensuring serious adverse events (any unintended injury or harm to a patient caused by medical care, rather than their underlying condition) for three (3) of 30 sampled patients (Patient 1, Patient 2, and Patient 11) were reported (Patient 1), analyzed (malfunction of critical equipment regarding Patient 1, delayed emergency response for Patients 1 and 2, and preventable death for Patient 11), and acted upon through the hospital's Quality Assurance and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) process. The GB failed to ensure that department leaders implemented, monitored, and evaluated corrective actions to prevent recurrence of these events.

This deficient practice resulted in delayed identification and correction of patient-safety issues, including malfunctioning ventilator alarm systems (event involving Patient 1), and delayed emergency responses (events involving Patient 1, and Patient 2), and failure to recognize and prevent fatal blood clots (event involving Patient 11). (Refer to A-0063)

The cumulative effect of these systemic failures resulted in the Governing Body's inability to ensure that patients received care in a safe environment and that serious clinical and equipment events were promptly recognized, investigated, and corrected. This lack of oversight and timely intervention caused patient harm to Patients 1, 2 and 11 by exposing them to unsafe conditions, delayed treatments, and potentially life-threatening situations that could have been prevented with proper management and response.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 16) participated in the development of his (Patient 16) plan of care (a comprehensive document that outlines the individualized healthcare strategy for a patient) and failed to ensure Patient 16 was informed of the status of Patient 16's discharge (the process of a patient leaving a healthcare facility, such as a hospital or nursing home, after receiving medical treatment), in accordance with the facility's policy and procedure regarding Patient Rights (subset of human rights).

This deficient practice resulted in Patient 16's inability to participate in the development of his discharge plan and resulted in Patient 16 not being informed of the status of his discharge. This deficient practice had the potential to result in lack of patient engagement with discharge plans and the likelihood of hospital readmission. (Refer to A-0130)

2. The facility failed to ensure a safe setting for one (1) of 30 sampled patients (Patient 1) who was ventilator-dependent (required a mechanical machine to help with breathing) through a tracheostomy (a surgically created opening in the neck into the windpipe to aid breathing) when the facility failed to:

2.a. Maintain a functional ventilator (mechanical machine to help with breathing) alarm system according to manufacturer specifications and the facility's policy and procedure titled, "Biomedical Engineering Medical Equipment Maintenance Program."

2.b. Activate a rapid response (RRT, a team of medical professionals who respond immediately to patients showing early signs of severe medical distress, such as abnormal heart rate or breathing), in accordance with the facility 's policy titled "Rapid Response," when Patient 1's heart rate (HR, number of times the heart beats per minute) stayed above 130 beats per minute (BPM) for more than one hour.

These deficient practices resulted in Patient 1 being disconnected from the ventilator for approximately 15-20 minutes without staff awareness, causing anoxic brain injury (severe brain damage caused by lack of oxygen) and a persistent vegetative state (a condition in which a person is awake but unaware due to extensive brain injury). This deficient practice also placed all ventilator-dependent patients at risk for serious harm or death. (Refer to A-0144)

The cumulative effect of these deficient practices resulted in the facility's failure to protect patient's rights to receive care in a safe setting and to ensure prompt emergency intervention for patients in distress. These systemic failures placed all patients, including those dependent on ventilators or requiring rapid response activation, at risk for serious injury, harm, or death.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for QAPI (Quality Assessment & Performance Improvement, a data-driven, proactive approach to improving the quality of care and services) was met, as evidenced by:

1. The facility's Quality Assurance Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) Committee failed to review and analyze data collected from two of 30 sampled patients' (Patient 11 and Patient 12) Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments, to ensure that the VTE risk assessments (used to identify individuals at risk of developing blood clots in the veins) were performed accurately and appropriate interventions were implemented to reduce the risk of patients developing blood clots during their hospital stay. In addition, the QAPI committee failed to ensure there was a process in place to direct nursing staff on the performance of accurate VTE risk assessments and the appropriate interventions to implement for patients identified with VTE risk level of Low, Moderate, or High risk.

This deficient practice of the QAPI's failure to review and analyze collected VTE risk assessments data, resulted in a missed opportunity to identify risks, improve care, and monitor performance, and implement targeted actions to prevent patient harm. This deficient practice placed Patients 11 and 12, including other patients, at risk of developing blood clots, when nursing staff performed inaccurate VTE assessments for patients (Patients 11 and 12), which resulted in the lack of appropriate VTE prophylactic (preventive) interventions for Patient 11, who was at high risk for VTE formation. Patient 11 developed a blood clot after undergoing a surgical procedure and subsequently expired (died) of a pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). (Refer to A-0273)

2. The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee, effectively tracked, investigated, analyzed, and implemented corrective actions for five (5) of 30 sampled patients (Patient 1, Patient 2, Patient 11, Patient 21, and Patient 22) who experienced serious adverse events (any unintended injury or harm to a patient caused by medical care, rather than their underlying condition), in accordance with the facility's QAPI plan. The QAPI program did not identify system-wide performance gaps (deficiencies or shortcomings that affect the overall performance of an entire system), ensure timely investigations of adverse patient events, or monitor corrective actions to prevent recurrence.

This deficient practice resulted in delayed review of adverse events involving serious patient harm, which can result in recurrence of patient harm and/or death for other patients if not addressed, when:

1. Patient 1 sustained anoxic brain injury (severe brain damage caused by lack of oxygen) after a ventilator alarm cable (a wire connecting the breathing machine to the nurse -call-system [communication tool that allows patients to alert staff when they need assistance]) failed and no maintenance or testing program existed. (Refer to A-0286)

2. Patient 2 expired (died) in the Post Anesthesia Care Unit (PACU, a specialized area in a hospital where patients who have undergone surgery or other procedure requiring anesthesia are monitored and cared for until they are stable and ready to be discharged) after staff failed to activate a Rapid Response Team (RRT, an emergency group that responds when a patient suddenly deteriorates) despite clear signs of distress (unstable patient condition) and dangerously low blood pressure. (Refer to A-0286)

3. Patient 11 died of pulmonary embolism (a blockage in the lungs caused by a blood clot) following inaccurate Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments and lack of preventive actions. This has the potential for inappropriate preventive measures, which placed patients at risk of developing blood clots in the legs. The blood clots can become dislodged and travel to the lungs and cause a pulmonary embolism (lungs become blocked from a blood clot) and may result in death. (Refer to A-0286)

4. Patient 21 and Patient 22 did not receive timely activation of RRT when Patient 21 experienced multiple episodes of seizure (sudden uncontrolled body movements caused by abnormal brain activity) and Patient 22 experienced low blood pressure, leading to delayed treatment and transfer to intensive care. (Refer to A-0286)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by:

1. The facility failed to ensure nursing staff performed accurate Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments, in accordance with the facility's policy regarding assessment/reassessment, for two of 30 sampled patients (Patients 11 and 12), in order to determine the patients' risk of developing a blood clot. The facility also failed to implement interventions to reduce the risk of blood clot formation for Patient 11, who was at high risk for developing blood clots.

The inaccurate VTE risk assessments and lack of implementation of interventions to reduce the risk of blood clot formation resulted in Patient 11 developing a blood clot in his (Patient 11) vein, developed pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot) and subsequent death. The deficient practice also had the potential of placing Patient 12 and other patients at risk of developing a blood clot, which may lead to patient harm, serious injury, and/or death. (Refer to A-0395)

2. The facility failed to ensure nursing staff documented adverse events (an unintended injury or complication that occurs as a result of medical treatment or care) in the facility's incident-report system, in accordance with the facility's policy titled, "Never Event management," when one (1) of 30 sampled patients (Patient 1) was accidentally disconnected from the ventilator (a machine that helps a patient breathe), and the ventilator alarm failed to alert staff due to a defective cable.

This deficient practice resulted in a delay in initiating an internal investigation of the event and allowed potentially defective ventilator-alarm cables to remain in use without prompt identification or corrective action, placing Patient 1 and other ventilator-dependent patients at continued risk for delayed emergency response, injury, or death if alarms failed again. (Refer to A-0395)


3. The facility failed to ensure nursing leadership properly supervised and evaluated the quality of care provided during and after emergency resuscitation (life-saving efforts when a patient's heart or breathing stops) for two (2) of 30 sampled patients (Patient 1 and Patient 2). Nursing staff did not complete required Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when heart stops beating effectively]) documentation (a hospital-wide record used to log actions, medications, and patient responses during cardiac or respiratory arrest [when breathing stops]) or post (after)-event review forms, as required by the facility's "Code Blue" policy.

This deficient practice resulted in delays in identifying and correcting problems that occurred during the resuscitation of Patient 1 and Patient 2, which may have contributed to delayed emergency treatment and placed all patients as risk for repeated errors during future life-threatening emergencies. (Refer to A-0395)


4. The facility failed to ensure nursing staff followed physician's order for continuous pulse-oximetry monitoring (continuous, non-invasive monitoring using a device attached to a patient's fingertip or earlobe that tracks oxygen saturation-the percentage of oxygen in the blood- and pulse rate, or how many times the heart beats per minute) for one (1) of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure, "Telemetry (the continuous, remote monitoring of a patient's vital signs, most commonly their heart rhythm) Policy."

This deficient practice placed Patient 3 at risk for undetected low oxygen levels, which could lead to a life-threatening condition such as hypoxia (a dangerous state where body tissues and organs do not receive enough oxygen). (Refer to A-0395)

5. The facility failed to ensure the patient Care Plans (provides direction regarding the type of nursing care a patient may need) for three of 30 sampled patients (Patient 13, 16, and 17), were customized or individualized to address the patients' specific care needs and risks, in accordance with the facility's policy regarding care plans. In addition, for Patient 13, the facility failed to implement a plan of care addressing Patient 13's immobility and electrolyte imbalance (the level of one or more electrolytes [example: calcium- a building block of bones, ensuring their strength; potassium- necessary for muscle functions] in your body is too low or too high) upon admission to the facility.

This deficient practice on the lack of an individualized care plan for each patient admitted to the hospital had the potential for Patients 13, 16, and 17's specific care needs to not be addressed leading to inconsistent and ineffective results. This deficient practice also had the potential for Patient 13 to be at increased risk for skin breakdown (damage/injury to the skin) due to lack of interventions to address immobility as well as heart complications or seizure (abnormal electrical brain activity causing uncontrolled movements or loss of awareness) due to lack of a specific care plan to address Patient 13's problem regarding electrolyte imbalance. (Refer to A-0396)

6. The facility failed to ensure nursing staff and Telemetry technician (staff who monitor heart rate and rhythm [the regular pattern of electrical impulses that control the heart's contractions and pumping action] on remote cardiac monitors) recognized and responded to significant changes in patient condition by activating rapid response (RRT, a team that responds in an emergency and provides immediate, critical care to patients showing sudden signs of decline), for three (3) of 30 sampled patients (Patient 2, Patient 21, and Patient 22), in accordance with the facility's policy and procedure titled, "Rapid Response Teams."

This deficient practice resulted in:

a. Patient 2 experiencing life-threatening blood loss in the post (after) - anesthesia care unit (PACU, a hospital recovery area after surgery) without prompt escalation of treatment, which likely contributed to Patient 2's death; (Refer to A-0398)

b. Patient 21 experiencing delayed evaluation and transfer to the ICU (Intensive Care Unit, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) after experiencing hypertension (HTN, high blood pressure), mental-status change (decrease in awareness or alertness) and a seizure (sudden uncontrolled muscle activity caused by abnormal brain electrical signals), all of which could have contributed to Patient 21's decline and death; and (Refer to A-0398)

c. Patient 22 remaining hypotensive (having abnormally low blood pressure) without activation of rapid response, thus placing Patient 22 at risk for cardiac arrest (sudden loss of heart function). (Refer to A-0398)


7. The facility failed to ensure nursing staff notified the physician of a change in patient condition, for one of 30 sampled patients (Patient 22), when Patient 22 was hypotensive (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]) on two separate occasions, in accordance with the facility's policy and procedure (P&P) titled, "Notification of Physician for Unusual Events or Change in Patient's Condition."

This deficient practice had the potential for Patient 22 to not have the necessary medical treatments to address Patient 22's hypotension, which could have placed Patient 22 at risk of deterioration and/or death. (Refer to A-0398)

8. The facility failed to ensure one of 30 sampled patients (Patient 22), was turned/repositioned every two (2) hours, in accordance with the facility's policy and procedure titled, "Pressure Injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) Assessment, Management, Prevention and Treatment Protocol."

This deficient practice had the potential to increase the risk of Patient 22 developing a worsening wound and pressure injury, which could lead to uncontrolled pain and/or infection. (Refer to A-0398)

9. The facility failed to ensure nursing staff provided pericare (cleaning the genitalia and buttocks area to prevent infection, skin breakdown, and promote comfort) for one of 30 sampled patients (Patient 22), in accordance with the facility's policy titled, "Plan for the Provision of Patient Care."

This deficient practice had the potential for Patient 22 to develop an infection, skin breakdown (damage or injury to the skin), and physical discomfort. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility's Governing Body (GB, the entity legally responsible for the hospital's management and has the ultimate authority and responsibility for the care and services rendered within the organization) failed to ensure effective oversight of the hospital's quality and safety systems by not ensuring serious adverse events (any unintended injury or harm to a patient caused by medical care, rather than their underlying condition) for three (3) of 30 sampled patients (Patient 1, Patient 2, and Patient 11) were reported (Patient 1), analyzed (malfunction of critical equipment regarding Patient 1, and preventable death for Patient 11), and acted upon through the hospital's Quality Assurance and performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) process. The GB failed to ensure that department leaders implemented, monitored, and evaluated corrective actions to prevent recurrence of these events.

This deficient practice resulted in delayed identification and correction of patient-safety issues, including malfunctioning ventilator alarm systems (event involving Patient 1), and delayed emergency responses (events involving Patient 1, and Patient 2), and failure to recognize and prevent fatal blood clots (event involving Patient 11).

Findings:

1. During an interview on 9/30/2025 at 3:48 p.m. with the Chief Nursing Officer (CNO), CNO stated, "The event happened on April 17 (2025). The patient (Patient 1) was on a ventilator (mechanical machine to help with breathing) and became disconnected, but the alarm at the nurses' station did not go off. We found that three (3) cables connecting the ventilator to the wall alarm were defective. There was no preventative-maintenance schedule or manufacture replacement interval for those cables. We replaced them after the event."

During an interview on 9/30/2025 at 4:10 p.m. with the Director of Biomedical engineering (DBM), the DBM stated: "If it (the ventilator alarm cables) stops working, then we replace it." We don't have a set schedule for replacing the ventilator alarm cables. We didn't test the new ones (ventilator alarm cables) before we deliver it to respiratory department (is the hospital unit that helps people with breathing problems)."

During an interview on 10/2/2025, at 9:31 a.m., the Director of Respiratory Services (DRS) stated, "We started testing all the ventilator alarms on 5/30/2025, after the compliance hotline (a confidential and often anonymous reporting system that allows employees and patients to report suspected illegal, unethical, or improper conduct without fear of retaliation) reported issues on 5/20/2025." The DRS confirmed this was 10 days after receiving the report from the compliance hotline and forty-five days after the event on 4/17/2025. The DRS also stated, "We found some cables didn't trigger the alarms, and those were replaced."

During a concurrent interview and record review on 10/3/2025 at 4:40 p.m., with the Governing Board Chair (GBC) of the Governing Body, the meeting minutes dated April through September 2025, were reviewed. GBC confirmed that the GB first heard about patient 1's ventilator alarm not working was on 9/10/2025; however, the incident occurred on 4/17/2025. The GB' s meeting minutes indicated, "Incident involving a patient who became disconnected from a ventilator and experienced altered mental status." The GBC stated, "The expectation is that if an adverse event such as a malfunction of an alarm system cause harm to a patient, it should immediately be reported to GB."

During a review of the facility's "Bylaws of the Governing Board (a governing board are the internal rules that define the structure, operations, and procedures of the board and the organization it oversees)," dated 9/2/2020, the Bylaws indicated, "The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Managers. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital CEO/Administrator. The Governing Board shall require the Medical Staff and staff of the Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, for establishment of a culture of safety and for identifying and resolving problems. The Governing Board, through the Hospital CEO/Administrator, shall support these activities and mechanisms. The Governing Board shall provide resources and support systems for performance assessment and improvement and risk management functions related to patient care and safety. The Governing Board shall consider and, if necessary, act upon the results reported from Performance Improvement activities ..."

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Governing Board has the ultimate authority and responsibility for the care and services rendered within the organization. The Board of Directors has delegated the responsibility of implementing an organization wide Pl Program to the Administration, Medical Staff and Quality Council. The Governing Board takes appropriate actions as needed on the following: The delivery of quality and safe patient care ...Risk Management activities: The organization Pl program is integrated with Risk Management since incident reports may document data that leads to tracking and analyzing the occurrences related to patient safety. The Risk Manager assures timely integration of this risk management information into the organization's performance improvement program activities. Examples of errors reported in the incident report are: medication errors; equipment failure; diagnostic errors; surgical errors; deaths due to restraints ..."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ..."

2. During a review of Patient 2's Operative Report, dated 8/18/2025, the Operative Report indicated the patient (Patient 2) underwent a left tunneled permacath placement (a catheter surgically inserted into a large vein for dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] access) from 8:15 a.m. to 8:22 a.m. on 8/18/2025.

During a concurrent interview and record review on 10/1/2025 at 1:57 p.m., with PACU (Post Anesthesia Care Unit, a specialized area in a hospital where patients who have undergone surgery or other procedures requiring anesthesia are monitored and cared for until they are stable and ready to be discharged) registered Nurse (RN) 1, Patient 2's Vital Signs (essential physiological measurements that indicate a person's overall health and well-being. Includes body temperature, blood pressure, heart rate) Flowsheet, dated 8/18/2025, was reviewed, RN 1 confirmed that Patient 2 arrived in the PACU at 8:38 a.m. with blood pressure of 74/35 (low; Normal range is 120/90) mmHg (unit of measurement). From 8:38 a.m. to 9:48 a.m. on 8/18/2025, Patient 2's blood pressure ranged between 50-80 mmHg and heart rate 52-59 bpm (beats per minute). RN 1 confirmed that Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when the heart stops beating]) was called at 9:48 a.m., an hour after Patient 1 experiencing severe hypotension (dangerously low blood pressure).

During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated, "The patient (Patient 2) was brought into the recovery room already with blood pressure dangerously low (reading is below 90 mmHg and/or the bottom number is below 60 mmHg) the blood pressure was 74 over 35 mm Hg (a unit of measurement). A rapid response (RRT, team of trained staff that respond to patient emergencies) should have been called immediately." CS further confirmed that the Code Blue was not called until over an hour later, and resuscitation (life-saving efforts when a patient's heart or breathing stops) was not successful. CS also stated that the event was discussed among the medical team, but it was not formally reviewed through the QAPI process or by the Government Body.

