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

1. The facility failed to ensure five (5) of 30 sampled patients (Patients 1, 3, 4, 5, and 6), family and significant others (immediate family and responsible party) were informed about the Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), and the right to formulate Advance Directive (AD - a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

This deficient practice resulted in the patients and their significant others not being given the opportunity to provide consent for the facility to treat patients upon admission and not knowing their rights to formulate their medical treatment care wishes during hospitalization. (Refer to A-0117)

2. The facility failed to follow the facility's fall prevention policy for two of 30 sampled patients (Patient 12 and Patient 16). This deficient practice placed patients at risk for falls and injury. (Refer to A-0144)


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 meet the Condition of Participation for Nursing Services as evidenced by:

1. The facility failed to ensure the nurse for one of 30 sampled patients (Patient 23), completed a skin assessment (visually inspecting and palpating the skin to identify any abnormalities) and documented upon downgrade of care transfer. Patient 23 was transferred to a medical surgical unit (a specific area within a hospital where patients receives care for a wide range of medical and surgical conditions) unit as a bed downgrade (the process of transferring a patient from a higher level of care, to a lower level as patient condition improves) from the intensive care unit (a specialty area within a hospital where patients receives intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency).

This deficient practice had the potential for delays in the care and identification of Patient 23's current skin condition and issues which could result to complications like worsening pressure ulcers (are localized injuries to the skin and underlying tissue caused by prolonged pressure, often over bony prominences) and infection. (Refer to A-0395)

2. The facility failed to ensure the nurse for three of 30 sampled patients (Patient 23, 25, and 27), implemented the following:

2.a. Patient 23's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection) was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

2.b. Patient 25's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Hysterectomy (a surgical procedure where the uterus is removed) was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

2.c. Patient 27's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection) was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

These deficient practices had the potential of failing to implement and develop clinically appropriate individualized goals and interventions for Patients 23, 25 and 27, which may result to complications on the patients' current condition and poor patient outcomes. (Refer to A-0396)

3. The facility failed to ensure the nurse adhere and follow the facility's policy and procedure for six of 30 sampled patients (Patient 1, Patient 8, Patient 16, Patient 18, Patient 20 and Patient 26) when:

3.a. The facility failed to ensure one of 30 sampled patients (Patient 1) was assessed and/or monitored for pain, according to facility's policies and procedures upon admission, before and after administration of pain medication.

This deficient practice had the potential for Patient 1's pain to be not managed appropriately and could prolong feeling of pain which could affect Patient 1's well-being. (Refer to A-0398)

3.b. The facility failed to follow facility policy and procedure for proper management of identified multiple pressure injury on the buttocks (PI, localized injury to the skin or underlying tissue usually over a bony prominence) for one of 30 sampled patients (Patient 30)
This deficient practice has to potential for Patient 8's multiple PI on the buttocks to worsen and develop infection. (Refer to A-0398)

3.c. The facility failed to ensure the nurse adhered to the policy & procedure (P&P) for intravenous (IV - a way of administering fluids, medications, or nutrients directly into a vein) therapy for one of 30 sampled patients (Patient 16) by not labeling one of Patient 16's peripheral IV catheter (a short, flexible tube inserted into a vein, typically in the hand, arm, or foot to use for fluids or medication) sites.

This deficient practice had the potential for infection due to a compromised IV site. (Refer to A-0398)

3.d. The facility failed to ensure their staff adhered to the policy & procedure (P&P) for pain management by not documenting pain reassessment for two of 30 sampled patients (Patient 18 and Patient 20).

This deficient practice had the potential to result in ineffective pain management. (Refer to A-0398)

3.e. The facility failed to ensure their staff assessed and documented one of 30 sampled patient's (Patient 26) surgical dressing (protective covering applied to a surgical incision to help it heal and prevent infection) and vaginal packing (a surgical procedure involving inserting gauze or sponge material into the vaginal cavity, typically after pelvic reconstructive surgery or vaginal hysterectomy) upon admission to medical surgical unit (a specific area within a hospital or healthcare facility dedicated to providing comprehensive medical and surgical care to patients) and failed to document surgeon's (doctor who did the surgery) discharge which should have included the discharge instructions for Patient 26.