During a concurrent interview and record review on 10/3/2025 at 1:21 p.m. with the Manager of Risk (MRM), the facility's "Rapid Response" policy and procedure (P&P), dated 5/2025, was reviewed. The P&P indicated, "Any staff member may activate the Rapid Response Team under a "No Blame' policy," with one of the criteria to activate a rapid response was "Changes in systolic blood pressure [SBP, the pressure in the arteries when the heart contracts and pumps blood throughout the body] (<80 mmHg) that is unresponsive to prescribed interventions." MRM confirmed that despite these criteria being met, QAPI did not review the delay or ensure retraining for staff. MRM stated he is involved in the QAPI committee. MRM confirmed the events involving delay in activating a Rapid Response (RRT, a team of clinicians who provide immediate assistance when a patient's condition suddenly worsens) data were not analyzed to identify patterns or delayed activations that could indicate systemic issues in emergency response. MRM confirmed that the facility lacked a system to track, or trend delayed emergency response.

During a review of the facility's "Bylaws of the Governing Board ( the internal rules that define the structure, operations, and procedures of the board and the organization it oversees)," dated 9/2/2020, the Bylaws indicated, "The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Managers. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital CEO/Administrator. The Governing Board shall require the Medical Staff and staff of the Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, for establishment of a culture of safety and for identifying and resolving problems. The Governing Board, through the Hospital CEO/Administrator, shall support these activities and mechanisms. The Governing Board shall provide resources and support systems for performance assessment and improvement and risk management functions related to patient care and safety. The Governing Board shall consider and, if necessary, act upon the results reported from Performance Improvement activities ..."

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Governing Board has the ultimate authority and responsibility for the care and services rendered within the organization. The Board of Directors has delegated the responsibility of implementing an organization wide Pl (Performance Improvement) Program to the Administration, Medical Staff and Quality Council. The Governing Board takes appropriate actions as needed on the following: The delivery of quality and safe patient care ...Risk Management activities: The organization Pl program is integrated with Risk Management since incident reports may document data that leads to tracking and analyzing the occurrences related to patient safety. The Risk Manager assures timely integration of this risk management information into the organization's performance improvement program activities. Examples of errors reported in the incident report are: medication errors; equipment failure; diagnostic errors; surgical errors; deaths due to restraints ..."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event (a serious, unexpected adverse event that results in death, permanent harm, or severe temporary harm to a patient in a healthcare setting), and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ..."

3. During an interview on 10/3/2025 at 1:20 p.m. with the manager of Risk management (MRM), the MRM stated, "We had a meeting called 'Event Call' on August 28 (2025) after the patient (Patient 11) died on August 26 (2025). We thought it was a fat embolism (fat particle released into the bloodstream after bone fracture). We didn't review the blood-clot [VTE, Venous Thromboembolism] risk assessments (a tool used by healthcare providers to identify patients at risk for developing blood clots) or interventions because we thought the cause was fat embolism. We usually don't follow up on autopsy because it's costly. We only learned the autopsy showed pulmonary embolism (blood clot blocking the lungs) when the surveyors asked for it."

During an interview on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), the DOQ stated, "The autopsy showed it was a pulmonary embolism. We weren't aware of that until the survey. We hadn't reviewed the VTE risk assessments for accuracy or looked at whether staff followed up with preventive treatment."

During an interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated the following: The facility had a meeting called "Event Call," on 8/28/2025 to address Patient 11's death on 8/26/2025, because Patient 11 died within 24 hours after undergoing a surgical procedure and anesthesia (a medical state that temporarily blocks pain and other sensations during medical procedures, such as surgery). The facility suspected a fat embolism (fat particle that is released into the bloodstream, is most commonly caused by long bone fractures) was the cause of Patient 11's death because Patient 11 had fracture (break in the bone) on the leg. Therefore, the accuracy of the VTE risk assessments nor the interventions for the VTE risk were not reviewed by the GB or Quality Council nor implemented corrective actions related to Patient 11's death.

During a review of the facility's "Bylaws of the Governing Board (the internal rules that define the structure, operations, and procedures of the board and the organization it oversees)" dated 9/2/2020, the Bylaws indicated, "The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Managers. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital CEO/Administrator. The Governing Board shall require the Medical Staff and staff of the Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, for establishment of a culture of safety and for identifying and resolving problems. The Governing Board, through the Hospital CEO/Administrator, shall support these activities and mechanisms. The Governing Board shall provide resources and support systems for performance assessment and improvement and risk management functions related to patient care and safety. The Governing Board shall consider and, if necessary, act upon the results reported from Performance Improvement activities ..."

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Governing Board has the ultimate authority and responsibility for the care and services rendered within the organization. The Board of Directors has delegated the responsibility of implementing an organization wide Pl Program to the Administration, Medical Staff and Quality Council. The Governing Board takes appropriate actions as needed on the following: The delivery of quality and safe patient care ...Risk Management activities: The organization Pl program is integrated with Risk Management since incident reports may document data that leads to tracking and analyzing the occurrences related to patient safety. The Risk Manager assures timely integration of this risk management information into the organization's performance improvement program activities. Examples of errors reported in the incident report are: medication errors; equipment failure; diagnostic errors; surgical errors; deaths due to restraints ..."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ..."

Based on interview and record review the facility failed to ensure one of 30 sampled patients (Patient 16) participated in the development of his (Patient 16) plan of care (a comprehensive document that outlines the individualized healthcare strategy for a patient) and failed to ensure Patient 16 was informed of the status of Patient 16's discharge (the process of a patient leaving a healthcare facility, such as a hospital or nursing home, after receiving medical treatment), in accordance with the facility's policy and procedure regarding Patient Rights (subset of human rights).

This deficient practice resulted in Patient 16's inability to participate in the development of his discharge plan and resulted in Patient 16 not being informed of the status of his discharge. This deficient practice had the potential to result in lack of patient engagement with discharge plans and the likelihood of hospital readmission.

Findings:

During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/15/2025, the H&P indicated the following: Chief Complaint: Buttock abscess (a localized collection of pus, a thick white or yellow fluid, that forms in response to an infection). The H&P also indicated "patient (Patient 11) with chronic osteomyelitis (inflammation of bone caused by infection), homeless, testicular (in the testicles) cancer in remission (indicates that the cancer has been suppressed or controlled) since 2021 ... presents ...for complications to his sacral (area of bone at the base of the spine) wound that developed after his bout with testicular cancer after cancer spread to bone ...Has been living in a car, was in a nursing home prior to that ..."

During a review of Patient 16's "Social Work Psychosocial (internal cognitive aspects of a person's life and how they interact with society) Note," dated 9/15/2025, the Note indicated the following: "Patient (Patient 16) was admitted with osteomyelitis to the sacral bone ...Patient (Patient 16) states he is homeless and has been living in his van." Patient (Patient 16) stated "I am very sick, and I can no longer live in my van anymore. My primary doctor said I need to be put in a nursing home." The Social Work Psychosocial Note further indicated "Patient (Patient 16) showed me a document apparently from his PCP (primary care provider) stating that he needs a SNF (Skilled Nursing Facility, a specialized residential center that provides post-hospitalization rehabilitation and medical care, often for short-term recovery after an illness or injury). I explained to the Patient that the attending physician will provide a DC (discharge) recommendation. I informed Patient that if a physician recommends SNF, the Case Management Department will contact his insurance for authorization and SNF referral."

During a review of Patient 16's "Social Work Transition Planning Ongoing Assessment Note," dated 9/19/2025, the note indicated the following: Patient 16's Vitals (Vital signs, essential physiological measurements that indicate a person's overall health and well-being. Includes body temperature, blood pressure, heart rate) and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated: Caregiver name/relationship, phone number. Additional details: 9/19/2025 - Patient (Patient 16) remains in Med/Surg unit (Medical Surgical Unit, a hospital ward where patients who are recovering from surgery or have medical conditions that require hospitalization receive care). Per Case Manager, Patient will need SNF for wound care treatment. Will f/u (follow up), as needed."

During a review of Patient 16's "Social Work Transition Planning Ongoing Assessment Note," dated 9/22/2025, the note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated: Additional details: 9/19/2025 - Patient (Patient 16) remains in Med/Surg unit. Per Case Manager, Patient will need SNF for wound care treatment. Will f/u (follow up, as needed. 9/22/2025 - Patient remained in Med/Surg. SNF placement for Patient is pending at this time. Will f/u (follow-up) as needed."

During a review of Patient 16's "Social Work Transition Planning Ongoing Assessment Note, "dated 9/26/2025, the note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated: Additional details: 9/19/2025 - Patient remains in Med/Surg unit. Per Case Manager, Patient will need SNF for wound care treatment. Will f/u (follow up, as needed. 9/22/2025 - Patient remained in Med/Surg. SNF placement for Patient is pending at this time. Will f/u as needed." The additional note for 9/26/2025 also indicated "Patient remains in Med/Surg unit. Patient is ambulating (to walk) around the unit. DC (discharge) Plan for Patient is SNF placement. Will f/u as needed."

During a review of Patient 16's "Social Work Transition Planning Ongoing Assessment Note, "dated 9/30/2025, the note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated: Additional details: 9/19/2025 - Patient remains in Med/Surg unit. Per Case Manager, Patient will need SNF for wound care treatment. Will f/u (follow up, as needed). 9/22/2025 - Patient remained in Med/Surg. SNF placement for Patient is pending at this time. Will f/u (follow-up) as needed. 9/26/2025 - Patient remains in Med/Surg unit. Patient is ambulating around the unit. DC (discharge) Plan for Patient is SNF placement. Will f/u as needed. 9/30/2025 - Patient remains in Med/Surg. Patient will be placed in a SNF when medically stable. Will f/u as needed."

During a review of Patient 16's "Case Management Transition Planning Initial Assessment Note, dated 9/21/2025, the Note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated: Patient 16's caregiver name/relationship and phone number. Case Management additional Information: Additional details: Case management note: Noted case management consult to arrange HH (home health) for home IV (in the vein) antibiotics (medication that kill bacteria infections), clinicals and order faxed to health plan ..."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/22/2025 at 11:22 a.m., the Note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated ...Additional Details: Packet sent to facility for SNF placement. Fax (Facsimile, a technology for sending a scanned copy of a document over a telephone line or other network, which is then printed by the receiving fax machine) ok (okay)."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/22/2025 at 5:44 p.m., the Note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. "Anticipated Discharge Needs Indicated ...Additional Details: Packet sent to the following SNFs for review ..."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/23/2025, the Note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. Anticipated Discharge Needs Indicated Patient 16's caregiver's name/relationship and phone number.

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/24/2025, the Note indicated the following: Patient 16's Vitals and Measurements, Inpatient Medications, Laboratory Results. Anticipated Discharge Needs Indicated Patient 16's caregiver's name/relationship and phone number. "Case Management additional information: Packet details sent to facility, will review. Addendum, at 5:06 p.m., multiple SNF declined Patient 16, one SNF declined (admission) due to wounds and living situation."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/25/2025 at 12:20 p.m., the Note indicated the following: "Interpreter Servies, No, interpretive services not required; Interpreter services declined reason: pending SNF placement, no accepting facility at this time ..."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/25/2025 at 5:42 p.m., the Note indicated Patient 16 "was referred to staff at a healthcare facility and declined ...due to wounds. Caregiver's name/relationship and phone number."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 9/30/2025 at 5:42 p.m., the Note indicated Additional details: "Spoke with staff from a Foundation, stating they are still reviewing. CM (case manager) will continue to follow up."

During a review of Patient 16's "Case Management Transition Planning Ongoing Assessment Note, dated 10/02/2025, the Note indicated additional details: "CM (case management) Note: Received a phone call for SNF coordinator for facility who stated that they are still working on finding a SNF placement for this patient (Patient 16). She (SNF coordinator) also provided the name of the assigned case manager."

During a concurrent observation and interview on 9/30/2025 at 10:20 a.m. with Patient 16, in the Medical Surgical unit, Patient 16 was observed sitting on his bed using a laptop. Patient 16 was alert and oriented. Patient 16 stated the physician agreed that he (Patient 16) needed to be placed in a skilled nursing facility (SNF), however he (Patient 16) was still there, at the facility, in "limbo (uncertain period of awaiting a decision or resolution)." Patient 16 stated he had been waiting to be discharged and pending placement for one week and nobody had reached out to him to inform him of the status of his discharge.

During a concurrent interview and record review on 10/3/2025 at 10 a.m. with the Director of Case Management (DCM), Patient 16's social worker's notes, dated 9/15/2025 through 10/2/2025, were reviewed, The DCM stated patients were evaluated upon admission regarding their discharge plan. The social workers and case managers handle the patient's discharge and placement. Social workers and case managers conducted virtual interdisciplinary rounds every day at 10 a.m. The virtual interdisciplinary rounds were conducted in collaboration with a physician, attending physician, social worker, case manager and nursing staff. The team discusses the pending discharge of patients. The patients were not present during these rounds. The DCM said either the social workers or case managers should inform the patients of any updates regarding their discharge or placement. Patients have the right to participate in their own discharge plan and patients have the right to be informed of the status of their discharge or placement. The DCM reviewed the initial social worker's note, dated 9/15/2025, and confirmed there was documentation indicating that a social worker spoke with Patient 16 regarding placement during discharge. The DCM reviewed the social worker and case management notes, dated 9/16/2025 through 10/2/2025, and verified there was no other follow up documentation indicating that neither the social worker nor the case manager communicated with Patient 16 to inform him (Patient 16) about the status of his discharge.

During a review of the facility's policy and procedure (P&P) titled, "Rights and Responsibilities of Patients," dated 1/2024, the P&P indicated the following: "The organization believes that patients have certain rights and responsibilities while under our care and service. These rights and responsibilities are codified in State and Federal regulations, as well as accreditation standards ...All hospital personnel shall observe and respect these patient's rights and responsibilities ...4. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care in terms you can understand. You have the right to effective communication and to participate in the development of your plan of care ...16. Be informed by the physician, or a delegate of the physician, of continuing health requirements and options following discharge from the hospital. You have the right to be involved in the development of and implementation of your discharge plan ..."

Based on observation, interview, and record review, the facility failed to ensure a safe setting for one (1) of 30 sampled patients (Patient 1) who was ventilator-dependent (required a mechanical machine to help with breathing) through a tracheostomy (a surgically created opening in the neck into the windpipe to aid breathing) when the facility failed to:

1. Maintain a functional ventilator (mechanical machine to help with breathing) alarm system according to manufacturer specifications and the facility's policy and procedure titled, "Biomedical Engineering Medical Equipment Maintenance Program."

2. Activate a rapid response (RRT, a team of medical professionals who responed immediately to patients showing early signs of severe medical distress, such as abnormal heart rate or breathing), in accordance with the facility 's policy titled "Rapid Response," when Patient 1's heart rate (HR, number of times the heart beats per minute) stayed above 130 beats per minute (BPM) for more than one hour.

These deficient practices resulted in Patient 1 being disconnected from the ventilator for approximately 15-20 minutes without staff awareness, causing anoxic brain injury (severe brain damage caused by lack of oxygen) and a persistent vegetative state (a condition in which a person is awake but unaware due to extensive brain injury). This deficient practice also placed all ventilator-dependent patients at risk for serious harm or death.

On 10/1/2025 at 3:54 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality Assurance Performance Improvement (DOQ), Director of Cardiopulmonary (DRS), Director of Labor and Delivery Services (DLD), Director of Emergency Services/Intensive Care Unit/Director of Nursing (DED/ICU), Director of Surgery Services (DIRS), Director of Medical Staff (MSD), Director of Security/Emergency Management/Environmental Services (DOS/EM), Manager of Risk Management (MRM), Supervisor of Medical Staff (MSS), Director Informatic Technician (IT 2), Informatic Technician (IT 3), and Informatic technician (IT 4).

The facility failed to ensure a safe setting for Patient 1, who was ventilator-dependent (required a mechanical machine to assist with breathing) via tracheostomy (surgically created opening in front of the neck that connects functional ventilator alarm system), and the facility failed to activate a rapid response (RRT, a team of specially trained medical professionals who are immediately called to the bedside of a patient with early signs of clinical deterioration [a decline in a patient's health status, characterized by worsening symptoms, vital signs -physiological measurements that indicate a person's basic bodily functions which include temperature, heart rate, blood pressure and respiratory rate, or other indicators of disease progression, such as abnormal vital signs or altered mental status [a significant change in a person's level of consciousness, awareness, and cognitive function- the mental processes of perception, thinking, reasoning, learning, and memory]), when Patient 1 developed abnormally fast heart rate, exceeding 130 beats per minute (BPM) for over six hours. There was over six (6) hours delay in calling a rapid response.

On 10/1/2025, the Director of Biomedical Engineering stated they (the facility maintenance team) did not perform scheduled inspections, preventive maintenance, or functional testing of the ventilator-wall- alarm cables. On 4/17/2025, staff were unaware that the alarm system failed to activate when Patient 1's ventilator became disconnected. On 9/30/2025, the Chief Nursing Officer (CNO) stated that the ventilator's wall alarm did not sound at the nurses' station; three connection cables were later found defective. The CNO confirmed there was no preventative-maintenance scheduled or manufacturer-based replacement interval for the alarm cables. As a result, Patient 1 was disconnected from the ventilator for approximately 15-20 minutes without staff awareness, causing anoxic brain injury (severe and irreversible brain damage due to lack oxygen) and a persistent vegetative state (a condition in which a person loses awareness and the ability to interact with the environment but retains basic functions such as reflex movements and regulation of heart rate and blood pressure).

On the morning of 4/17/2025, Patient 1's heart rate (HR) increased above 130s starting at 10:05 a.m. The "Event List Report (a system log showing significant telemetry [the continuous, remote monitoring of a patient's vital signs, most commonly their heart rhythm] alerts)," dated 4/17/2025, indicated multiple alarms was alerting for HR higher than 120 from 10:05 a.m. and dropped to 30 BPM (bradycardia, abnormal slow heart rate - a normal resting heart rate for adults ranges from 60 to 100 BPM). On 10/2/2025, the CNO confirmed that this (multiple instances of HR higher than 130 BPM) met the criteria under the facility's "Rapid Response" policy, which required an RRT to be called when a patient's HR exceeded130 BPM. These 6 hours delay in emergency activation likely contributed to Patient 1's anoxic brain injury.

On 10/3/2025 at 6:02 p.m., the IJ was removed in the presence of the CEO, CNO, DOQ, DRS, DLD, DED/ICU, DIRS, DOS/EM, MRM, Clinical Education Director (CE), Director of Medical Surgical and Telemetry (DMST), Supervisor of Health Information Management (HIMS), Director of Pharmacy Services (DPM), Infection preventionist (IP), Director of Facility (DF), Clinical Informatic (IT 2), and Director of Admitting Department (DA) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan included: All ventilator nurse call (VNC) cables were tagged, tested, and logged into the biomedical asset management system on 10/2/2025. A six-month preventive maintenance schedule was established by manufacturer specifications, and the Biomedical Engineering Director now performs weekly audits of the maintenance log for compliance. A detailed workflow was created for replacement, malfunction reporting, and manufacturer investigation of defective cables, with documentation required for each action. Respiratory Therapy (RT, healthcare professionals who specialize in the assessment, diagnosis, and treatment of patients with breathing difficulties) staff were directed to function-test ventilator alarms every two hours during patient care and record results in the electronic medical record (EMR). The RT Director will review this documentation daily to ensure compliance.

The facility revised its policy titled, "Ventilator Alarm/Check (approved 10/1/2025)," to include verification of external alarm connections, cable integrity checks, and confirmation that audible and visual alerts, function both at the bedside and at the nurses' station. All RT staff received education and competency validation on the updated policy at the start of each shift until full department training was achieved.

For telemetry alarm management, a Cardiac Monitoring Technician Quick Reference Guide and an updated Telemetry Monitor Tech Report were implemented to ensure prompt identification and escalation of abnormal cardiac events (including sustained tachycardia [an abnormally fast heart rate; a heart rate more than 100 BPM at rest], bradycardia, or rhythm changes). Education was provided to all telemetry technicians and licensed nurses on relevant policies, including "Chain of Command," "Medical Device Alarm Safety," and "Notification of Physician for Unusual Events or Change in Patient Condition." The updated reporting tool now includes patient identifiers, baseline rhythm, alarm thresholds, and documentation of the nurse notified and time of response. Ongoing accountability systems were established: RT staff perform and document ventilator alarm checks every two hours; RT Director audits alarm documentation daily; Biomedical Engineering tracks preventive maintenance and work order completion; Telemetry Monitor Technicians record alarm events, with licensed nurses required to respond immediately; if no response, escalation occurs to the Charge Nurse, then the House Supervisor, and finally Rapid Response activation; Directors of Nursing, Biomedical, and RT audit compliance and report to the Chief Nursing Officer (CNO), who maintains overall accountability.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/17/2025, the "H&P" indicated, Patient 1's medical history included type 2 diabetes (a chronic condition where blood sugar is too high), tracheostomy (a surgically created opening in the neck into the windpipe to aid breathing) dependence, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a waste product of the body that is transported in the blood from the tissues to the lungs and then breathed out]). Patient 1 was admitted to evaluate possible tuberculosis (TB, an infectious airborne disease caused by bacteria).

During a review of Patient 1's "Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when the heart stops beating]) Consultation Note," dated 4/17/2025, the record indicated that "the patient (Patient 1) apparently became disconnected from the ventilator and was noted to become profoundly bradycardic (heart rate below 60 beats per minute), briefly pulseless (no heartbeat) and apneic (not breathing)."

During a concurrent observation and interview on 9/30/2025 at 10:14 a.m. with Respiratory therapist (RT) 1 in room ABC, RT 1 demonstrated that the ventilator alarm cable connected to the wall panel also housed the patient call bell system (a system that alerts nurses when a patient needs help). RT 1 stated, "If the cable malfunctions, the alarm won't sound at the nurses' station."

During an interview on 9/30/2025 at 3:48 p.m. with the CNO, the CNO stated Patient 1 was placed in a negative-pressure room (a room that prevents airborne contaminants from escaping) while being ruled out for TB. Following the incident, the facility's internal review found that the ventilator alarm system did not activate when disconnected. Three (3) ventilator alarm cables were later found defective. The CNO confirmed that the facility continued to use the same cable model without a replacement scheduled or manufacturer guidance.

During an interview on 9/30/2025 at 4:10 p.m. with the Director of Biomedical Engineering (DBM), the DBM confirmed there were no manufacturer recommendations or preventive maintenance procedures for the ventilator cables. The DBM stated, "If it stops working, then we replace it." The DBM also confirmed that the Biomedical Department did not contact the manufacturer after the event or function-test new cables before use.

During an interview on 10/1/2025 at 9:31 a.m. with the Director of Respiratory Services (DRS), the DRS stated cables were only checked when connecting a ventilator for patient use. The DRS stated the metal pins in the cables could bend or break, preventing proper alarm activation.

During an interview on 10/1/2025 at 10:03 a.m. with the Lead Respiratory Therapist (LRT), the LRT confirmed that the cables were "not routinely inspected for wear and tear."

During a review of the facility's policy and procedure (P&P) titled, "Biomedical Engineering Medical Equipment Maintenance Program," dated 8/2025, the policy indicated:

"The Medical Equipment Management Program (MEMP) is to establish systems and procedures that assure all equipment used in the care and treatment of patients within the hospital environment is safe and properly maintained according to the manufacturer's specifications. Biomedical Engineering Management will inspect new clinical equipment before initial use and at scheduled intervals thereafter."

During a review of the facility's policy and procedure (P&P) titled, "Alarms, Medical Device Alarm Safety," dated 1/2024, the P&P indicated, "Staff is expected to verify that critical (life threatening) alarms are in the on position ... Operational functionality of medical device alarms will be checked in accordance with manufacturer instructions as part of the equipment(s) biomedical preventive maintenance and repair program. In addition, users of medical devices shall verify as appropriate that critical alarms are in the "on" position and sufficiently audible."

During a review of the facility's policy and procedure (P&P) titled, "Ventilator Safety," dated 1/2024, the P&P indicated, "Alarms must be checked and patient assessed to correct alarm ... Monitoring devices should be checked frequently for efficiency.

2. During a concurrent interview and record review on 10/2/2025 at 11:00 a.m. with the Chief Nursing Officer (CNO), Patient 1's "Event List Report (a system log showing significant telemetry [the continuous, remote monitoring of a patient's vital signs, most commonly their heart rhythm] alerts)," dated 4/17/2025, was reviewed. The report indicated that Patient 1's heart rate readings indicated sustained tachycardia (a heart rate faster than 100 beats per minute [BPM]) starting at 10:05 a.m., (120 BPM), rose to 166 BPM at 2:45 p.m., and dropped to 30 BPM at 4:15 p.m. when the Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when heart stops beating effectively]) was called (more than eight hours after the abnormal heart rate began). CNO confirmed that these readings met the facility's Rapid Response (RRT, a team of medical professionals who reponed immediately to patients showing early signs of severe medical distress, such as abnormal heart rate or breathing)" policy criteria for activation (HR >130 BMP). However, no rapid response was initiated prior to the cardiac arrest.

During an interview on 10/1/2025 at 11:20 a.m. with the Director of Quality Assurance Performance Improvement (DOQ), the DOQ stated, "Nurses are empowered to call a Rapid Response at any time they believe a patient's condition is deteriorating." The DOQ confirmed that staff failed to follow the policy regarding rapid response activation.

During an interview on 10/1/2025 at 2:22 p.m. with Registered Nurse (RN) 4, RN 4 stated they were unaware that Patient 1's heart rate was elevated throughout the day. RN 4 confirmed they did not verify ventilator alarm function during the shift.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response," dated 5/2025, the P&P indicated, "Criteria for calling the team may include but are not limited to changes in heart rate or rhythm (acute or subtle) less than 40 or greater than 130 BPM; respiratory rate less than 8 or greater than 30 per minute; patient in distress; or any situation where staff believes immediate assistance is needed."

During a review of the facility's policy and procedure (P&P) titled, "Rights and Responsibilities of Patients," dated 1/2024, the P&P indicated, "To ensure the rights of all patients, all individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated ... Receive care in a safe setting."

Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) Committee failed to review and analyze data collected from two of 30 sampled patients' (Patient 11 and Patient 12) Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments to ensure that the VTE risk assessments (used to identify individuals at risk of developing blood clots in the veins) were performed accurately and appropriate interventions were implemented to reduce the risk of patients developing blood clots during their hospital stay. In addition, the QAPI committee failed to ensure there was a process in place to direct nursing staff on the performance of accurate VTE risk assessments and the appropriate interventions to implement for patients identified with VTE risk level of Low, Moderate, or High risk.

This deficient practice of the QAPI's failure to review and analyze collected VTE risk assessments data, resulted in a missed opportunity to identify risks, improve care, and monitor performance, and implement targeted actions to prevent patient harm. This deficient practice placed Patients 11 and 12, including other patients, at risk of developing blood clots, when nursing staff performed inaccurate VTE assessments for patients (Patients 11 and 12), which resulted in the lack of appropriate VTE prophylactic (preventive) interventions for Patient 11, who was at high risk for VTE formation. Patient 11 developed a blood clot after undergoing a surgical procedure and subsequently expired (died) of a pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot).

Findings:

1. During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated he (CS) was also involved in the Quality Council Committee. The CS stated he (CS) was aware of Patient 11's death, that occurred on 8/26/2025. The facility suspected Patient 11 passed away from fat embolism (fat particle that is released into the bloodstream, is most commonly caused by long bone fractures). CS was not aware of the medical examiner report (autopsy report, a medical examination of a body after death to find out how and why someone died) indicating Patient 11 died of a pulmonary embolism due to a blood clot, until today 10/2/2025 when CS was informed by the surveyors. The CS stated sequential compression devices (SCD, a device used to improve circulation in the legs to help prevent blood clots) should automatically be placed on all patients who were in bed and not moving, unless there were contraindications, such as bleeding, surgery, or wound, to reduce the patients risk of developing a blood clot. It (SCD) should not require a physician's order. The CS stated there was no algorithm (a set of clear, step-by-step instructions) or process in place for VTE (Venous Thromboembolism, when blood clot forms in the vein) prevention at the facility. CS said that (no algorithm or process) was a system failure on the facility's part. In addition, the CS stated he was not aware that the VTE risk assessments (used to identify individuals at risk of developing blood clots in the veins) were inaccurate for Patient 11.

During an interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated the following: MRM was involved in the QAPI program. The QAPI was a hospital-wide program, and its goal was to help the facility improve healthcare service, performance, maintain good standards and comply with regulatory requirements. The MRM stated that VTE was one of the facility's Core Measures (a set of standardized, evidence-based healthcare practices designed to improve patient outcomes and ensure high-quality care).
The collection of the VTE data was performed by an "abstractor," who worked remotely. The abstractor reviewed medical records and documents furnished by the facility to determine whether patients were assessed for VTE risk and whether interventions for VTE prophylaxis (actions taken to prevent a disease or condition) were implemented for patients. The MRM said that the accuracy of the VTE assessments was not reviewed and analyzed in order to identify areas of patient care improvement and come up with effective action plans to address VTE risk assessments and interventions. The MRM further stated nobody made rounds on patients to follow-up and ensure the appropriate VTE prophylaxis interventions were implemented.

During the same interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated that over the past four (4) years there has not been any incidents of a patient developing a VTE. However, MRM could not explain how the QAPI Committee came up with that number. MRM stated the facility did not follow up on autopsy reports for patients who met the criteria for an autopsy (Per Coroner Case guidelines, such as deaths within 24 hours of surgery or anesthesia, due to drowning, drug addition, associated with crimes ...) because it was too costly. The MRM stated that Patient 11 died within 24 hours, on 8/26/2025, of having a surgical procedure and receiving general anesthesia. The facility suspected the cause of death was a fat embolism due to Patient 11 having surgery on the leg. The facility became aware that Patient 11 died of a pulmonary embolism on 9/30/2025, when the surveyors requested the autopsy results for Patient 11. In addition, the facility was not aware that VTE risk assessments performed by nursing staff were inaccurate.

During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/23/2025, the H&P indicated Patient 11 was 63 years old, who had a fall (an unintentional decent to the ground, floor, or other lower surface, with or without injury) while working. The H&P also indicated Patient 11 "was loading and unloading big pipes ...the pipes started falling down and Patient 11 suffered a 5-to-6-foot fall ...Assessment and Plan indicated Patient 11 suffered a fracture (break) to the right proximal humerus (upper arm bone), left tib-fib (tibia-fibula, bones to lower leg) fracture and compression (pressure) fracture of the spine (backbone)."

During a review of Patient 11's "Computerized Provider Order Entry (CPOE, electronically transmit treatment instructions, such as medication, laboratory, and radiology orders, replacing traditional paper or verbal methods to improve patient safety and care quality)," dated 8/23/2025 at 2:33 p.m., the CPOE indicated "Lovenox (enoxaparin, a "blood thinner' to reduce the risk of blood clots). Per Rx (prescription) - DVT (deep vein thrombosis, blood cloth that forms in one or more of the dep veins, typically in the legs) prophylaxis (preventive measure taken to avoid or reduce the risk of complications), pharmacy to dose rate and frequency."

During a review of Patient 11's Medication Administration Record (MAR), dated 8/23/2025, the MAR indicated Patient 11 received enoxaparin 40 mg (milligrams, a unit of measurement) subcutaneously (under the skin) in the middle of the abdomen at 8:46 p.m. on 8/23/2025.

During a review of Patient 11's "CPOE," dated 8/24/2025 at 7:34 a.m., the CPOE indicated to discontinue Lovenox (enoxaparin).

During a review of Patient 11's VTE (Venous Thromboembolism, blood clot forms in a vein) assessments, dated 8/23/2025 at 1:14 p.m., the VTE assessment indicated the following: Low Risk Factors: Age 60 or below. VTE Prophylaxis interventions: Graduated Knee-High Compression Stocking (a stocking that applies the highest pressure at the ankle and gradually deceases it up the leg to help promote blood flow and reduce swelling) - Applied. VTE Risk Level: Low Risk. (The assessment was incorrect, Patient 11 was actually 63 years old and was at high risk for VTE because of Patient 11's fracture of the left leg, this was verified by the Director of Quality [DOQ] during an interview).

During a review of Patient 11's VTE assessments, dated 8/23/2025 at 8 p.m., 8/24/2025 at 8 p.m., 8/25/2025 at 6:55 a.m., and 8 p.m., the VTE assessments indicated the following: Patient 11 was 61 to 75 years old, Moderate Risk, No Mechanical VTE prophylaxis (a non-invasive method that uses medical devices to prevent blood clots. Example: Sequential Compression Device [SCD, medical device used to prevent blood clots in hospitalized or immobile patients by intermittently inflating and deflating sleeves or cuffs around the legs to improve circulation]), Pharmacological prophylaxis (the use of medication to prevent a condition or complication). (The assessment was incorrect because Patient 11 was at high risk for VTE and was not receiving any VTE prophylaxis at that time, this was verified by the DOQ during an interview).

During a review of Patient 11's VTE assessment, dated 8/26/2025 at 6 p.m., the VTE assessments indicated Moderate Risk Factors included his (Patient 11) age of 61 - 75. The Risk Level was not documented. VTE Interventions: Intermittent Pneumatic Compression Device applied to the Right (leg). (The assessment was incomplete because Patient 11's VTE risk level was not documented; this was verified by the DOQ during an interview).

During a review of Patient 11's Physician Progress Note, dated 8/26/2025, the Physician progress note indicated Patient 11 was in critical condition in the Intensive Care Unit (provides critical care for severely ill or injured patients who need intensive medical monitoring and round-the -clock care). The Physician Progress Note also indicated "Left lower leg procedure took about 45 minutes today (8/26/2025) spent about 80 minutes in the operating room (OR). Rapid deterioration (worsening of condition) after procedure took place ...diagnosis: respiratory failure a serious condition that happens when the lungs cannot get enough oxygen into the blood), left tib-fib fracture. The patient deteriorated rapidly and unexpectedly. I was informed at around midnight that the patient (Patient 11) has passed (died)."

During a review of Patient 11's Autopsy report titled, "Medical Examiner," date of death 8/26/2025, the Autopsy report indicated Patient 11 died in the hospital. Cause A: Pulmonary Embolism. Cause B: Phlebothrombosis (a blood clot forms in a vein without significant inflammation).

During a concurrent interview and record review on 9/30/2025 at 11:16 a.m. with the Director of Surgery (DIRS), in the Post Anesthesia Care Unit (PACU, a specialized area in a hospital where patients who have undergone surgery or other procedure requiring anesthesia are monitored and cared for until they are stable and ready to be discharged), Patient 11's "OR (Operating Room) Log," was reviewed. The DIRS stated Patient 11 arrived to the PACU on 8/26/2025 at 2:40 p.m. after undergoing a surgical procedure, a placement of intramedullary (within a bone) nails to the left tibia (leg). Patient 11 arrived on a ventilator (breathing machine) and intubated (a tube inserted into the airway to maintain an open passage for air and oxygen to reach the lungs) from the OR and was transferred to the ICU at 4:10 p.m.

During a concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), Patient 11's History and Physical and VTE risk assessments, were reviewed. The DOQ stated the following: Patient 11 was 63 years old and was admitted, on 8/23/2025, from another hospital for surgical repair for a fracture of the left leg due to a fall while Patient 11 was working. Patient 11's VTE risk assessments were inaccurate because Patient 11 was 63 years old and had a High risk factor of fracture to the leg. Patient 11 should have been assessed as having a High risk for VTE, not low or moderate risk. In addition, the VTE assessments indicated no mechanical VTE prophylaxis was provided. It also indicated that Patient 11 had been receiving pharmacological prophylaxis, however, Patient 11 only received pharmacological prophylaxis, once, on 8/23/2025, then it was discontinued by the physician. Patient 11 had surgical repair of the fracture to the left leg on 8/26/2025, had unstable vital signs and remained intubated after the procedure, due to unstable vital signs. Patient 11 was transferred to the ICU, made a DNR (Do Not Resuscitate, instructs healthcare providers not to perform life-sustaining measures) and passed away on 8/26/2025 at 11 p.m.

During the same interview on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), the DOQ stated the facility followed up on the Autopsy on 9/30/2025 (when the surveyors were at the facility for a survey). The Autopsy indicated Patient 11 died of a pulmonary embolism (lungs become blocked by a blood clot). The DOQ stated VTE assessments should be done once per shift, per policy regarding assessments. The DOQ verified there was no specific policy regarding VTE assessments indicating what do when patients were at risk for developing blood clots. The DOQ was unsure of what the process was for implementing interventions for patients at risk of blood clot formation. The DOQ verified there was no process in place to address VTE, only that an assessment should be done. In addition, the DOQ was not previously aware that the VTE assessments were inaccurate. The DOQ stated patients who were at risk of blood clot formation should have sequential compression device placed on the legs to promote circulation and to have medications for blood clots, if indicated.

During an interview on 9/30/2025 at 3:57 p.m. with the Manager of Risk Management (MRM), the MRM stated there was no process in place that indicated the steps to take when a patient was at low, moderate, or high risk of developing a blood clot.

During a concurrent interview and record review on10/1/2025 at 10:44 a.m. with the Pharmacist Informatics Specialist (IT 2) Patient 11's orders were reviewed. The IT 2 stated there were no orders for Sequential Compression Device (SCD, used to prevent blood clots in deep veins) for Patient 11.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the P&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours.

During a review of an undated, blank form titled, "Daily Focus Assessment," for VTE assessments, the form indicated that VTE risk level factors, were as follows:
Low Risk Factors: Age 60 or below, Obesity (BMI less than 35), Dehydration, Congestive Heart Failure, Minor Surgery, Expected stay less than 2 days, and Pregnancy.
Moderate Risk Factors: Age 61 to 75, Prior history of VTE, Impaired mobility for more than 72 hours, Moderate to Major Surgery, Central Venous Access, Estrogen based replacement therapy, Sickle Cell disease. High Risk Factors: Age 75 or above, Stroke, Fracture of hip, pelvis, or leg, Hip or Knee replacement, Morbid Obesity, Acute Myocardial Infarction (heart attack), Postpartum (after childbirth) with immobility for more than 24 hours.

During the review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the H&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours. Assessment/Reassessment parameters: Total system assessment every shift or if condition changes. Specific VTE assessments were not included in the policy, this was verified by the DOQ.