These deficient practices had the potential of failing to adequately monitor, identify and intervene complications immediately after surgery in the and after discharge of the patient which can lead to delayed healing, increased pain, and elevate patient risk of infection. (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 failed to ensure five (5) of 30 sampled patients (Patients 1, 3, 4, 5, and 6), family and significant others (immediate family and responsible party) were informed about the Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), and the right to formulate Advance Directive (AD - a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

This deficient practice resulted in the patients and their significant others not being given the opportunity to provide consent for the facility to treat patients upon admission and not knowing their rights to formulate their medical treatment care wishes during hospitalization.

Findings:

1. A review of Patient 1's face sheet (a document that summarizes a patient's basic information for quick reference), dated 9/10/2023, indicated patient (Patient 1) arrived at the emergency department (ED) by ambulance for not breathing.

On 4/16/2025, at 1:13 p.m., during concurrent interview with director of emergency department (DED) and record review of Patient 1's ambulance report, dated 9/10/2023, DED stated security found patient (Patient 1) unconscious and ambulance staff gave Narcan (a medicine that can save someone from a heroin, fentanyl, or prescription opioid medicine overdose).

Concurrently, during review of Patient 1's conditions of admission (COA - the requirements that an individual must meet to be formally admitted to a hospital), dated 9/10/2023, DED stated Patient 1 did not sign the COA and stated COA indicated patient (Patient 1) was unable to sign.

On 4/18/2025, at 10:26 a.m., during interview with accreditation and licensing coordinator (ALC), ALC stated Patient 1 and significant others (immediate family and responsible party) had no documentation of receiving information for advance directive (AD - a written statement of a person's wishes regarding medical treat, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

A review of the facility's conditions of admission (COA - a documentation of a patient's consent for hospital care) form, undated, indicated the following:
1. Consent to medical and surgical procedures.
2. Consent to nursing care ordered by the physician.
3. Acknowledgement of patient rights and responsibilities.

A review of facility's Signature on Admission/Registration Forms policy, dated 1/6/2023, indicated the following:
1. Signatures on a Conditions of Admissions (COA - documentation of a patient's consent for hospital care) form and other forms will be obtained for each patient admitted or registered for services.
2. COA - for used to document the patient's consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and to document the patient agreement to arbitrate any disputes that may arise with insurance company.
3. Registration representative must obtain and witness the patient's or legal representative's full legal signature at the time of admission/registration.
4. The date and time should always be the date and time the form was signed, even if the form is signed after admission due to the patient's incompetence during admission, due to emergency medical condition.
5. If the patient's condition does not permit him/her to sign, staff are responsible for notifying coworker and the patient's nurse that a signature is needed - either from a spouse or other family member, willing to sign, to obtain a signature.
6. The consent becomes effective when the patient becomes hospitalized and receives care and treatment, including observation services for more than 24 hours.
7. All documents with signatures must be scanned.

2. A review of Patient 3's face sheet, dated 4/1/2025, indicated patient (Patient 3) arrived at the ED (Emergency Department) via ambulance for a problem with high blood sugar.

On 4/17/2025, at 11:30 a.m., during concurrent interview with senior director of telemetry (SDT) and record review of Patient 3's COA (COA - a documentation of a patient's consent for hospital care), dated 4/11/2025, SDT stated COA was not signed by patient and significant others (immediate family and responsible party) and COA indicated patient (Patient 3) was unable to sign due to medical condition.

On 4/18/2025, at 10:26 a.m., during concurrent interview with accreditation and licensing coordinator (ALC) and record review of Patient 3's advance directive (AD - a written statement of a person's wishes regarding medical treat, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), dated 4/11/2025, ALC stated patient (Patient 3) was unable to answer questions and unable to sign.