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Hospital-wide Performance Improvement (PI) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing, facility-wide, contract services, improved outcomes and reduction in medical errors. This PI Plan describes the communication and coordination of all organizational activities directed toward improving patient care ...Provides high quality, cost effective clinical services and demonstrates the outcomes of services through a system of data collection, aggregation, and analysis ...Provides a mechanism to assure that all patients receive the same level of care. Provides a culture that promotes risk reduction strategies to prevent adverse outcomes to patients ...The Quality Council will assure the integration and coordination of medical staff, nursing, and support services in PI activities including patient safety related project. They (Quality Council) will also review and analyze reports presented by the Medical Staff Departments / Committees, department PI activities which include all disciplines in the hospital. Analysis of Data: Data on performance measures will be analyzed to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities for improvement and changes that will lead to improvement.

2. During a review of Patient 12's "History and Physical (H&P)," dated 9/26/2025, the H&P indicated Patient 12 was 64-year-old, "presents after a mechanical fall (a fall that is attributed to external factors, such as tripping, slipping, or stumbling) where she (Patient 12) landed on the right patella (knee) ...found to have a distal femur (thigh) fracture with hemarthrosis (blood accumulation) to the right patellar region."

During a review of Patient 12's VTE Risk Assessments, dated 9/26/2025 through 9/29/2025, the VTE Risk Assessments indicated a VTE Risk Level of Moderate Risk. The assessment did not include Patient 12's High Risk Factor of having a fracture in the leg. (The assessment was inaccurate; this was verified by the DOQ during an interview).

During an interview on 9/30/2025 at 4:10 p.m. with Registered Nurse (RN) 3, RN 3 stated the following: VTE assessments were done every four (4) or eight (8) hours, but she (RN 3) was not sure about the frequency. If patients had a fracture to the legs, they were considered to be at high risk of developing blood clots. If a patient was a high risk, they should be placed on mechanical VTE (Sequential Compression Device [SCD, used to prevent blood clots in the deep veins]) or prescribed pharmacological (medication) prophylaxis. Both SCDs and pharmacological prophylaxis required a physician's order. If there were no orders, the nurse should call the physician for orders.

During a concurrent interview and record review on 9/30/2025 at 4:30 p.m. with the DOQ, Patient 12's VTE Risk assessments, dated 9/26/2025 through 9/29/2025, were reviewed. The DOQ verified that Patient 12 had a high risk for developing a blood clot. The DOQ stated that VTE assessments for Patient 12 were not accurate. The purpose of the VTE assessments was to determine the patient's risk of developing a blood clot which guides what interventions would be implemented to reduce the risk of developing a blood clot.

During a review of Patient 12's physician's order, dated 9/26/2025 at 5:29 a.m., the physician's order indicated to start Heparin (a fast-acting "blood thinner" that prevents the formation of new blood clots) 5,000 Units (a unit of measurement) 9 a.m., route; Subcutaneous (under the skin), every 8 hours.

During a review of Patient 12's Medication Administration Record (MAR), dated 9/26/2025, the MAR indicated that Patient 12 received the first dose of Heparin 5,000 Units at 9:12 a.m.

During a review of an undated, blank form titled, "Daily Focus Assessment," for VTE assessments, the form indicated that VTE risk level factors, were as follows:
-Low Risk Factors: Age 60 or below, Obesity (BMI less than 35), Dehydration, Congestive Heart Failure (a condition where the heart muscle is weakened and cannot pump blood effectively), Minor Surgery, Expected stay less than 2 days, and Pregnancy.
-Moderate Risk Factors: Age 61 to 75, Prior history of VTE, Impaired mobility for more than 72 hours, Moderate to Major Surgery, Central Venous Access, Estrogen based replacement therapy, Sickle Cell disease (a genetic blood disorder that causes red blood cells to become abnormally shaped [sickle-shaped]).
-High Risk Factors: Age 75 or above, Stroke (when blood flow to the brain is interrupted), Fracture of hip, pelvis, or leg, Hip or Knee replacement, Morbid Obesity, Acute Myocardial Infarction (heart attack), Postpartum (after childbirth) with immobility for more than 24 hours.

During an interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated the following: MRM was involved in the QAPI program. The QAPI was a hospital-wide program, and its goal was to help the facility improve healthcare service, performance, maintain good standards and comply with regulatory requirements. The MRM stated that VTE was one of the facility's Core Measures (a set of standardized, evidence-based healthcare practices designed to improve patient outcomes and ensure high-quality care).
The collection of the VTE data was performed by an "abstractor," who worked remotely. The abstractor reviewed medical records and documents furnished by the facility to determine whether patients were assessed for VTE risk and whether interventions for VTE prophylaxis (actions taken to prevent a disease or condition) were implemented for patients. The MRM said that the accuracy of the VTE assessments was not reviewed and analyzed in order to identify areas of patient care improvement and come up with effective action plans to address VTE risk assessments and interventions. The MRM further stated nobody made rounds on patients to follow-up and ensure the appropriate VTE prophylaxis interventions were implemented.

During the same interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated that over the past four (4) years there has not been any incidents of a patient developing a VTE. However, MRM could not explain how the QAPI Committee came up with that number. In addition, the facility was not aware that VTE risk assessments performed by nursing staff were inaccurate.

During an interview on 9/30/2025 at 3:57 p.m. with the Manager of Risk Management (MRM), the MRM stated there was no process in place that indicated the steps to take when a patient was at low, moderate, or high risk of developing a blood clot.

During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated there was no algorithm (a set of clear, step-by-step instructions) or process in place for VTE (Venous Thromboembolism, when blood clot forms in the vein) prevention at the facility.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the P&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours. Assessment/Reassessment parameters: Total system assessment every shift or if condition changes. Specific VTE assessments were not included in the policy, this was verified by the DOQ.

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Hospital-wide Performance Improvement (PI) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing, facility-wide, contract services, improved outcomes and reduction in medical errors. This PI Plan describes the communication and coordination of all organizational activities directed toward improving patient care ...Provides high quality, cost effective clinical services and demonstrates the outcomes of services through a system of data collection, aggregation, and analysis ...Provides a mechanism to assure that all patients receive the same level of care. Provides a culture that promotes risk reduction strategies to prevent adverse outcomes to patients ...The Quality Council will assure the integration and coordination of medical staff, nursing, and support services in PI activities including patient safety related project. They (Quality Council) will also review and analyze reports presented by the Medical Staff Departments / Committees, department PI activities which include all disciplines in the hospital. Analysis of Data: Data on performance measures will be analyzed to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities for improvement and changes that will lead to improvement.

Based on interview and record review, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI, system that collects and analyzes data to identify and correct quality-of-care problems) committee, effectively tracked, investigated, analyzed, and implemented corrective actions for five (5) of 30 sampled patients (Patient 1, Patient 2, Patient 11, Patient 21, and Patient 22) who experienced serious adverse events (any unintended injury or harm to a patient caused by medical care, rather than their underlying condition), in accordance with the facility's QAPI plan. The QAPI program did not identify system-wide performance gaps (deficiencies or shortcomings that affect the overall performance of an entire system), ensure timely investigations of adverse patient events, or monitor corrective actions to prevent recurrence.

This deficient practice resulted in delayed review of adverse events involving serious patient harm, which can result in recurrence of patient harm and/or death for other patients if not addressed, when:

1. Patient 1 sustained anoxic brain injury (severe brain damage caused by lack of oxygen) after a ventilator alarm cable (a wire connecting the breathing machine to the nurse -call-system [communication tool that allows patients to alert staff when they need assistance]) failed and no maintenance or testing program existed.

2. Patient 2 expired in the Post Anesthesia Care Unit (PACU, a specialized area in a hospital where patients who have undergone surgery or other procedure requiring anesthesia are monitored and cared for until they are stable and ready to be discharged) after staff failed to activate a Rapid Response Team (RRT, an emergency group that responds when a patient suddenly deteriorates) despite clear signs of distress (unstable patient condition) and dangerously low blood pressure.

3. Patient 11 died of pulmonary embolism (a blockage in the lungs caused by a blood clot) following inaccurate Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments and lack of preventive actions. This has the potential for inappropriate preventive measures, which placed patients at risk of developing blood clots in the legs. The blood clots can become dislodged and travel to the lungs and cause a pulmonary embolism (lungs become blocked from a blood clot) and may result in death.

4. Patient 21 and Patient 22 did not receive timely activation of RRT when Patient 21 experienced multiple episodes of seizure (sudden uncontrolled body movements caused by abnormal brain activity) and Patient 22 experienced low blood pressure, leading to delayed treatment and transfer to intensive care.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/17/2025, the "H&P" indicated, Patient 1's medical history included type 2 diabetes (a chronic condition where blood sugar is too high), tracheostomy dependence (patient requiring a tube inserted into their windpipe at the neck to assist breathing), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a waste product of the body that is transported in the blood from the tissues to the lungs and then breathed out]). Patient 1 was admitted for evaluation of possible tuberculosis (TB, an infectious airborne disease caused by bacteria).

During an interview on 10/1/2025 at 9:30 a.m. with the Chief Nursing Officer (CNO), the CNO stated that the ventilator disconnection for Patient 1 occurred on 4/17/2025, but the Risk Management Department was unaware because staff did not enter the event into the internal incident-reporting system (the database for logging patient-safety events). The CNO stated the issue came to light only after a complaint was received through the compliance hotline (are telephone or online services allowing employees and other stakeholders to report ethics violations or misconduct confidentially) on 5/20/2025, 33 days later. The CNO stated when the investigation began, the facility discovered the ventilator alarm cables connecting to the wall alarm were defective and had never been tested or replaced on schedule. Three (3) defective cables were found across the hospital.

During an interview on 10/2/2025, at 9:31 a.m., the Director of Respiratory Services (DRS) stated, "We started testing all the ventilator alarms on 5/30/2025, after the compliance hotline (a confidential and often anonymous reporting system that allows employees and patients to report suspected illegal, unethical, or improper conduct without fear of retaliation) reported issues on 5/20/2025." The DRS confirmed this was 10 days after receiving the report from the compliance hotline and forty-five days after the event on 4/17/2025. The DRS also stated, "We found some cables didn't trigger the alarms, and those were replaced."

During a review of the facility's policy and procedure (P&P) titled, "Biomedical Engineering Medical Equipment Maintenance Program," dated 8/2025, the policy indicated:
"The Medical Equipment Management Program (MEMP) is to establish systems and procedures that assure all equipment used in the care and treatment of patients within the hospital environment is safe and properly maintained according to the manufacturer's specifications. Biomedical Engineering Management will inspect new clinical equipment before initial use and at scheduled intervals thereafter."

During a review of the hospital's policy and procedure (P&P) titled, "Rapid Response Teams" (dated 5/2025), the policy indicated, "Purpose: To ensure rapid intervention in cases of patient deterioration and improve patient outcomes by facilitating early recognition, prompt assessment, and immediate implementation of a multidisciplinary approach. Any staff member may activate the Rapid Response Team under a 'No Blame' policy ...The criteria included: heart rate < 40 or > 130 beats per minute, systolic blood pressure < 80 mmHg, respiratory rate < 8 or > 30 per minute, acute mental status change, seizure activity, patient distress or, unresponsiveness."

During a review of the facility's policy and procedure titled, "Quality Assurance and Performance Improvement Plan," dated 5/2025, the policy indicated: The Hospital - wide Performance Improvement (Pl) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing ...improved outcomes and reduction of medical errors. This Pl plan describes the communication and coordination of all organizational activities directed toward improving patient care. The organization Pl program is integrated with Risk Management since incident reports may document data that leads to tracking and analyzing the occurrences related to patient safety. The Risk Manager assures timely integration of this risk management information into the organization's performance improvement program activities. Examples of errors reported in the incident report are: equipment failure ... P - Recognize an opportunity and plan a change
D - Test the change. Carry out a small-scale study.
C - Review the test, analyze the results and identify what you've learned.
A - Take action based on what you learned in the study step ...
Scope of Data Collection: Adverse patient events ...Operative or other procedures that place patients at risk of disability or death. All significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses ... Data on performance measures will be analyze to: Monitor the effectiveness and safety of services and quality of care, identify opportunities for improvement and changes that will lead to improvement... Data will be intensively assessed when the organization detects or suspects a significant undesirable performance or variation. Intense analysis is called for when: Levels of performance, patterns, or trends vary significantly and undesirably from those expected. Performance varies significantly and undesirably from that of other organizations or recognized standards. A sentinel event has occurred (root cause analysis)."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ...

2. During a review of Patient 2's Operative Report, dated 8/18/2025, the Operative Report indicated Patient 2 underwent left tunneled permacath placement (a catheter surgically inserted into a large vein for dialysis access) from 8:15 a.m. to 8:22 a.m. on 8/18/2025.

During a concurrent interview and record review on 10/1/2025 at 1:57 p.m., with PACU (Post Anesthesia Care Unit, a specialized area in a hospital where patients who have undergone surgery or other procedures requiring anesthesia are monitored and cared for until they are stable and ready to be discharged) registered Nurse (RN) 1, Patient 2's Vital Signs Flowsheet, dated 8/18/2025, was reviewed, RN 1 confirmed that Patient 2 arrived in the PACU at 8:38 a.m. with blood pressure of 74/35 (low; Normal range is 120/90) mmHg (unit of measurement). From 8:38 a.m. to 9:48 a.m. on 8/18/2025, Patient 2's blood pressure ranged between 50-80 mmHg and heart rate 52-59 bpm (beats per minute). RN 1 confirmed that Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when the heart stops beating]) was called at 9:48 a.m., an hour after Patient 1 experiencing severe hypotension (dangerously low blood pressure).

During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated he was also involved in the Quality Council Committee. CS stated for Patient 2, who bled in the Post-Anesthesia Care Unit (PACU, the recovery area after surgery), a rapid response should have been called immediately but was delayed by over an hour.

During a concurrent interview and record review on 10/3/2025 at 1:21 p.m. with the Manager of Risk (MRM), the facility's "Rapid Response" policy and procedure (P&P), dated 5/2025, was reviewed. The P&P indicated, "Any staff member may activate the Rapid Response Team under a "No Blame' policy," with one of the criteria to activate a rapid response which was "Changes in systolic blood pressure [SBP, the pressure in the arteries when the heart contracts and pumps blood throughout the body] (<80 mmHg) that is unresponsive to prescribed interventions." MRM confirmed that despite these criteria being met, QAPI did not review the delay or ensure retraining for staff. MRM stated he is also involved in the QAPI committee. MRM confirmed the events involving delay in activating a Rapid Response (RRT, a team of clinicians who provide immediate assistance when a patient's condition suddenly worsens) data were not analyzed to identify patterns or delayed activations that could indicate systemic issues in emergency response. MRM confirmed that the facility lacked a system to track, or trend delayed emergency response.

During a review of the facility's policy and procedure titled, "Quality Assurance and Performance Improvement Plan," dated 5/2025, the policy indicated: The Hospital - wide Performance Improvement (Pl) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing ...improved outcomes and reduction of medical errors. This Pl plan describes the communication and coordination of all organizational activities directed toward improving patient care. The organization Pl program is integrated with Risk Management since incident reports may document data that leads to tracking and analyzing the occurrences related to patient safety. The Risk Manager assures timely integration of this risk management information into the organization's performance improvement program activities. Examples of errors reported in the incident report are: equipment failure ... P - Recognize an opportunity and plan a change
D - Test the change. Carry out a small-scale study.
C - Review the test, analyze the results and identify what you've learned.
A - Take action based on what you learned in the study step ...
Scope of Data Collection: Adverse patient events ...Operative or other procedures that place patients at risk of disability or death. All significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses ... Data on performance measures will be analyze to: Monitor the effectiveness and safety of services and quality of care, identify opportunities for improvement and changes that will lead to improvement... Data will be intensively assessed when the organization detects or suspects a significant undesirable performance or variation. Intense analysis is called for when: Levels of performance, patterns, or trends vary significantly and undesirably from those expected. Performance varies significantly and undesirably from that of other organizations or recognized standards. A sentinel event has occurred (root cause analysis)."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: "The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ..."

3. During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated he was also involved in the Quality Council Committee. The CS stated he was aware of Patient 11's death, that occurred on 8/26/2025. The facility suspected Patient 11 passed away of a fat embolism (fat particle that is released into the bloodstream, is most commonly caused by long bone fractures). CS was not aware of the medical examiner report (autopsy report, a medical examination of a body after death to find out how and why someone died) indicating Patient 11 died of a pulmonary embolism due to a blood clot, until today- 10/2/2025 when CS was informed by the surveyors. In addition, the CS stated he was not aware that the VTE risk assessments were inaccurate for Patient 11 nor was he (CS) aware of the lack of VTE preventive measures taken for Patient 11.

During an interview on 10/3/2025 at 1:20 p.m. with the Manager of Risk Management (MRM), the MRM stated the following: The facility had a meeting called "Event Call," on 8/28/2025, to address Patient 11's death on 8/26/2025, because Patient 11 died within 24 hours after undergoing a surgical procedure and anesthesia (a medical state that temporarily blocks pain and other sensations during medical procedures, such as surgery). The facility suspected a fat embolism (fat particle that is released into the bloodstream, is most commonly caused by long bone fractures) was the cause of Patient 11's death because Patient 11 had fracture (break in the bone) on the leg. Therefore, the accuracy of the VTE risk assessments nor the interventions for the VTE risk were not reviewed by the facility, to ensure that the proper VTE prophylaxis interventions had been implemented for Patient 11. The case was referred to the coroner for an autopsy, because Patient 11 died within 24 hours of surgery and anesthesia. The MRM stated the facility does not usually follow up on autopsy reports because it was too costly. The MRM stated the facility became aware that Patient 11 died of a pulmonary embolism on 9/30/2025, when the surveyors requested the autopsy results for Patient 11. In addition, the facility was not aware that VTE risk assessments performed by nursing staff were inaccurate and no additional actions were taken by the facility.

During a review of Patient 11's VTE (Venous Thromboembolism, blood clot forms in a vein) assessments, dated 8/23/2025 at 1:14 p.m., the VTE assessment indicated the following: Low Risk Factors: Age 60 or below. VTE Prophylaxis interventions: Graduated Knee-High Compression Stocking (a stocking that applies the highest pressure at the ankle and gradually deceases it up the leg to help promote blood flow and reduce swelling) - Applied. VTE Risk Level: Low Risk. (The assessment was incorrect, Patient 11 was actually 63 years old and was at high risk for VTE because of Patient 11's fracture of the left leg, this was verified by the Director of Quality [DOQ] during an interview).

During a review of Patient 11's VTE assessments, dated 8/23/2025 at 8 p.m., 8/24/2025 at 8 p.m., 8/25/2025 at 6:55 a.m., and 8 p.m., the VTE assessments indicated the following: Patient 11 was 61 to 75 years old, Moderate Risk, No Mechanical VTE prophylaxis (a non-invasive method that uses medical devices to prevent blood clots. Example: Sequential Compression Device [SCD, medical device used to prevent blood clots in hospitalized or immobile patients by intermittently inflating and deflating sleeves or cuffs around the legs to improve circulation]), Pharmacological prophylaxis (the use of medication to prevent a condition or complication). (The assessment was incorrect because Patient 11 was at high risk for VTE and was not receiving any VTE prophylaxis at that time, this was verified by the DOQ during an interview).