A review of the facility's conditions of admission (COA - a documentation of a patient's consent for hospital care) form, undated, indicated the following:
1. Consent to medical and surgical procedures.
2. Consent to nursing care ordered by the physician.
3. Acknowledgement of patient rights and responsibilities.

A review of facility's Signature on Admission/Registration Forms policy, dated 1/6/2023, indicated the following:
1. Signatures on a Conditions of Admissions (COA - documentation of a patient's consent for hospital care) form and other forms will be obtained for each patient admitted or registered for services.
2. COA - for used to document the patient's consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and to document the patient agreement to arbitrate any disputes that may arise with insurance company.
3. Registration representative must obtain and witness the patient's or legal representative's full legal signature at the time of admission/registration.
4. The date and time should always be the date and time the form was signed, even if the form is signed after admission due to the patient's incompetence during admission, due to emergency medical condition.
5. If the patient's condition does not permit him/her to sign, staff are responsible for notifying coworker and the patient's nurse that a signature is needed - either from a spouse or other family member, willing to sign, to obtain a signature.
6. The consent becomes effective when the patient becomes hospitalized and receives care and treatment, including observation services for more than 24 hours.
7. All documents with signatures must be scanned.

3. A review of Patient 4's face sheet, dated 4/15/2025, indicated patient arrived in the ED by ambulance for respiratory failure (not breathing).

On 4/18/2025, at 10:27 a.m., during concurrent interview with director of emergency department (DED) and record review of Patient 4's ambulance report, dated 4/15/2025, DED stated patient was brought to the ED via ambulance from a nursing home with low blood pressure and low oxygen saturation.

Concurrently, during record review of Patient 4's COA (COA - a documentation of a patient's consent for hospital care), dated 4/15/2025, DED stated COA was not signed and COA indicated patient was unable to sign due to medical condition.

On 4/18/2025, at 10:26 a.m., during interview with accreditation and licensing coordinator (ALC), ALC stated Patient 4 and significant others (immediate family and responsible party) had no documentation of receiving information for advance directive (AD - a written statement of a person's wishes regarding medical treat, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).

A review of the facility's conditions of admission (COA - a documentation of a patient's consent for hospital care) form, undated, indicated the following:
1. Consent to medical and surgical procedures.
2. Consent to nursing care ordered by the physician.
3. Acknowledgement of patient rights and responsibilities.

A review of facility's Signature on Admission/Registration Forms policy, dated 1/6/2023, indicated the following:
1. Signatures on a Conditions of Admissions (COA - documentation of a patient's consent for hospital care) form and other forms will be obtained for each patient admitted or registered for services.
2. COA - for used to document the patient's consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and to document the patient agreement to arbitrate any disputes that may arise with insurance company.
3. Registration representative must obtain and witness the patient's or legal representative's full legal signature at the time of admission/registration.
4. The date and time should always be the date and time the form was signed, even if the form is signed after admission due to the patient's incompetence during admission, due to emergency medical condition.
5. If the patient's condition does not permit him/her to sign, staff are responsible for notifying coworker and the patient's nurse that a signature is needed - either from a spouse or other family member, willing to sign, to obtain a signature.
6. The consent becomes effective when the patient becomes hospitalized and receives care and treatment, including observation services for more than 24 hours.
7. All documents with signatures must be scanned.

4. A review of Patient 5's face sheet, dated 4/10/2025, indicated patient (Patient 5) arrived at the ED via ambulance for difficulty breathing.

On 4/18/2025, at 1:50 p.m., during concurrent interview with nurse manager (NM) 1 and NM 2, and record review of Patient 5's COA (COA - a documentation of a patient's consent for hospital care), dated 4/10/2025, NM1 stated patient (Patient 5) did not sign the COA and stated the COA indicated patient (Patient 5) was unable to sign due to medical reasons.