During a review of Patient 11's Physician Progress Note, dated 8/26/2025, the Physician progress note indicated Patient 11 was in critical condition in the Intensive Care Unit (provides critical care for severely ill or injured patients who need intensive medical monitoring and round-the -clock care). The Physician Progress Note also indicated "Left lower leg procedure took about 45 minutes today (8/26/2025) spent about 80 minutes in the operating room (OR). Rapid deterioration (worsening of condition) after procedure took place ...diagnosis: respiratory failure a serious condition that happens when the lungs cannot get enough oxygen into the blood), left tib-fib (tibia-fibula, shin bone and calf bone) fracture. The patient deteriorated rapidly and unexpectedly. I was informed at around midnight that the patient (Patient 11) has passed (died)."

During a review of Patient 11's Autopsy report titled, "Medical Examiner," date of death 8/26/2025, the Autopsy report indicated Patient 11 died in the hospital. Cause A: Pulmonary Embolism. Cause B: Phlebothrombosis (a blood clot forms in a vein without significant inflammation).

During an interview on 9/30/2025 at 3:57 p.m. with the Manager of Risk Management (MRM), the MRM stated there was no process in place that indicated the steps to take when a patient was at low, moderate, or high risk of developing a blood clot.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the H&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours. Assessment/Reassessment parameters: Total system assessment every shift or if condition changes. Specific VTE assessments were not included in the policy, this was verified by the DOQ.

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan."

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Hospital-wide Performance Improvement (PI) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing, facility-wide, contract services, improved outcomes and reduction in medical errors. This PI Plan describes the communication and coordination of all organizational activities directed toward improving patient care ...Provides high quality, cost effective clinical services and demonstrates the outcomes of services through a system of data collection, aggregation, and analysis ...Provides a mechanism to assure that all patients receive the same level of care. Provides a culture that promotes risk reduction strategies to prevent adverse outcomes to patients ...The Quality Council will assure the integration and coordination of medical staff, nursing, and support services in PI activities including patient safety related project. They (Quality Council) will also review and analyze reports presented by the Medical Staff Departments / Committees, department PI activities which include all disciplines in the hospital. Analysis of Data: Data on performance measures will be analyzed to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities for improvement and changes that will lead to improvement.

4.a. During a review of Patient 21's "History and Physical Note," dated 7/8/2025, the record indicated Patient 21 was admitted to the facility for dizziness. Patient 21 had a medical history of gastric bypass (surgery that makes the stomach smaller, helping with diet and weight control).

During a review of Patient 21's "Admitting Team Progress Note," dated 7/13/2025, the record indicated, "Patient (Patient 21) was transferred to ICU (Intensive Care Unit, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) overnight due to persistent altered mental status (level of thinking and understanding is different from normal for that person), confusion, and also status (after) epilepticus (seizure [sudden uncontrolled body movements caused by abnormal brain activity])."

During a review of Patient 21's "Intensivist Consultation Note," dated 7/13/2025, the record indicated Patient 21 was transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) from the telemetry (a specialized hospital unit that provides continuous monitoring of heart rate and rhythm) unit for "Worsening altered mental status and another seizure episode. Currently, he remains lethargic (a state of feeling tired, sluggish, and lacking energy) and drowsy, not following commands but opening his eyes to pain stimuli (how someone responds to the senses and helps determine an individual's level of alertness)."

During an interview on 10/3/2025 at 9:30 a.m. with House Supervisor (HS), HS stated nurses were expected to follow guidelines for calling a rapid response. HS stated the nurses were always told if there was a variance in the BP reading, the nurses were expected to recheck. HS stated nurses were also expected to call a rapid response for new or prolonged seizures, and for mental status changes. HS stated the danger of not calling a rapid response would be a deterioration of patient condition and death. HS also stated it would also be the failure to initiate what the patient needed and was a medical necessity to improve their status. HS also acknowledged there would be a delay in treatment in care if a rapid response was not called.

During an interview on 10/1/2025 at 2:00 p.m. with the Director of Medical-Surgical and Telemetry (DMST), the DMST confirmed that Patient 21 and 22 also experienced seizures (is abnormal electrical activity in the brain which causes changes in awareness and muscle control) and hypotension (dangerously low blood pressure, normal blood pressure typically ranges from 90/60 to 120/80 mm Hg [unit of measurement]) without timely activation of a rapid response (RRT, a team of specially trained medical professionals who are immediately called to the bedside of a patient with early signs of clinical deterioration, such as abnormal vital signs or altered mental status), and that these cases (for Patient 2, this occurred on 8/18/2025, on 7/12/2025 for Patient 21, and on 7/26/2025 for Patient 22), were not reviewed by the QAPI or Governing Body committees.

During an interview on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), the DOQ confirmed: that these events (delay in activating RRT for Patient 2, Patient 21, and Patient 22) were not reviewed through the Quality Assurance and Performance Improvement (QAPI) or Governing Body committees to identify causes or prevent recurrence.

During a concurrent interview and record review on 10/3/2025 at 1:21 p.m. with the Manager of Risk Management (MRM). the facility's QAPI meeting minutes, from April 2025 through August 2025, was reviewed. MRM confirmed that QAPI documentation did not contain evidence of review or data analysis of rapid response activations or delays.

During a review of the hospital's policy titled, "Rapid Response Teams" (dated 5/2025), the policy stated, "Purpose: To ensure rapid intervention in cases of patient deterioration and improve patient outcomes by facilitating early recognition, prompt assessment, and immediate implementation of a multidisciplinary approach. Any staff member may activate the Rapid Response Team under a 'No Blame' policy ...' The criteria included:
Heart rate < 40 or > 130 beats per minute, Systolic blood pressure < 80 mmHg, respiratory rate < 8 or > 30 per minute, acute mental status change, seizure activity, and patient distress or unresponsiveness."

During a review of the facility's policy and procedure (P&P) titled, "Never Event Management," dated 5/2025, the P&P indicated the following: The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRD), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient ...Root Cause Analysis (RCA): A standardized investigative process for identifying the casual root factor (s) that underlie variation in performance, including the occurrence or possible occurrence of a never event. The intent of the RCA is to identify system vulnerabilities so that they can be eliminated or mitigated through corrective actions for sustained system improvement and to prevent further harm. Corrective Action Plan: The product of the RCA which identifies the strategies an organization intends to implement to reduce the risk of similar events occurring in the future. The corrective action plan addresses responsibility for implementation, oversight, and strategies for measuring effectiveness of the actions taken ...The Quality and Risk Management Department shall coordinate and identify the appropriate multidisciplinary review team to facilitate the RCA and corrective action plan ...

During a review of the facility's "Quality Assurance and Performance Improvement (QAPI) Plan," dated 5/2025, the QAPI Plan indicated the following: The Hospital-wide Performance Improvement (PI) Plan describes the systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness, ongoing, facility-wide, contract services, improved outcomes and reduction in medical errors. This PI Plan describes the communication and coordination of all organizational activities directed toward improving patient care ...Provides high quality, cost effective clinical services and demonstrates the outcomes of services through a system of data collection, aggregation, and analysis ...Provides a mechanism to assure that all patients receive the same level of care. Provides a culture that promotes risk reduction strategies to prevent adverse outcomes to patients ...The Quality Council w

Based on interview and record review, the facility failed to ensure the hospital Medical Staff enforced its Bylaws (a set of rules and regulations that govern the medical practitioners within a hospital or healthcare facility, outlining the standards for membership, privileges, and conduct to ensure quality patient care) when one of ten sampled members of the Medical Staff was allowed to perform surgical procedures for which the practitioner had not been granted specific privileges (the specific permissions a healthcare facility grants to a medical professional to provide patient care and perform certain services within the facility). The practitioner placed a Permacath central venous catheter (a tunneled catheter used for long-term vascular access, such as for hemodialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) for one of 30 sampled patients (Patient 2) on 8/18/2025, despite not having specific privileges for catheter insertions. The patient experienced immediate postoperative bleeding complications and died within three hours of surgery.

The failure of the facility's Medical Staff to adhere to its Bylaws enabled a Medical Staff member to perform certain surgical procedures without the Credentials Committee and Medical Executive Committee's (MEC, a group of physicians that represents the medical staff and makes key decisions about patient care, medical staff policies, and the quality of medical services) review and consideration of the member's current professional competence for those procedures, and without the Governing Board's approval of those specific privileges. This deficient practice raised concern for risk of harm to the patients undergoing procedures performed by the practitioner.

Findings:

During a record review on 10/2/2025 at 8:55 a.m., in the presence of the Director of Medical Staff (DMS), the credential files of ten (10) selected sample of the facility's Medical Staff, were reviewed with the assistance of the Medical Staff Manager (MSM). The file of one of ten (1 of 10) practitioners, MD3, whose current reappointment spans from 2/1/2024 to 1/31/2026, indicated MD3 had requested and was granted privileges to perform specific vascular surgery (manages diseases of the arteries, veins, and lymphatic vessels, excluding the heart and brain) procedures, seventeen (17) in total. Insertion of catheters was not listed among the seventeen procedures. No evidence that the practitioner was granted privileges (the specific permissions a healthcare facility grants to a medical professional to provide patient care and perform certain services within the facility) for any other procedures besides those listed under vascular surgery could be found from review of the files for the current reappointment.

During an interview on 10/2/2025 at 8:55 a.m. with the MSM,, the MSM confirmed that for the current reappointment period, the vascular surgery privileges form was the sole privilege delineation form submitted by MD3. For the preceding reappointment interval of 2/1/2022 to 1/31/2024, the MSM reported no privilege delineation forms at all could be located from MD3's credentialing records.

During a review of MD3's credential documents from the initial appointment in 2020, the credential documents indicated that at initial appointment, the practitioner had submitted a separate request for specific general surgery privileges, in addition to that for vascular surgery, and the requested privileges had been approved at the time, conditionally with proctoring (a healthcare professional who observes and evaluates the performance of another healthcare professional, typically during a medical procedure), a requirement for all initial Medical Staff applicants. Several specific procedures were listed under the requested and approved general surgery privileges, one of which was "insertion and management of catheter."

During an interview on 10/1/2025 at 1:05 p.m. with MD 3, regarding the placement of a Permacath central venous catheter (a tunneled catheter used for long-term vascular access, such as for hemodialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) for Patient 2, who suffered immediate postoperative (during, relating to, or denoting the period following a surgical operation) bleeding complications following the catheter insertion by the practitioner, MD3 denied noting any major issues intraoperatively (occurring or performed during the course of a surgical operation) and reported having performed catheter insertions numerous times at the facility, as often as two to three times a day.

During a telephone interview on 10/3/2025 at 2:15 p.m. with the Chair of the Department of Surgery (CS), who also served as the Vice Chief of Medical Staff, the issue of MD3 currently performing general surgery procedures, in particular, catheter insertions, without specific privileges granted for these procedures, was pointed out. The CS stated, "I thought catheter placement was included under vascular surgery privilege delineation form. If not, it should be included, it was probably overlooked. This is a concern for us to look into." The CS added that now that the issue had been identified, the facility was currently actively working on making sure all privilege delineation forms were correct and up-to-date.

During a review of the Medical Staff Bylaws (a set of rules and regulations that govern the medical practitioners within a hospital or healthcare facility, outlining the standards for membership, privileges, and conduct to ensure quality patient care), approved by the Governing Board and adopted on 12/21/2020, read:
- Under Article V, Section 5.1 Exercise of Privileges, "Except as otherwise provided in these Bylaws, a member providing clinical services at this hospital shall be entitled to exercise only those clinical privileges specifically granted."
-Under Section 5.2 Delineation of Privileges in General, the Bylaws states, "Each application of appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. A request by a member for a modification of clinical privileges may be made at any time, but such requests must be supported by documentation of training and/or experience supportive of the request [ ...] Requests for clinical privileges shall be evaluated on the basis of the member's education, training, current licensure, experience, demonstrated professional competence and judgment, clinical performance, and the documented results of patient care and other quality review and monitoring which the Medical Staff deems appropriate."

Based on observation, interview and record review, the facility failed to:

1. Ensure nursing staff performed accurate Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments, in accordance with the facility's policy regarding assessment/reassessment, for two of 30 sampled patients (Patients 11 and 12), in order to determine the patients' risk of developing a blood clot. The facility also failed to implement interventions to reduce the risk of blood clot formation for Patient 11, who was at high risk for developing blood clots.

The inaccurate VTE risk assessments and lack of implementation of interventions to reduce the risk of blood clot formation resulted in Patient 11 developing a blood clot in his (Patient 11) vein, developed pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot) and subsequent death. The deficient practice also had the potential of placing Patient 12 and other patients at risk of developing a blood clot, which may lead to patient harm, serious injury, and/or death.

2. Ensure nursing staff documented adverse events (an unintended injury or complication that occurs as a result of medical treatment or care) in the facility's incident-report system, in accordance with the facility's policy titled, "Never Event management," when one (1) of 30 sampled patients (Patient 1) was accidentally disconnected from the ventilator (a machine that helps a patient breathe), and the ventilator alarm failed to alert staff due to a defective cable.

This deficient practice resulted in a delay in initiating an internal investigation of the event and allowed potentially defective ventilator-alarm cables to remain in use without prompt identification or corrective action, placing Patient 1 and other ventilator-dependent patients at continued risk for delayed emergency response, injury, or death if alarms failed again.

3. Ensure nursing leadership properly supervised and evaluated the quality of care provided during and after emergency resuscitation (life-saving efforts when a patient's heart or breathing stops) for two (2) of 30 sampled patients (Patient 1 and Patient 2). Nursing staff did not complete required Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest [when heart stops beating effectively]) documentation (a hospital-wide record used to log actions, medications, and patient responses during cardiac or respiratory arrest [when breathing stops]) or post (after)-event review forms, as required by the facility's "Code Blue" policy.

This deficient practice resulted in delays in identifying and correcting problems that occurred during the resuscitation of Patient 1 and Patient 2, which may have contributed to delayed emergency treatment and placed all patients as risk for repeated errors during future life-threatening emergencies.

4. Ensure nursing staff followed physician's order for continuous pulse-oximetry monitoring (continuous, non-invasive monitoring using a device attached to a patient's fingertip or earlobe that tracks oxygen saturation-the percentage of oxygen in the blood- and pulse rate, or how many times the heart beats per minute) for one (1) of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure, "Telemetry (the continuous, remote monitoring of a patient's vital signs, most commonly their heart rhythm) Policy."

This deficient practice placed Patient 3 at risk for undetected low oxygen levels, which could lead to a life-threatening condition such as hypoxia (a dangerous state where body tissues and organs do not receive enough oxygen).

On 10/1/2025 at 3:58 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality (DOQ), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Cardiopulmonary/Respiratory Services (DRS), Director of Emergency Services and Intensive Care Unit (DED/ICU), Director of Surgery (DIRS), Director of Security/Emergency Management (DOS/EM), Pharmacist Informatics Specialist (IT 2), Clinical Informatics (IT 3), Informatics (IT 4), Medical Staff Director (MSD), Manager of Risk Management (MRM), Medical Staff Services (MSS), Director of Labor and Delivery (DLD), and the Director of Medical Surgical and Telemetry (DMST).
For Patient 11: Patient 11 was transferred to the facility on 8/23/2025 for surgical intervention of a fracture (break in the bones) that Patient 11 sustained after falling off of a truck while working. Patient 11 sustained fractures to the left lower leg, right arm/shoulder and a compression (pressure) fracture to the spine. Patient 11 was 63 years old and the fracture to Patient 11's left leg placed Patient 11 at high risk for developing a blood clot. Patient 11's Venous Thromboembolism (VTE, blood clot forms in a vein) risk assessments were inaccurately documented by the nurses, which indicated that Patient 11 was at low or moderate risk of developing a blood clot. Patient 11 received Lovenox (a "blood thinner" to reduce the risk of blood clots) on 8/23/2025, then it was discontinued by the physician the next morning on 8/24/2025. There were no orders for Sequential Compression Device (SCD, used to prevent blood clots in deep veins).

On 8/26/2025, Patient 11 underwent a surgical procedure, a placement of intramedullary (within a bone) nails to the left tibia (leg). Patient 11 arrived at the Post Anesthesia Care Unit (PACU, a specialized area in a hospital where patients who have undergone surgery or other procedures requiring anesthesia are monitored and cared for until they are stable and ready to be discharged) on a ventilator (breathing machine) and intubated (a tube inserted into the airway to maintain an open passage for air and oxygen to reach the lungs) from the operating room. Patient 11's vital signs were unstable, and Patient 1's respiratory status deteriorated rapidly. Patient 11 was transferred to the Intensive Care Unit (provides treatment for patients with severe, life-threatening illnesses or injuries), where Patient 11 was made a DNR (Do Not Resuscitate, a medical order that instructs healthcare providers not to perform life-sustaining measures if a patient's heart or breathing stops) and passed away on 8/26/2025 at 11 p.m. The medical examiner determined Patient 11 died of a pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot).

For Patient 12: Patient 12, a 64-year-old, presented to the facility after a mechanical fall where she (Patient 12) landed on the right patella (knee) and was found to have a distal femur (thigh) fracture with hemarthrosis (blood accumulation) to the right patellar region. Patient 12's fracture to the right thigh placed Patient 12 at High risk for blood clot formation, however, Patient 12's VTE risk assessments indicated Patient 12 was a Moderate Risk. The inaccurate assessment placed Patient 12 at risk of not receiving the appropriate interventions to reduce the risk of developing a blood clot, which could become dislodged and travel to the lungs, possibly resulting in a pulmonary embolism, and possibly death.

On 10/3/2025 at 1:26 p.m., the facility submitted an Immediate Jeopardy Removal Plan (IJRP, interventions to correct the deficient practice) for review and approval. The IJRP included the following:

The facility created a policy for Venous Thromboembolism (VTE) and a VTE assessment tool. The process indicated to use VTE assessment tool on admission, every Monday, or with change of condition. The assessment tool should be placed in the patient's chart. Risk factors were categorized, for Low, Moderate or High Risk. If the patient meets the criteria identified on low, moderate, and high-risk factor, the highest risk level should be assigned. Contraindications should also be documented. For low, moderate, or high risk, the nurse should implement early ambulation, patient education, and notifying the physician to order VTE prophylaxis, either mechanical or pharmacological. All licensed staff would be educated on the VTE assessment and tool. The Director of Nursing will assign the charge nurse or resource nurse to audit compliance every shift, for all new patients and review two (2) random charts. The audits will check for completeness, accuracy and appropriate VTE prophylaxis. Inaccurate assessments will be corrected by the assigned nurse. The charge nurse will perform rounds and validate the appropriate VTE is implemented. The Director of Nursing will have oversight. The CNO is responsible for sustaining compliance.

On 10/3/2025 at 5:59 p.m., in the presence of the facility's-CEO, CNO, DOQ, and MRM, the facility was informed that the team was unable to validate the IJRP through observation, interview and record review.

On 10/3/2025 at 6:02 p.m., the facility was placed on a 23-day termination track (a process that places a hospital or other provider on a termination track if deficiencies are found that pose an immediate jeopardy to patient health and safety).

On 10/3/2025 at 6:02 p.m., the survey team exited the facility without removing the Immediate Jeopardy (IJ) after determining through observation, interviews, and record reviews, that the facility had not implemented its IJ Removal Plan.