On 4/18/2025, at 10:26 a.m., during concurrent interview with accreditation and licensing coordinator (ALC) and record review of Patient 5's advance directive (AD - a written statement of a person's wishes regarding medical treat, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), dated 4/10/2025, ALC stated Patient 5 was unable to answer questions and unable to sign.

A review of the facility's conditions of admission (COA - a documentation of a patient's consent for hospital care) form, undated, indicated the following:
1. Consent to medical and surgical procedures.
2. Consent to nursing care ordered by the physician.
3. Acknowledgement of patient rights and responsibilities.

A review of facility's Signature on Admission/Registration Forms policy, dated 1/6/2023, indicated the following:
1. Signatures on a Conditions of Admissions (COA - documentation of a patient's consent for hospital care) form and other forms will be obtained for each patient admitted or registered for services.
2. COA - for used to document the patient's consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and to document the patient agreement to arbitrate any disputes that may arise with insurance company.
3. Registration representative must obtain and witness the patient's or legal representative's full legal signature at the time of admission/registration.
4. The date and time should always be the date and time the form was signed, even if the form is signed after admission due to the patient's incompetence during admission, due to emergency medical condition.
5. If the patient's condition does not permit him/her to sign, staff are responsible for notifying coworker and the patient's nurse that a signature is needed - either from a spouse or other family member, willing to sign, to obtain a signature.
6. The consent becomes effective when the patient becomes hospitalized and receives care and treatment, including observation services for more than 24 hours.
7. All documents with signatures must be scanned.

5. A review of Patient 6's face sheet, dated 4/2/2025, indicated patient (Patient 6) arrived at the ED by ambulance with body pain.

On 4/16/2025, at 4:10 p.m., during concurrent interview with senior director of telemetry (SDT) and record review of Patient 6's COA (COA - a documentation of a patient's consent for hospital care), dated 4/2/2025, SDT stated COA was not signed by patient (Patient 6) and COA indicated patient (Patient 6) was unable to sign due to medical condition.

On 4/18/2025, at 10:26 a.m., during concurrent interview with accreditation and licensing coordinator (ALC) and record review of Patient 6's advance directive (AD - a written statement of a person's wishes regarding medical treat, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), dated 4/2/2025, ALC stated patient (Patient 6) was unable to answer questions and unable to sign.

A review of the facility's conditions of admission (COA - a documentation of a patient's consent for hospital care) form, undated, indicated the following:
1. Consent to medical and surgical procedures.
2. Consent to nursing care ordered by the physician.
3. Acknowledgement of patient rights and responsibilities.

A review of facility's Signature on Admission/Registration Forms policy, dated 1/6/2023, indicated the following:
1. Signatures on a Conditions of Admissions (COA - documentation of a patient's consent for hospital care) form and other forms will be obtained for each patient admitted or registered for services.
2. COA - for used to document the patient's consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and to document the patient agreement to arbitrate any disputes that may arise with insurance company.
3. Registration representative must obtain and witness the patient's or legal representative's full legal signature at the time of admission/registration.
4. The date and time should always be the date and time the form was signed, even if the form is signed after admission due to the patient's incompetence during admission, due to emergency medical condition.
5. If the patient's condition does not permit him/her to sign, staff are responsible for notifying coworker and the patient's nurse that a signature is needed - either from a spouse or other family member, willing to sign, to obtain a signature.
6. The consent becomes effective when the patient becomes hospitalized and receives care and treatment, including observation services for more than 24 hours.
7. All documents with signatures must be scanned.

Based on observation, interview and record review, the facility failed to follow and implement the facility's fall prevention policy measures for two of 30 sampled patients (Patient 12 and Patient 16). This deficient practice placed patients at risk for falls and injury.

Findings:

1. During an observation on 4/15/2025 at 2:15 p.m., outside Patient 12's room, there was a signage 'Fall Precautions - check with nurse before entering' on the door into the room of Patient 12. At that time, Patient 12 was wearing slip resistant socks, the bed was in the lowest position possible, but there was no band around Patient 12's wrist indicating he (Patient 12) was at risk for falling.

During an interview on 4/15/2025 at 2:15 p.m., with Registered Nurse (RN) 8, while in the room of Patient 12, RN 8 stated the fall precautions sign outside Patient 12's room indicated the following: Patient on bed alarm, call light in reach of patient, wrist band indicating patient is at risk of falling, use of non-skid socks, patient educated on use of call light when needing help. RN 8 acknowledged Patient 12 did not currently have a band around his (Patient 12) wrist indicating he was at risk for falling.

During a review of Patient 12's 'Physician History & Physical (H&P - a formal and complete assessment of the patient and the problem),' dated 4/12/2025, this report indicated Patient 12 stated she (Patient 12) received 5 gunshot wounds in her 40's (age), resulting in limited ambulation due to a femur injury requiring repair. The H&P also indicated Patient 12 can ambulate with a walker but frequently uses a wheelchair.

During a review of the 'Flowsheet' for Patient 12, dated 4/15/2025, this document indicated the John Hopkins Fall Assessment Tool Fall Risk Score was greater than 13 (high risk).

During a review of the 'Fall Prevention and Management in Adults - E.87200.609' policy #13313124, this policy indicated patients at 'High' risk (greater than 13) shall be assessed for fall risk upon admission and during hospital stay; patient beds shall be in the lowest position and bed wheels locked; the patient's call light shall be within reach; video monitoring or bedside sitter should be considered. The 'Fall Prevention and Management in Adults' policy also indicated there shall be a yellow fall risk wristband on patients with fall risks greater than 13.

2. During a review of Patient 16's "History & Physical (H&P - a formal and complete assessment of the patient and the problem)," dated 4/14/2025, the H&P indicated Patient 16 was admitted to the facility to undergo bypass graft surgery (a procedure to bypass blocked or narrowed arteries in the heart, improving blood flow to the heart muscle).

During a review of Patient 16's "Adult Assessment" documentation, dated 4/14/2025, at 5:00 p.m., the "Assessment" indicated that on the Johns Hopkins Fall Assessment Tool (a tool that helps medical staff determine whether a patient admitted into the hospital is at high or low risk of falls), Patient 16 scored a 12. A score of 12 indicates a moderate risk of falls.

During a concurrent observation and interview with the Nurse Manager of the Telemetry unit (NM 1), on 4/15/2025, at 2:25 p.m., Patient 16 was seen lying in bed with a yellow wristband and slip-resistant socks. However, there was no signage on the door to Patient 16's room indicating Patient 16 was at risk for falls. NM 1 acknowledged that there was no fall risk signage on the door.

During an interview with Patient 16, on 4/15/2025, at 2:28 p.m., Patient 16 stated he (Patient 16) normally uses a cane or a walker to help him (Patient 16) walk at home.

During an interview with NM 1, on 4/15/2025, at 2:35 p.m., NM 1 stated that there should be a magnet on the patient's door to help indicate to the nurses which patient is a fall risk and which is not.

During a review of the facility's policy & procedure (P&P) titled, "Fall Prevention and Management in Adults," last revised 7/2023, the P&P indicated:
"Crosswalk for Fall Prevention/Interventions based on Risk:
'Moderate Risk': 6-13
Fall Magnet: Yes"

Based on interview, and record review, the facility failed to ensure the nurse for one of 30 sampled patients (Patient 23), completed a skin assessment (visually inspecting and palpating the skin to identify any abnormalities) and documented upon downgrade of care transfer. Patient 23 was transferred to a medical surgical unit (a specific area within a hospital where patients receives care for a wide range of medical and surgical conditions) unit as a bed downgrade (the process of transferring a patient from a higher level of care, to a lower level as patient condition improves) from the intensive care unit(a specialty area within a hospital where patients receives intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency).