On 10/16/2025 at 11:21 a.m., the IJ was removed in the presence of the Chief Nursing Officer (CNO), Manager of Risk Management (MRM), Chief Executive Officer (CEO), Systems Manager of Clinical Quality Program & Data Analytics (SMCQPDA), Corporate Senior Director of Quality & Risk (CSDQR), and the Medical Director of the Emergency Department (MDED). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews.

Findings:

1.a. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/23/2025, the H&P indicated Patient 11 was 63 years old, who had a fall (an unintentional descent to the ground, floor, or other lower surface, with or without injury) while working. The H&P also indicated Patient 11 "was loading and unloading big pipes ...the pipes started falling down and Patient 11 suffered a 5-to-6-foot fall ...Assessment and Plan indicated Patient 11 suffered a fracture (break) to the right proximal humerus (upper arm bone), left tib-fib (tibia-fibula, lower leg) fracture and compression (pressure) fracture of the spine (backbone)."

During a review of Patient 11's "Computerized Provider Order Entry (CPOE, electronically transmit treatment instructions, such as medication, laboratory, and radiology orders, replacing traditional paper or verbal methods to improve patient safety and care quality)," dated 8/23/2025 at 2:33 p.m., the CPOE indicated "Lovenox (enoxaparin, a "blood thinner' to reduce the risk of blood clots). Per Rx (prescription) - DVT (deep vein thrombosis, blood clot that forms in one or more of the deep veins, typically in the legs) prophylaxis (preventive measures taken to avoid or reduce the risk of complications), pharmacy to dose rate and frequency."

During a review of Patient 11's Medication Administration Record (MAR), dated 8/23/2025, the MAR indicated Patient 11 received enoxaparin 40 mg subcutaneously (under the skin) in the middle of the abdomen at 8:46 p.m.

During a review of Patient 11's "CPOE," dated 8/24/2025 at 7:34 a.m., the CPOE indicated to discontinue Lovenox (enoxaparin).

During a concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), Patient 11's VTE (Venous Thromboembolism, blood clot forms in a vein) assessments, dated 8/23/2025 at 1:14 p.m., was reviewed. The VTE assessment indicated the following: Low Risk Factors: Age 60 or below. VTE Prophylaxis interventions: Graduated Knee-High Compression Stocking (a stocking that applies the highest pressure at the ankle and gradually decreases it up the leg to help promote blood flow and reduce swelling)- Applied. VTE Risk Level: Low Risk. (The assessment was incorrect, Patient 11 was actually 63 years old and was at high risk for VTE because of Patient 11's fracture of the left leg, this was verified by the Director of Quality [DOQ] during the interview).

During a concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), Patient 11's VTE assessments, dated 8/23/2025 at 8 p.m., 8/24/2025 at 8 p.m., 8/25/2025 at 6:55 a.m., and 8 p.m., were reviewed. The VTE assessments indicated the following: Patient 11 was 61 to 75 years old, Moderate Risk, No Mechanical VTE prophylaxis (a non-invasive method that uses medical devices to prevent venous thromboembolism. Example: Sequential Compression Device [SCD, medical device used to prevent blood clots in hospitalized or immobile patients by intermittently inflating and deflating sleeves or cuffs around the legs to improve blood circulation]), Pharmacological prophylaxis (the use of medications to prevent a condition or complication). (Per the VTE risk assessment criteria, the assessment was incorrect because Patient 11 was at high risk for VTE and was not receiving any VTE prophylaxis at that time, this was verified by the DOQ during the interview).

During a concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), Patient 11's VTE assessment, dated 8/26/2025 at 6 p.m., was reviewed. The VTE assessments indicated Moderate Risk Factors included his (Patient 11) age of 61 - 75. The Risk Level was not documented. VTE Interventions: Intermittent Pneumatic Compression Device applied to the Right (leg). The DOQ verified that the assessment was incomplete because Patient 11's VTE risk level was not documented.

During a review of Patient 11's "Post-Procedure Assessment Report," dated 8/26/2025 at 3:04 p.m., documented by the PACU (Post Anesthesia Care Unit, recovery room in a hospital where patients who have undergone surgery or other procedures requiring anesthesia are closely monitored and cared for until they are stable to be discharged) nurse, the report indicated the following:

-At 2:40 p.m., "Received patient (Patient 11), Surgery: Left tibia intermedullary nailing (a surgical procedure to treat a fracture [break in the bone] in the left shinbone (tibia) by inserting a metal rod, or nail, down the center of the bone) ...patient (Patient 11) is sedated (calm, relaxed, sleepy state), has tachycardia (elevated heart rate), on a ventilator (breathing machine). Heart rate was 123 (high, normal is 60 - 100), blood pressure was 77/47 (low, normal is 120/80), Oxygen saturation (measurement of the amount of oxygen in the blood) was 92% (normal is 92 - 100 %). A second assessment indicated that the heart rate was 123 (high), blood pressure was 86/46 (low), and oxygen saturation was 90% (low) ..." Patient 11 was transferred to the ICU (Intensive Care Unit, a specialized hospital department that provides high-level medical care to patients with life-threatening illnesses or injuries) at 3:04 p.m. on 8/26/2025.

During a review of Patient 11's "Operative Report," dated 8/26/2025 at 6:25 p.m., the Operative Report indicated the following: "Procedure performed: Left tibia nailing ..." The Operative Report also indicated that "prior to making the incision (a cut in the skin), anesthesia noted patient (Patient 11) was somewhat tachycardic (high heart rate) in the 100's and had O2 (oxygen saturation) that were little bit low, in the 90's or below 90's ...Anesthesia was able to stabilize the patient (Patient 11) somewhat and gave permission to proceed ...The reduction was satisfactory in the nail placement ...Sterile dressings were placed ...At this point anesthesia team recommended that the patient go straight to ICU. The anesthesia team did not recommend extubation (removal of tube in the airway). The patient (Patient 11) still seems tachycardic and was not sat'ing (saturating, oxygenation level) that well. The patient (Patient 11) was then taken to the ICU as soon as a bed was available."

During a review of Patient 11's Physician Progress Note, dated 8/26/2025, the Physician progress note indicated Patient 11 was in critical condition in the Intensive Care Unit.. The Physician Progress Note also indicated "Left lower leg procedure took about 45 minutes today (8/26/2025), spent about 80 minutes in the operating room (OR). Rapid deterioration (worsening of condition) after procedure took place ...diagnosis: respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood), left tib-fib fracture. The patient deteriorated rapidly and unexpectedly. I was informed at around midnight that the patient (Patient 11) has passed (died)."

During a review of Patient 11's Autopsy report titled, "Medical Examiner," date of death 8/26/2025, the Autopsy report indicated Patient 11 died in the hospital. Cause A: Pulmonary Embolism. Cause B: Phlebothrombosis (a blood clot forms in a vein without significant inflammation).

During a concurrent interview and record review on 9/30/2025 at 11:16 a.m. with the Director of Surgery (DIRS), in the Post Anesthesia Care Unit (PACU, a specialized area in a hospital where patients who have undergone surgery or other procedures requiring anesthesia are monitored and cared for until they are stable and ready to be discharged), Patient 11's "OR (Operating Room) Log," was reviewed. The DIRS stated Patient 11 arrived at the PACU on 8/26/2025 at 2:40 p.m. after undergoing a surgical procedure, a placement of intramedullary (within a bone) nails to the left tibia (leg). Patient 11 arrived on a ventilator (breathing machine) and intubated (a tube inserted into the airway to maintain an open passage for air and oxygen to reach the lungs) from the OR and was transferred to the ICU at 4:10 p.m.

During a concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), Patient 11's History and Physical and VTE risk assessments, were reviewed. The DOQ stated the following: Patient 11 was 63 years old and was admitted, on 8/23/2025, from another hospital for surgical repair for a fracture of the left leg due to a fall while Patient 11 was working. Patient 11's VTE risk assessments were inaccurate because Patient 11 was 63 years old and had a High-risk factor of fracture to the leg. Patient 11 should have been assessed as having a High risk for VTE, not low or moderate risk.

During the same concurrent interview and record review on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), the VTE assessments indicated no mechanical VTE prophylaxis was provided. It also indicated that Patient 11 had been receiving pharmacological prophylaxis, however, Patient 11 only received pharmacological prophylaxis, once, on 8/23/2025, then it was discontinued by the physician. Patient 11 had surgical repair of the fracture to the left leg on 8/26/2025, had unstable vital signs and remained intubated after the procedure, due to unstable vital signs. Patient 11 was transferred to the ICU, made a DNR (Do Not Resuscitate, instructs healthcare providers not to perform life-sustaining measures) and passed away on 8/26/2025 at 11 p.m.

During the same interview on 9/30/2025 at 1:43 p.m. with the Director of Quality (DOQ), the DOQ stated the facility followed up on the Autopsy on 9/30/2025 (when the surveyors were at the facility for a survey). The Autopsy indicated Patient 11 died of a pulmonary embolism (lungs become blocked by a blood clot). The DOQ stated VTE assessments should be done once per shift, per policy regarding assessments. The DOQ verified there was no specific policy regarding VTE assessments indicating what do when patients were at risk for developing blood clots. The DOQ was unsure of what the process was for implementing interventions for patients at risk of blood clot formation. The DOQ verified there was no process in place to address VTE, only that an assessment should be done. In addition, the DOQ was not previously aware that the VTE assessments were inaccurate. The DOQ stated patients who were at risk of blood clot formation should have sequential compression device placed on the legs to promote circulation and to have medications for blood clots, if indicated.

During an interview on 9/30/2025 at 3:57 p.m. with the Manager of Risk Management (MRM), the MRM stated there was no process in place that indicated the steps to take when a patient was at low, moderate, or high risk of developing a blood clot.

During a concurrent interview and record review on 10/1/2025 at 10:44 a.m. with the Pharmacist Informatics Specialist (IT 2), Patient 11's orders, were reviewed. The IT 2 stated there were no orders for Sequential Compression Device (SCD, used to prevent blood clots in deep veins) for Patient 11.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the P&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours. Assessment/Reassessment parameters: Total system assessment every shift or if condition changes. Specific VTE assessments were not included in the policy, this was verified by the DOQ.

1.b. During a review of Patient 12's "History and Physical (H&P)," dated 9/26/2025, the H&P indicated Patient 12, a 64-year-old, "presents after a mechanical fall where she (Patient 12) landed on the right patella (knee) ...found to have a distal femur (thigh) fracture with hemarthrosis (blood accumulation) to the right patellar region."

During a concurrent interview and record review on 9/30/2025 at 4:30 p.m. with the director of Quality (DOQ), Patient 12's VTE Risk Assessments, dated 9/26/2025 through 9/29/2025, were reviewed. The VTE Risk Assessments indicated a VTE Risk Level of Moderate Risk. The assessment did not include Patient 12's High Risk Factor of having a fracture in the leg. The DOQ verified that the assessment was inaccurate.

During an interview on 9/30/2025 at 4:10 p.m. with Registered Nurse (RN) 3, RN 3 stated the following: VTE assessments were done every four (4) or eight (8) hours, but she (RN 3) was not sure about the frequency. If patients had a fracture to the legs, they were considered to be at high risk of developing blood clots. If a patient was a high risk of developing clots, they should be placed on mechanical VTE (Sequential Compression Device [SCD, used to prevent blood clots in the deep veins]) or prescribed pharmacological (medication) prophylaxis. Both SCDs and pharmacological prophylaxis required a physician's order. If there were no orders, the nurse should call the physician to obtain orders for SCD or pharmacological prophylaxis.

During an interview on 9/30/2025 at 4:30 p.m. with the DOQ, Patient 12's VTE Risk assessments, dated 9/26/2025 through 9/29/2025, were reviewed. The DOQ verified that, per the VTE risk criteria, Patient 12 had a high risk for developing a blood clot, because Patient 12 had a fracture on the leg. The DOQ stated that VTE assessments for Patient 12 were not accurate. The purpose of the VTE assessments was to determine the patient's risk of developing a blood clot which guides what interventions would be implemented to reduce the risk of developing a blood clot.

During a review of Patient 12's physician's order, dated 9/26/2025 at 5:29 a.m., the physician's order indicated to start Heparin (a fast-acting "blood thinner" that prevents the formation of new blood clots) 5,000 Units (a unit of measurement) at 9 a.m., route; Subcutaneous (under the skin), every 8 hours.

During a review of Patient 12's Medication Administration Record (MAR), dated 9/26/2025, the MAR indicated that Patient 12 received the first dose of Heparin 5,000 Units at 9:12 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment," dated 9/2025, the P&P indicated the following: Upon admission to the patient care unit, each patient will be assessed by a registered nurse (RN) to determine any immediate needs and appropriate assignment of the care and data collection ...For Med/Surg: implements admission assessment upon arrival and completes within 12 hours. Assessment/Reassessment parameters: Total system assessment every shift or if condition changes. Specific VTE assessments were not included in the policy, this was verified by the DOQ.

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/17/2025, the "H&P" indicated, Patient 1's medical history included type 2 diabetes (a chronic condition where blood sugar is too high), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) dependence, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a waste product of the body that is transported in the blood from the tissues to the lungs and then breathed out]). Patient 1 was admitted to evaluate possible tuberculosis (TB, an infectious airborne disease caused by bacteria).

During an interview on 10/1/2025 at 9:30 a.m. with the Chief Nursing Officer (CNO), the CNO stated the incident occurred on 4/17/2025, when Patient 1, who was ventilator-dependent, became disconnected from the ventilator (breathing machine) due to a faulty alarm cable. The CNO confirmed that the incident was not entered into the facility's internal event-reporting system (the system used to record and track patient safety events). The CNO stated, "The risk department didn't know about it until May 20 (2025), when we received an email from the compliance hotline (a confidential phone number or web link where anyone can report concerns about potential illegal activities, unethical behavior, or policy violations within the hospital, often anonymously). Patient 1's daughter had reported that the ventilator alarm did not go off."

During the same interview on 10/1/2025 at 9:30 a.m. with the CNO, the CNO confirmed that the hospital leadership was unaware of the event until 34 days later and that an investigation did not begin until 5/20/2025. The CNO further stated chart reviews showed nurses were in the room giving blood around 3:45 p.m. on the day of the incident (4/17/2025), but the disconnection went undetected for approximately 15-20 minutes.

During an interview on 10/2/2025, at 9:31 a.m., the Director of Respiratory Services (DRS) stated, "We started testing all the ventilator alarms on 5/30/2025, after the compliance hotline (a confidential and often anonymous reporting system that allows employees and patients to report suspected illegal, unethical, or improper conduct without fear of retaliation) reported issues on 5/20/2025." The DRS confirmed this was 10 days after receiving the report from the compliance hotline and forty-five days after the event on 4/17/2025. The DRS also stated, "We found some cables didn't trigger the alarms, and those were replaced."

During a review of the facility's policy and procedure (P&P) titled, "Never Event management," dated 5/2025, the P&P indicated, "The purpose of this policy is to standardize the components of the never event response to ensure a common approach and to maximize the understanding of the event under assessment in a quest to reduce the probability of such an event in the future ...Never Event: Also known as Serious Reportable Event (SRE), Sentinel Event, and Adverse Reportable Event are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a problem in the safety and credibility of a health care facility. A never event is a serious, harmful clinical event that should never happen to a patient. All references to "never event" or "serious reportable event" are specific to the National Quality Forum (NQF) list available in the Appendix. The NQF developed the list of SRE's with the support of CMS ...Any hospital employee, manager, or physician who becomes aware of a never event shall enter an incident report through the facilities event reporting system and immediately call the Quality and Risk Management Department and/or direct supervisor."

3.a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/17/2025, the "H&P" indicated, Patient 1's medical history included type 2 diabetes (a chronic condition where blood sugar is too high), tracheostomy dependence, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a waste product of the body that is transported in the blood from the tissues to the lungs and then breathed out]). Patient 1 was admitted to evaluate possible tuberculosis (TB, an infectious airborne disease caused by bacteria).

During a review of Patient 1's Code Blue Consultation Note, date 4/17/2025, the record showed the patient (Patient 1) became disconnected from a ventilator (a machine that helps a patient breathe). Patient 1's heart rate (number of times the heart beats per minute) fell into the 30's, a condition known as bradycardia (an abnormal slow heartbeat that can lead to cardiac arrest [when heart stops beating effectively]).

During a concurrent interview and record review on 10/2/2025 at 2:30 p.m. with the House Supervisor (HS), Patient 1's "Evaluation of Resuscitation (life-saving efforts when a patient's heart or breathing stops)," dated 4/17/2025, was reviewed. HS stated the purpose of the form was "to analyze care provided during an arrest (cardiac or respiratory), ensure adherence to established guidelines, identify opportunities to improve performance, and improve outcomes," after every Code Blue (a hospital-wide alert that a patient's heart or breathing has stopped). The form included checkpoints such as "Code Blue Activated/Announced according to policy?" and required a debrief (a short team discussion to review how the event went). The HS stated, "The debrief is not done all the time, because nurses are busy. We are failing in the completion of the debrief huddle that should be happening after each code."

During the same interview and record review on 10/2/2025 at 2:30 p.m. with the HS, Patient 1's "Code Blue Record," dated 4/17/2025, was reviewed. The record indicated that Patient 1 went into arrest at 4:20 p.m., but cardiopulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) started two (2) minutes later, at 4:22 p.m. HS confirmed that the report indicated there was 2 minutes delay in initiating CPR, but HS was unsure of the reason for the delay. HS also confirmed that the "Evaluation of Resuscitation Record" was blank and no cardiac rhythm strips (electrocardiogram printouts showing the heart's electrical activity and rhythm [the pattern and timing of the heartbeat, which is controlled by the heart's electrical system]) were attached to the documentation.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue," dated 5/2023, the P&P indicated, "A 'Code Blue' can be called when a patient has had a significant life-threatening change. Hospital staff with current BLS certification will perform basic CPR within the hospital ...Post CPR responsibilities: Nursing Supervisor will complete arrest sheet with assistance of primary nurse ... Administrative Nursing Supervisor: Responsibility: Critiques Code Blue: Administrative Nursing Supervisor obtains input from Code Blue Team members for completion of Code Blue Evaluation (Critique). An occurrence report shall be initiated, and critique included and forwarded to Performance Improvement Department."

During a review of the facility's policy and procedure (P&P) titled, "Plan for the Provision of Patient Care," dated 7/2024, the P&P indicated, "All departments are responsible for following the hospital's plan for improving Organizational Performance including planned performance assessment and improvement activities, initiating activities designed to follow-up on unusual occurrences or specific concer

Based on interview and record the facility failed to ensure the patient Care Plans (provides direction regarding the type of nursing care a patient may need) for three of 30 sampled patients (Patient 13, 16, and 17), were customized or individualized to address the patients' specific care needs and risks, in accordance with the facility's policy regarding care plans. In addition, for Patient 13, the facility failed to implement a plan of care addressing Patient 13's immobility and electrolyte imbalance (the level of one or more electrolytes [example: calcium- a building block of bones, ensuring their strength; potassium- necessary for muscle functions] in your body is too low or too high) upon admission to the facility.

This deficient practice on the lack of an individualized care plan for each patient admitted to the hospital had the potential for Patients 13, 16, and 17's specific care needs to not be addressed leading to inconsistent and ineffective results. This deficient practice also had the potential for Patient 13 to be at increased risk for skin breakdown (damage/injury to the skin) due to lack of interventions to address immobility as well as heart complications or seizure (abnormal electrical brain activity causing uncontrolled movements or loss of awareness) due to lack of a specific care plan to address Patient 13's problem regarding electrolyte imbalance.

Findings:

1. During a concurrent interview and record review on 10/2/2025 at 9 a.m. with the Clinical Informatics (IT 3), Patient 13's History and Physical (H&P), nursing Admission Assessment Report, and Patient Care Plan Report, dated 9/10/2025, were reviewed. IT 3 stated the following: The care plan was a guide used to direct patient care and address the patient's care needs. Patient 13 was admitted on 9/10/2025 for evaluation of bilateral (both) leg pain and Patient 13's diagnosis included electrolyte imbalance (the level of one or more electrolytes [example: calcium- a building block of bones, ensuring their strength; potassium- necessary for muscle functions] in the body is too low or too high) and functional quadriplegia (complete immobility of all four limbs due to a severe underlying medical condition). Patient 13 was bedbound (confined to a bed or a chair most of the time).

During the same concurrent interview and record review on 10/2/2025 at 9 a.m. with the Clinical Informatics (IT 3), IT 3 verified that a care plan addressing Patient 13's electrolyte imbalance was not developed upon admission and the care plan addressing Patient 13's immobility (inability to move) was developed only on 9/17/2025 (seven days after admission), the day Patient 13 was discharged. In addition, IT 3 stated that care plans addressing Patient 13's Risk for Aspiration (the accidental inhalation of foreign materials, such as food, liquids, or saliva, into the lungs) and Risk for Injury, and Risk for Impaired Tissue Integrity included interventions that did not apply to Patient 13 were initiated. The Care Plan titled, "Risk for Aspiration," included interventions for Enteral (delivering nutrition directly into the stomach or intestines through a tube) feedings, such as, monitor for congestion ...monitor feeding tube residual (the amount of fluid remaining in the stomach after a meal or feeding), elevate the head of bed during enteral feeding-----all of which did not apply to patient 13 because Patient 13 did not have a feeding tube.

During the same concurrent interview and record review on 10/2/2025 at 9 a.m. with the Clinical Informatics (IT 3), IT 3 verified that the Care Plan titled, "Risk for Injury," included interventions that did not apply to Patient 13, such as implementing seizure (convulsions) precautions. Patient 13 did not have a history of seizures.
The Care Plan titled, "Risk for Impaired Tissue Integrity (a condition where the skin and underlying tissues are damaged or compromised, leading to disruptions in their normal functions)," also included interventions for monitoring a dialysis catheter (a thin, flexible tube inserted into a large vein to provide access to the blood stream for hemodialysis, a treatment that removed waste products and excess fluid from the body). IT 3 stated Patient 13 did not have a dialysis catheter and thus the care plan regarding dialysis catheter care did not apply to Patient 13. IT 3 stated some of the interventions in the care plans did not apply to Patient 13. IT 3 said patient interventions should be customized to the patient's needs. Interventions that would not apply to patients should be removed from the care plan. The care plans should be initiated upon admission and should be customized to address patient care needs.

During a concurrent interview and record review on 10/2/2025 at 1:56 p.m. with Registered Nurse (RN) 9, Patient 13's care plans, were reviewed. RN 9 stated the following: Care plans should be initiated upon admission to maintain a patient's wellbeing and to provide care according to specific patient needs. Patient 13 should have had a care plan developed for electrolyte imbalance and impaired mobility upon admission to ensure implementation of appropriate interventions, per patient care needs. RN 9 reviewed Patient 13's documentation for Activities of Daily Living (ADLs), dated 9/11/2025 through 9/17/2025, and stated that Patient 13 remained in bed throughout her (Patient 13) entire admission to the facility.

During a review of Patient 13's "H&P," dated 9/15/2025, the H&P indicated the following: Patient 13 was transferred from nursing facility for further evaluation of bilateral lower extremity pain. Patient 13 had a past medical history significant for diabetes type II (long-term condition in which the body has trouble controlling blood sugar), functional quadriplegia (complete immobility of all four limbs due to a severe underlying medical condition), Chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The H&P also indicated Patient 13 presented with electrolyte (minerals in the body, such as sodium and potassium, that balance the amount of water in the body and are crucial for nerve and muscle contractions) abnormalities.

During a review of Patient 13's nursing "Admission Assessment Report," dated 9/10/2025 at 12:52 a.m., the Admission Assessment Report indicated the following: Patient 13 arrived on the Medical Surgical Unit at 12:10 a.m. from the Emergency Department. Activities of Daily Living (ADL) assessment indicated Patient 13 was unable to bathe or feed self. Patient 13 needed total assistance with toileting, oral care and grooming. Musculoskeletal (relating to bones and muscles, joints) assessment indicated Patient 13 was bedbound (confined to a bed or a chair most of the time) with signs and symptoms of stiffness and weakness. The left and right upper extremities (arms) were contracted (tightening or shortening of the muscle). The Fall Risk Evaluation indicated a score of 45 (moderate risk for falls). The Integumentary (skin) assessment included a Braden Scale (a tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers or bedsores) score of 14 (indicated a risk for skin breakdown).

During a review of Patient 13's "Patient Care Plan Report," initiated on 9/10/2025, the report indicated that the following plans of care were initiated upon admission ...Infection (Actual); Pain - Chronic Pain (Actual); Risk for Impaired Swallowing (Actual); Risk for Impaired Tissue Integrity (Actual), included interventions for monitoring a dialysis catheter (Patient 13 did not have a dialysis catheter); Risk for Injury (Actual), interventions included implementing seizure precautions (Patient 13 did not have seizure or history of seizure episodes); Safety - Risk for Aspiration (Actual), included interventions for enteral feedings, such as, monitor for congestion ...monitor feeding tube residual, elevate the head of bed during enteral feeding (Patient 13 did not have enteral feeding), Nutri - Chewing / Swallowing Difficulty (Actual). On 9/17/2025 at 12:43 p.m., Functional - Impaired Mobility (Actual) was initiated.

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Multidisciplinary," dated 9/2025, the P&P indicated the following: Purpose: To communicate information for continuity of care, to coordinate activities of the multidisciplinary staff care for the patient, to develop long and short-term goals for the patient, and to identify the problems, needs, and concerns of the patient. The care plan is initiated by the Registered Nurse within 24 hours of admission, reviewed every 24 hours and updated as necessary. Other healthcare team members will make entries in the care plan upon admission and continue throughout the patient's hospital stay. Data gathered from the various clinical disciplines are integrated into a common patient medical record to assure that patient needs are appropriately identified, and that care and service are effectively coordinated. As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patients' most pressing needs are met.

2. During a review of Patient 16's "H&P," dated 9/15/2025, the H&P indicated the following: "Chief Complaint: Buttock abscess (a localized collection of pus, a thick white or yellow fluid, that forms in response to an infection). Patient 16 with chronic osteomyelitis (inflammation of bone caused by infection), homeless, testicular (in the testicles) cancer in remission since 2021 ... presents ...for complications to his sacral (area of bone at the base of the spine) wound that developed after his bout with testicular cancer after cancer spread to bone ...Has been living in a car, was in a nursing home prior to that ..."

During a concurrent interview and record review on 10/3/2025 at 9:26 a.m. with IT 3, Patient 16's H&P and Patient Care Plan Report, were reviewed. IT 3 stated that Patient 16 did not have a history of seizures. Patient 16's care plan addressing Safety/Risk for Injury should not include implementing seizure precautions. IT 3 further said that Care plans should be customized to address patient's specific needs.

During a review of Patient 16's "Patient Care Plan Report," initiated on 9/14/2025, the report indicated a care plan titled, "Safety - Risk for Injury (Actual)," was developed. Interventions included the implementation of seizure precautions.

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Multidisciplinary," dated 9/2025, the P&P indicated the following: Purpose: To communicate information for continuity of care, to coordinate activities of the multidisciplinary staff care for the patient, to develop long and short-term goals for the patient, and to identify the problems, needs, and concerns of the patient. The care plan is initiated by the Registered Nurse within 24 hours of admission, reviewed every 24 hours and updated as necessary. Other healthcare team members will make entries in the care plan upon admission and continue throughout the patient's hospital stay. Data gathered from the various clinical disciplines are integrated into a common patient medical record to assure that patient needs are appropriately identified, and that care and service are effectively coordinated. As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patients' most pressing needs are met.

3. During a review of Patient 17's "H&P," dated 9/30/2025, the H&P indicated the following: Per Emergency Department (ED) report, Patient 17 was brought to the ED (Emergency Department) from current skilled nursing facility (SNF, a residential healthcare setting that provides round-the-clock medical care and therapy for patients recovering from serious illnesses or injuries) for evaluation. The H&P also indicated Per SNF staff, "patient (Patient 17) complained of chest pain ...patient (Patient 17) had a history of Coronary Artery Disease (CAD, arteries that supply blood to the heart become narrowed or blocked), Chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), Gastroesophageal reflux disease (GERD, stomach contents leak backward from the stomach into the food esophagus or food pipe), Diabetes Mellitus (high sugar levels in the blood), and hypertension (high blood pressure) ..."

During a concurrent interview and record review on 10/3/2025 at 9:26 a.m. with IT 3, Patient 17's H&P and Patient Care Plan Report, were reviewed. IT 3 stated that Patient 17 did not have a history of seizures. IT 3 said Patient 17's care plan addressing Safety/Risk for Injury should not include implementing seizure precautions. IT 3 further stated Care plans should be customized to address a patient's specific care needs.

During a review of Patient 17's "Patient Care Plan Report," initiated on 9/30/2025, the report indicated a care plan titled, "Safety - Risk for Injury (Actual)," was developed. Interventions included the implementation of seizure precautions.

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Multidisciplinary," dated 9/2025, the P&P indicated the following: Purpose: To communicate information for continuity of care, to coordinate activities of the multidisciplinary staff regarding care for the patient, to develop long and short-term goals for the patient, and to identify the problems, needs, and concerns of the patient. The care plan is initiated by the Registered Nurse within 24 hours of admission, reviewed every 24 hours and updated as necessary. Other healthcare team members will make entries in the care plan upon admission and continue throughout the patient's hospital stay. Data gathered from the various clinical disciplines are integrated into a common patient medical record to assure that patient needs are appropriately identified, and that care and service are effectively coordinated. As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patients' most pressing needs are met.

Based on interview and record review, the facility failed to:

1. Ensure nursing staff and Telemetry technician (staff who monitor heart rate and rhythm [the regular pattern of electrical impulses that control the heart's contractions and pumping action] on remote cardiac monitors) recognized and responded to significant changes in patient condition by activating rapid response (RRT, a team that responds in an emergency and provides immediate, critical care to patients showing sudden signs of decline), for three (3) of 30 sampled patients (Patient 2, Patient 21, and Patient 22), in accordance with the facility's policy and procedure titled, "Rapid Response Teams."

This deficient practice resulted in:

a. Patient 2 experiencing life-threatening blood loss in the post (after) - anesthesia care unit (PACU, a hospital recovery area after surgery) without prompt escalation of treatment, which likely contributed to Patient 2's death;

b. Patient 21 experiencing delayed evaluation and transfer to the ICU (Intensive Care Unit, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) after experiencing hypertension (HTN, high blood pressure), mental-status change (decrease in awareness or alertness) and a seizure (sudden uncontrolled muscle activity caused by abnormal brain electrical signals), all of which could have contributed to Patient 21's decline and death; and

c. Patient 22 remaining hypotensive (having abnormally low blood pressure) without activation of rapid response, thus placing Patient 22 at risk for cardiac arrest (sudden loss of heart function).

2. Ensure nursing staff notified the physician of a change in patient condition, for one of 30 sampled patients (Patient 22), when Patient 22 was hypotensive (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]) on two separate occasions, in accordance with the facility's policy and procedure (P&P) titled, "Notification of Physician for Unusual Events or Change in Patient's Condition."

This deficient practice had the potential for Patient 22 to not have the necessary medical treatments to address Patient 22's hypotension, which could have placed Patient 22 at risk of deterioration and/or death.

3. Ensure one of 30 sampled patients (Patient 22), was turned/repositioned every two (2) hours, in accordance with the facility's policy and procedure titled, "Pressure Injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) Assessment, Management, Prevention and Treatment Protocol."

This deficient practice had the potential to increase the risk of Patient 22 developing a worsening wound and pressure injury, which could lead to uncontrolled pain and/or infection.

4. Ensure nursing staff provided pericare (cleaning the genitalia and buttocks area to prevent infection, skin breakdown, and promote comfort) for one of 30 sampled patients (Patient 22), in accordance with the facility's policy titled, "Plan for the Provision of Patient Care."

This deficient practice had the potential for Patient 22 to develop an infection, skin breakdown (damage or injury to the skin), and physical discomfort.

On 10/3/2025 at 12:13 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Nursing Officer (CNO). The IJ was related to the facility's failure to ensure that nursing and telemetry staff (staff who monitor patient heart rhythms and vital signs) promptly activated the Rapid Response (RRT, a group of trained team professionals who provide immediate assistance when a patient's condition suddenly worsens) for Patient 2, Patient 21, and Patient 22, when they experienced sudden clinical changes (any unexpected, significant deviation from a patient's normal condition) that met the criteria for RRT activation.

For Patient 2: On 8/18/2025, A Rapid Response was not activated until 9:48 a.m., more than one hour after Patient 2 arrived in the Post-Anesthesia Care Unit (PACU, the recovery area after surgery) with a blood pressure (BP) of 74/35 (severe hypotension, meaning dangerously low blood pressure, reading is below 90 mmHg and/or the bottom number is below 60 mmHg) mmHg (millimeters of mercury, a unit of measurement) and a heart rate of 25 beats per minute (bradycardia, an abnormally slow heart rate that can cause cardiac arrest [when the heart stops beating effectively]). A Code Blue (a hospital-wide emergency alert indicating a patient is experiencing cardiac arrest) was eventually initiated (at 9:48 a.m.); however, resuscitation efforts (life-saving efforts when a patient's heart or breathing stops) were unsuccessful, and Patient 2 died. On 10/2/2025 at 12:10 p.m., the Chief of Surgery (CS) stated, "A rapid response should have been called immediately."

For Patient 21: On 7/12/2025 at 4:00 p.m., nursing staff failed to activate a Rapid Response for Patient 21, who was experiencing seizures (sudden uncontrolled body movements caused by abnormal brain activity) and altered mental status (a change in awareness or alertness). Patient 21 was transferred to the Intensive Care Unit (ICU, specialized department for critically ill or injured patients) at 4:48 p.m. and was later declared brain-dead (a medical and legal definition of death that occurs when all brain functions, including the brain stem, cease irreversibly) on 8/5/2025. On 10/1/2025 the Director of Medical-Surgical and Telemetry (DMST) confirmed that Patient 21's clinical condition met the facility's policy criteria for Rapid Response activation due to seizure activity and neurological decline (a sudden worsening of brain function, such as confusion or loss of consciousness [a state where a person is not awake and aware of their surroundings], often indicating serious brain injury or reduced blood flow to the brain).

For Patient 22: On 7/26/2025 at 8:00 a.m., nursing staff did not activate a Rapid Response for Patient 22, who was having repeated episodes of hypotension (low blood pressure, defined as less than 90/60 mm Hg). Patient 22's BP (Blood Pressure) readings were 75/38 mmHg on 7/26/2025 and 82/57 mmHg on 7/27/2025, both BP readings meeting the definition of hypotension. On 10/2/2025, the DMST confirmed that Patient 22's condition also met the criteria for Rapid Response activation under the facility's "Rapid Response" policy.

On 10/3/2025 at 6:03 p.m., the IJ was removed in the presence of the CEO, CNO, DOQ, DRS, DLD, DED/ICU, DIRS, DOS/EM, MRM, Clinical Education Director (CE), Director of Medical Surgical and Telemetry (DMST), Supervisor of Health Information Management (HIMS), Director of Pharmacy Services (DPM), Infection preventionist (IP), Director of Facility (DF), Clinical Informatic (IT 2), and Director of Admitting Department (DA) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan included: Posters with criteria for calling an RRT were posted in nursing care areas; staff in the medical-surgical telemetry unit (MST), intensive care unit (ICU), perinatal unit and post anesthesia care unit (PACU) were educated on the RRT policy; mock (pretend) RRTs were conducted in the PACU, MST, and ICU for day shift and would continue for night shift staff; on every shift for each unit, the charge nurse would get updates from the licensed nurses on patient status in all units except for perinatal unit at night, where the house supervisor would meet with staff; sign in sheets would be collected and reviewed by the nursing unit directors weekly and the CNO would provide oversight.

Findings:

1.a. During a review of Patient 2's "Operative Report," dated 8/18/2025, the Operative Report indicated Patient 2 underwent left tunneled permacath placement (a catheter surgically inserted into a large vein for dialysis [a medical treatment to remove waste products and excess fluid from the blood when the kidneys are no longer working properly] access) from 8:15 a.m. to 8:22 a.m.

During a concurrent interview and record review on 10/1/2025 at 1:57 p.m. with PACU (Post Anesthesia Care Unit, a hospital recovery area after surgery) registered Nurse (RN) 1, Patient 2's Vital Signs Flowsheet, dated 8/18/2025, was reviewed, RN 1 confirmed that Patient 2 arrived in the PACU at 8:38 a.m. with a blood pressure of 74/35 (severe hypotension; an abnormally low blood pressure where the systolic blood pressure [the top number in a blood pressure reading] is below 90 mmHg or a diastolic blood pressure [the bottom number] is below 60 mmHg) mmHg (unit of measurement) , heart rate of 61 beats per minute (bpm), and oxygen saturation 98% on 6 liters of supplemental oxygen. From 8:38 a.m. to 9:48 a.m. on 8/18/2025, Patient 2's blood pressure ranged between 50-80 mmHg and heart rate 52-59 bpm. RN 1 confirmed that a Code Blue was called at 9:48 a.m., an hour after Patient 1 started experiencing severe hypotension at 8:38 a.m., in which a rapid response was not activated to address Patient 1's hypotension.

During the same interview on 10/1/2025 at 1:57 p.m. with RN 1, RN 1 stated that Patient 2 arrived to PACU, already hypotensive, on 8/18/22025. RN 1 notified the vascular surgeon (MD 3) and the anesthesiologist (Anes 1), who remained at the bedside of Patient 2 and gave fluids and albumin (a protein solution used to raise blood pressure), but Patient 2's condition did not improve.

During the same interview on 10/1/2025 at 1:57 p.m. with RN 1, RN 1 stated MD 3 inserted a chest tube (a tube placed in the chest to drain blood or air) in Patient 2's chest that drained approximately 3,700 milliliters (mL, a unit of measurement) of serosanguineous fluid (a mixture of blood and clear fluid). RN 1 confirmed that 3,700 mL was an abnormal large amount of chest tube drainage. RN 1 further stated she (RN 1) did not call a rapid response because "neither doctor told me to."

During a review of Patient 2's Medication Administration Record (MAR, document that tracks all medications a patient or resident is given by a healthcare professional), dated 8/18/2025, the MAR indicated the patient (Patient 2) received Levophed (a medication used to increase blood pressure) at 9:35 a.m., 57 minutes after arrival to PACU with hypotension (low blood pressure).