This deficient practice had the potential for delays in the care and identification of Patient 23's current skin condition and issues which could result to complications like worsening pressure ulcers (are localized injuries to the skin and underlying tissue caused by prolonged pressure, often over bony prominences) and infection.

Findings:

During a review of Patient's 23 "History and Physical," dated 04/13/2025, the record indicated that Patient is 92-year-old male with past medical history of schizophrenia(a chronic mental disorder that affects how a person thinks, feels, and behaves), and bipolar disorder(a mental health condition characterized by significant shifts in mood, energy, and activity levels, causing periods of intense highs manic episodes) and lows depressive episodes) presented in the emergency department (ED) from outside facility due to episodes of tachycardia(heart rate faster than 100 beats per minute) and shortness of breath. Patient was reported to be noncommunicative (unable to talk) at baseline. Patient may require transfer to intensive care unit.

During a concurrent interview and record review on 04/15/2025 at 2:33 p.m. of Patient 23's medical record titled "Adult Assessment Intervention", dated 4/15/2025, and interview with nurse manager 2 (NM 2), the Patient 23's record did not indicate that a skin assessment was completed at time of transfer to the medical surgical unit from the intensive care unit. NM 2 stated that patient was transferred on 4/15/2025 at 5:59 a.m. The nurse who received the patient failed to complete a skin assessment upon transfer this morning. NM 2 added, it was in the policy that a skin assessment must be completed upon patient admission, transfer and discharge. This process was important to verify patients skin condition upon receiving of a patient to the unit, so that proper preventive skin injury intervention can be applied.

During a review of the Policy and Procedure titled "Pressure Injury - Prevention and Treatment Policy", with last revised date of 9/27/2023, the document indicated the following:

Conduct a thorough skin assessment taking into account the individual's uniqueness,
-Nursing will perform a head-to-toe risk assessment by performing a visual inspection of the patient's skin on admission, to unit every shift, when there is a change in condition, upon return from any prolonged procedure or surgery lasting greater than 2 hours, as the patient's condition changes, and as warranted by MD.
-Document findings and incorporate into plan of care.

Based on interview, and record review, the facility failed to ensure the nurse for three of 30 sampled patients (Patient 23, 25, and 27), implemented the following:

1 Patient 23's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection)was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

2. Patient 25's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Hysterectomy (a surgical procedure where the uterus is removed) was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

3. Patient 27's plan of care (POC, a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection) was initiated and developed upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans).

These deficient practices had the potential of failing to implement and develop clinically appropriate individualized goals and interventions for Patients 23, 25 and 27, which may result in complications on the patients' current condition and poor patient outcomes.

Findings:

1. During a review of Patient's 23's "History and Physical" (H&P - a formal and complete assessment of the patient and the problem), dated 04/13/2025, the H&P indicated that Patient 23 had past medical history of schizophrenia(a chronic mental disorder that affects how a person thinks, feels, and behaves), and bipolar disorder(a mental health condition characterized by significant shifts in mood, energy, and activity levels, causing periods of intense highs manic episodes) and lows depressive episodes (feeling of mood being down), presented in the emergency department (ED) from outside facility due to episodes of tachycardia(heart rate faster than 100 beats per minute) and shortness of breath.

In the ED (emergency department) patient (Patient 23) was tachypneic (rapid breathing) with respiratory rate (breathing rate) range between 36 and 40 and required placement of BiPAP (a breathing device that delivers different pressures for inhalation and exhalation, helping individuals with breathing difficulties). Patient 23's computed tomography angiography (CTA, a detailed images of the blood vessels in the chest, including the heart, lungs, and major arteries) chest showing bilateral dependent pneumonia (pneumonia affecting both lungs).