During an interview on 10/1/2025 at 3:21 p.m. with the Director of Emergency Services (DED), the DED stated that the Rapid Response Team (RRT, a team of specially trained medical professionals who are immediately called to the bedside of a patient with early signs of clinical deterioration, such as abnormal vital signs or altered mental status), should be activated when a patient's condition met the criteria outlined in the RRT's policy. The DED mentioned that when the RRT was summoned, they (the RRT) will bring specialized staff to the bedside who can assess the situation and assist with starting emergency medications.

During a review of the Code Blue Report, dated 8/18/2025, the report indicated the emergency team arrived at 9:48 a.m., nearly one hour after the onset of shock (when the body is not receiving enough blood flow to adequately supply oxygen and nutrients to vital organs and tissues; a life-threatening medical emergency that can lead to organ failure and death if not treated promptly). The resuscitation was unsuccessful, and the patient (Patient 2) expired (died) at 10:30 a.m. on 8/18/2025.

During an interview on 10/2/2025 at 12:10 p.m. with the Chief of Surgery (CS), the CS stated, "A rapid response should have been called immediately; I would have taken the patient back to the operating room."

During an interview on 10/1/2025 at 3:12 p.m. with the Director of Emergency Services (DED), the DED stated, "Any staff member can activate a rapid response to get help quickly from trained staff and ensure prompt transfer to intensive care (a specialized medical unit within a hospital that provides highly specialized and intensive treatment to critically ill patients)."

During a review of the hospital's policy and procedure (P&P) titled, "Rapid Response Teams," (dated 5/2025), the policy stated, "Purpose: To ensure rapid intervention in cases of patient deterioration and improve patient outcomes by facilitating early recognition, prompt assessment, and immediate implementation of a multidisciplinary approach. Any staff member may activate the Rapid Response Team under a 'No Blame' policy.' The criteria included: Heart rate < 40 or > 130 beats per minute, Systolic blood pressure < 80 mmHg, Respiratory rate < 8 or > 30 per minute, Acute mental status change, Seizure activity, and Patient distress or unresponsiveness."

1.b. During a review of Patient 21's "History and Physical Note," dated 7/8/2025, the record indicated Patient 21 was admitted to the facility for dizziness. Patient 21 had a medical history of gastric bypass (surgery that makes the stomach smaller, helping with diet and weight control).

During a review of Patient 21's "Neurology (a branch of medicine that focuses on the diagnosis, treatment, and study of disorders affecting the nervous system. The nervous system includes the brain, spinal cord, nerves, and muscles) Consultation Note," dated 7/9/2025, the record indicated Patient 21 was seen for dizziness. The record did not indicate a past or current history of seizure (sudden uncontrolled muscle activity caused by abnormal brain electrical signals), nor any antiepileptic (used to prevent seizures) medications.

During a review of Patient 21's "Admitting Team Progress Note," dated 7/13/2025, the record indicated, "Patient (Patient 21) was transferred to ICU (Intensive Care Unit, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) overnight, due to persistent altered mental status (level of thinking and understanding is different from normal for that person), confusion and also status (after) epilepticus (seizure)."

During a review of Patient 21's "Intensivist Consultation Note," dated 7/13/2025, the record indicated Patient 21 was transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) from the telemetry (a specialized hospital unit that provides continuous monitoring of heart rate and rhythm) unit for "Worsening altered mental status and another seizure episode. Currently, he remains lethargic (a state of feeling tired, sluggish, and lacking energy) and drowsy, not following commands but opening his (Patient 21) eyes to pain stimuli (how someone responds to the senses and helps determine an individual's level of alertness)."

During a review of Patient 21's "Neurology Progress Note," dated 8/5/2025, the record indicated, "Pt (Patient 21) is brain dead."

1.b.i. During an interview on 10/1/2025 at 3:17 p.m. with the Director of Quality (DQ), DQ stated a Rapid response should be called if there was a sudden change in condition. DQ also stated a rapid response could be called if the nurse wanted somebody to take a look at the patient, and calling a rapid response would make the interventions done faster instead of paging the doctor and waiting for a response. DQ further stated there would be no harm to call for a rapid response.

During a concurrent interview and record review on 10/2/2025 at 11:05 a.m. with Pharmacy Informatics Specialist (IT 2), Patient 21's "Vital Signs Report," dated 7/8/2025 to 7/12/2025, was reviewed. The record indicated Patient 21's blood pressure (BP, amount of force needed to move blood throughout the body and organs, with normal range of 120/90 millimeters of Mercury [mmHg, a unit of measurement]) remained high, with the systolic (SBP, first set of numbers in blood pressure when the heart contracts and pushes out blood) in the 150s to 170s and diastolic (DBP, second set of numbers in blood pressure when the heart relaxes and fills with blood) in the 100s to 120s until eventually decreasing to normal limits on 7/11/2025. The record indicated the following:

-On 7/8/2025 at 12:00 a.m., Patient 21's BP was 173/99;
-On 7/8/2025 at 4:00 a.m., Patient 21's BP was 156/72
-On 7/8/2025 at 8:00 a.m., Patient 21's BP was 169/99. From this time onward until 7/9/2025 at 8:15 p.m., Patient 21's SBP remained in the 150s to 170s, and DBP remained in the 100s to 120s.
-On 7/9/2025 at 8:15 p.m., Patient 21's BP was 158/76.
-On 7/10/2025 at 2:08 a.m., Patient 21's BP was 157/126. From this time onward until 7/10/2025 at 11:04 p.m., Patient 21's SBP remained in the 150s to 170s, and DBP frequently remained in the 100s to 120s.
-On 7/10/2025 at 11:04 p.m., Patient 21's BP was 154/98, and at 11:27 p.m., Patient 21's BP was 156/107.
-On 7/11/2025 at 12:00 a.m., Patient 21's BP was 101/60, within normal limits. Patient 21's BP continued to be mostly within normal limits through 7/12/2025, while Patient 21 was on the telemetry unit (a hospital department for patients who require constant electronic monitoring of their vital signs, such as heart rate, blood pressure, and oxygen saturation).

During an interview on 10/2/2025 at 2:00 p.m. with the Director of Medical-Surgical Telemetry (DMST), DMST stated the purpose of calling a rapid response was to prevent further deterioration, and for the team to gather information, support the nurses, and decide if the patient needed transfer to ICU. DMST acknowledged there would be no harm in calling a rapid response.

During a concurrent interview and record review on 10/2/2025 at 2:27 p.m. with the Director of Medical-Surgical Telemetry (DMST), Patient 21's "Vital Signs Report," dated 7/8/2025 to 7/12/2025, was reviewed. DMST acknowledged Patient 21's BP readings were not normal. DMST stated a rapid response could be called for extreme or severe hypertension (HTN, high blood pressure) as in the case of Patient 21. DMST stated complications of uncontrolled persistent HTN could be cardiac arrest (heart stops beating), potential stroke (loss of blood flow to a part of the brain), and heart attack (blood stops flowing to parts of the heart).

During a concurrent interview and record review on 10/2/2025 at 2:27 p.m. with DMST, the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, was reviewed. DMST reviewed the criteria for calling a rapid response. DMST acknowledged Patient 21's high blood pressure fit under the criteria to call for a rapid response.

During an interview on 10/2/2025 at 4:15 p.m. with Registered Nurse (RN) 7, RN 7 stated having a high blood pressure for too long could lead to a stroke (loss of blood flow to a part of the brain) or heart attack.

During an interview on 10/3/2025 at 9:30 a.m. with House Supervisor (HS), HS stated nurses were expected to follow guidelines for calling a rapid response. HS stated the nurses were always told if there was a variance in the BP reading, the nurses were expected to recheck and call for a rapid response if the hypertension remained persistent. HS stated nurses were also expected to call a rapid response for new or prolonged seizures, and for mental status changes as in the case of Patient 21. HS stated the danger of not calling a rapid response would be a deterioration of patient's condition and death. HS also stated it would also be a failure not to initiate interventions the patient needed and a medical necessity to improve their clinical status. HS also acknowledged there would be a delay in treatment in care if a rapid response was not called.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, the P&P indicated: "Criteria for calling the Team may include but are not limited to one or more of the following:

1. Changes in HR or rhythm (Acute or subtle). < 40 or > 130 bpm
2. Changes in SBP (<80 mmHg) that is unresponsive to prescribed interventions, or a +/- 30% change from patient's baseline
3. Respiratory rate (<8, >30/min)
4. Acute mental status change
5. Pulse oximetry changes (<90% despite 02) or significant increase in oxygen delivery method
6. Patient in distress
7.Persistent chest pain that is unresponsive to existing protocols and/or prescribed interventions
8. Seizures."

1.b.ii. During a concurrent interview and record review on 10/1/2025 at 2:25 p.m. with the Director of Quality (DOQ), Patient 21's "Daily Assessment Inquiry," dated 7/11/2025 and 7/12/2025, was reviewed. The record indicated the following for Patient 21's Level of Consciousness (LOC, level of being alert and aware) and Glascow Coma Scale (GCS, level of awareness with a maximum level of 15 indicating full awareness):

-On 7/11/2025 at 8:00 a.m., Patient 21's "Level of Consciousness (LOC)" was "Awake/Alert," and had a Glascow Coma Scale (GCS) of 15.
-On 7/11/2025 at 8:07 a.m., Patient 21 was Lethargic (too tired or sleepy), had a GCS score of 12, and a note that indicated, "Pt (Patient 21) refuses to open eyes or take pills. Too lethargic."
-On 7/11/2025 at 8:07 p.m., Patient 21 was Lethargic and had a GCS score of 12.
-On 7/12/2025 at 12:32 a.m. and at 4:01 a.m., Patient 21 had no change from the previous assessment.
-On 7/12/2025 at 8:00 a.m., Patient 21 was arousable and lethargic and had a GCS score of 11. At 12:00 p.m., Patient 21 was arousable and had a GCS score of 13.

During an interview on 10/1/2025 at 3:17 p.m. with the Director of Quality (DQ), DQ stated a Rapid response should be called if there was a sudden change in a patient's condition. DQ also stated a rapid could be called if the nurse wanted somebody to take a look at the patient and calling a rapid response would make the interventions done faster instead of paging the doctor and waiting for a response. DQ further stated there would be no harm to call for a rapid response.

During a concurrent interview and record review on 10/2/2025 at 2:27 p.m. with the Director of Medical-Surgical Telemetry (DMST), Patient 21's "Daily Assessment Inquiry," dated 7/10/2025 to 7/12/2025, was reviewed. DMST acknowledged Patient 21's neurological status changes from alert with a GCS of 15 on 7/10/2025 to the changes on 7/11/2025 and 7/12/2025. DMST stated this was concerning and would have raised a flag as a change of condition.

During a concurrent interview and record review on 7/12/2025 at 2:27 p.m. with DMST, the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, was reviewed. DMST reviewed the criteria for calling a rapid response. DMST acknowledged Patient 21's mental status change fit under the criteria to call for a rapid response.

During an interview on 10/3/2025 at 9:30 a.m. with House Supervisor (HS), HS stated nurses were expected to follow guidelines for calling a rapid response. HS stated the nurses were always told if there was a variance in the BP reading, the nurses were expected to recheck and call for a rapid response if the hypertension remained persistent. HS stated nurses were also expected to call a rapid response for new or prolonged seizures, and for mental status changes as in the case of Patient 21. HS stated the danger of not calling a rapid response would be a deterioration of patient's condition and death. HS also stated it would also be a failure not to initiate interventions the patient needed and a medical necessity to improve their clinical status. HS also acknowledged there would be a delay in treatment in care if a rapid response was not called.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, the P&P indicated: "Criteria for calling the Team may include but are not limited to one or more of the following:
1. Changes in HR or rhythm (Acute or subtle). < 40 or > 130 bpm
2. Changes in SBP (<80 mmHg) that is unresponsive to prescribed interventions, or a +/- 30% change from patient's baseline
3. Respiratory rate (<8, >30/min)
4. Acute mental status change
5. Pulse oximetry changes (<90% despite 02) or significant increase in oxygen delivery method
6. Patient in distress
7.Persistent chest pain that is unresponsive to existing protocols and/or prescribed interventions
8. Seizures."

1.b.iii. During a review of Patient 21's "Progress Notes Report," dated 7/12/2025, the record indicated a nursing entry at 6:24 p.m. for a 4:00 p.m. incident of seizure, "Patient (Patient 21) had seizure on and off. Called Dr. (name of physicians), new order carried out. Consult (name of physician) for HR (heart rate) 130's. (name of physician) came and checked patient's condition. Continue to monitor condition. Administered Keppra (medication to prevent seizures) as ordered." The record further indicated at 4:48 p.m., Patient 21 was "Transferred to ICU (intensive care unit, area that requires frequent monitoring and treatment) as ordered. No s/s (signs and symptoms) of seizure at this time."

During an interview on 10/2/2025 at 10:00 a.m. with Registered Nurse (RN) 3, RN 3 stated a rapid response could be called for a patient who was unstable, their condition suddenly changes, was not responsive, had seizures, or needed emergency treatments. RN 3 stated the emergency room (ER) doctor, ICU or ER nurse, and respiratory therapist responds. RN 3 stated typical emergency medications given for seizures would be Ativan (medication to treat seizures) or Valium (also known as Diazepam, a medication to help control seizures).

During the same interview on 10/2/2025 at 10:00 a.m. with RN 3, RN 3 confirmed Patient 21 did not have seizure history before. RN 3 stated Patient 21 did not have a seizure that lasted for a long time and could not recall how long the patient (Patient 21) had a seizure for. RN 3 stated she (RN 3) did not call a rapid response, and there was no need to call it because she had called Patient 21's doctors and received orders to give Keppra (Levetiracetam, medicine given to prevent seizures) and transfer Patient 21 to the ICU. RN 3 further stated if Patient 21 continued to have seizures, she would have had to call a rapid response. RN 3 also stated Patient 21 was confused and his (Patient 21) condition was "up and down."

During a concurrent interview and record review on 10/2/2025 at 11:32 a.m. with Pharmacy Informatics Specialist (IT 2), Patient 21's "Medication Administration History Report," dated 7/12/2025, was reviewed. The record indicated on 7/12/2025 at 3:43 p.m. in the telemetry unit, Patient 21 received the first dose of Levetiracetam (Keppra, medication used to prevent seizure) 1000 milligrams (mg, a unit of measure). Patient 21 received the next dose of Keppra on 7/12/2025 at 8:31 p.m. in the ICU. Patient 21 did not receive an emergency seizure medication prior to being transferred to the ICU.

During a concurrent interview and record review on 10/2/2025 at 2:27 p.m. with DMST, the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, was reviewed. DMST reviewed the criteria for calling a rapid response. DMST acknowledged Patient 21's seizure fit under the criteria to call for a rapid response.

During an interview on 10/2/2025 at 4:15 p.m. with Registered Nurse (RN) 7, RN 7 stated the danger of having a seizure could be going into a coma (person is not conscious and/or responsive). RN 7 also stated she (RN 7) would call a rapid response if a patient had a new onset seizure.

During an interview on 10/3/2025 at 9:30 a.m. with House Supervisor (HS), HS stated nurses were expected to follow guidelines for calling a rapid response. HS stated the nurses were always told if there was a variance in the BP reading, the nurses were expected to recheck and call for a rapid response if the hypertension remained persistent. HS stated nurses were also expected to call a rapid response for new or prolonged seizures, and for mental status changes as in the case of Patient 21. HS stated the danger of not calling a rapid response would be a deterioration of patient's condition and death. HS also stated it would also be a failure not to initiate interventions the patient needed and a medical necessity to improve their clinical status. HS also acknowledged there would be a delay in treatment in care if a rapid response was not called.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, the P&P indicated: "Criteria for calling the Team may include but are not limited to one or more of the following:

1. Changes in HR or rhythm (Acute or subtle). < 40 or > 130 bpm
2. Changes in SBP (<80 mmHg) that is unresponsive to prescribed interventions, or a +/- 30% change from patient's baseline
3. Respiratory rate (<8, >30/min)
4. Acute mental status change
5. Pulse oximetry changes (<90% despite 02) or significant increase in oxygen delivery method
6. Patient in distress
7.Persistent chest pain that is unresponsive to existing protocols and/or prescribed interventions
8. Seizures."

1.c. During a review of Patient 22's "History and Physical (H&P)," dated 7/4/2025, the H&P indicated Patient 22 was admitted to the facility for chest pain. Patient 22's medical history included dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and hypertension (HTN-high blood pressure [BP, measures the amount of force needed to move blood throughout the body and to the organs]).

During a review of Patient 22's "Vitals Inquiry," dated 7/26/2025, the record indicated the following for Patient 22's blood pressure (BP, normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]):

-On 7/26/2025 at 8:00 p.m., BP 75/38; and
-On 7/27/2025 at 8:00 p.m., BP 82/57 (24 hours after the abnormal [not normal] BP range)

During a review of Patient 22's "Progress Note Inquiry," dated 7/28/2025, the record indicated at 7:23 a.m., Patient 22 had BP 81/34. A later entry at 7:47 a.m. indicated a rapid response was called for Patient 22 for BP of 77/31.

During a review of Patient 22's "Rapid Response Team Record," dated 7/28/2025, the record indicated at 7:30 a.m., a rapid response was called for "B/P (blood pressure) low 77/31." The record further indicated Patient 22 had an order to receive normal saline (fluids used to raise BP) and ICU transfer.

During a concurrent interview and record review on 10/1/2025 at 10:10 a.m. with the Manager of Risk Management (MRM), Patient 22's "Progress Note Inquiry," dated 7/26/2025 to 7/27/2025, was reviewed. MRM confirmed nursing staff did not document a recheck of Patient 22's BP and what was done when it was low, and that nursing staff did not document nurse to physician communication. MRM stated if the BP was low, the nurse should have notified the physician and call a rapid response.

During an interview on 10/1/2025 at 10:15 a.m., MRM stated a rapid response should have been called, instead, it was delayed and this delay in activating a rapid response could have led to many things like something irreversible (an outcome or consequence that is permanent and could not be reversed or treated even with further medical treatment).

During an interview on 10/1/2025 at 3:17 p.m. with the Director of Quality (DQ), DQ stated a Rapid response should be called if there was a sudden change in condition. DQ also stated a rapid response could be called if the nurse wanted somebody to take a look at the patient, which would make the interventions done faster instead of paging the doctor and waiting for a response. DQ further stated there would be no harm to call for a rapid response.

During a concurrent interview and record review on 10/2/2025 at 2:00 p.m. with the Director of Medical-Surgical Telemetry (DMST), Patient 22's "Vitals Inquiry," dated 7/26/2025 to 7/28/2025, was reviewed. DMST acknowledged Patient 22's BP readings of 75/83 on 7/26/2025 at 8:00 p.m. and of 82/57 on 7/27/2025 at 8:00 p.m., were abnormal.

During a concurrent interview and record review on 7/12/2025 at 2:27 p.m. with DMST, the facility's policy and procedure (P&P) titled, "Rapid Response Teams," dated 5/2025, was reviewed. DMST reviewed the criteria for calling a rapid response. DMST acknowledged Patient 22's low blood pressure fit under the criteria to call for a rapid response.

During an in