During a concurrent interview and record review on 04/16/2025 at 4:03 p.m. of Patient 23's medical record titled, "Adult Plan of Care", dated 4/14/2024, and interview with nurse manager 2 (NM2), the record shows that a plan of care for pneumonia was not initiated. NM2 stated that, admitting nurse should have initiate a plan of care for pneumonia. NM 2 added, a plan of care is important because provides the care team a framework for organizing care, prioritizing needs, promoting communication, and documenting interventions to help meet goals.

During a review of the Policy and Procedure titled "Patient Plan of Care" (Policy No.: E.87200.613), with last revised date of 1/24/2025, the document indicates the following:
A. Upon admission, disciplines will complete an assessment/evaluation of their patient within their scope of practice and initiate or contribute to patient's individualized plan of care.

2. During a review of Patient 25's "Visit Note - Pre Op (Doctor's note created during clinic visit before scheduled surgery)," dated 04/11/2025, the Visit Note indicated that Patient 25 had chief complaint of fibroids (non-cancerous tumors [abnormal growth] that develop in the muscular wall of the uterus) and is being seen for initial gynecologic evaluation (a physical examination of a woman's reproductive organs). Patient 25 agreed for surgical intervention and expressed understanding of the risk, benefits and treatment options. Patient 25 has selected to proceed with surgery discussed. Patient 25 was scheduled for abdominal hysterectomy (a surgical procedure where the uterus is removed through an incision in the abdomen.) with salpingectomy (a surgical procedure where one or both fallopian tubes are removed).

During a concurrent interview and record review on 04/17/2025 at 10:11 a.m., of Patient 25's medical record titled "Adult Plan of Care", dated 4/14/2024, and interview with registered nurse 9 (RN9), there was no plan of care for hysterectomy initiated. RN9 stated that, admitting nurse should have initiated a plan of care for hysterectomy. A plan of care was important because it identified patient care progression toward goal outcome.

During a review of the Policy and Procedure titled "Patient Plan of Care" (Policy No.: E.87200.613), with last revised date of 1/24/2025, the document indicates the following:
B. Upon admission, disciplines will complete an assessment/evaluation of their patient within their scope of practice and initiate or contribute to patient's individualized plan of care.

3. During a review of Patient 27's "Visit Note - Pre Op" (Doctor's note created during clinic visit before scheduled surgery), dated 04/15/2025, the Visit Note indicated that Patient 27 was admitted for consultation complaints of heavy menses with pelvic pain. Recent ultrasound in January 2025 resulted with enlarged uterus (womb) with multiple fibroids (non-cancerous tumors that develop in the muscular wall of the uterus). Patient had expressed understanding of the risk, benefits and treatment options. Patient 27has selected to proceed with surgery discussed. Patient was scheduled for hysterectomy.

During a concurrent interview and record review on 04/17/2025 at 10:11 a.m. of Patient 27's medical record titled, "Adult Plan of Care", dated 4/10/2024 - 4/17/2024, and interview with registered nurse 9 (RN9), there was no plan of care for hysterectomy initiated. RN9 stated that, admitting nurse should have initiated a plan of care for hysterectomy. A plan of care was important because it identifies patient care progression toward goal outcome.

During a review of the Policy and Procedure titled "Patient Plan of Care" (Policy No.: E.87200.613), with last revised date of 1/24/2025, the document indicates the following:
C. Upon admission, disciplines will complete an assessment/evaluation of their patient within their scope of practice and initiate or contribute to patient's individualized plan of care.

Based on observation, interview, and record review, the facility failed to ensure the nurse adhere and follow the facility's policy and procedure for six of 30 sampled patients (Patient 1, Patient 8, Patient 16, Patient 18, Patient 20 and Patient 26) when:

1. The facility failed to ensure one of 30 sampled patient (Patient 1) was assessed and/or monitored for pain, according to the facility's policies and procedures upon admission, before and after administration of pain medication.
This deficient practice had the potential for Patient 1's pain to not be managed appropriately and could prolong feeling of pain which could affect Patient 1's well- being.

2. The facility failed to follow facility policy and procedure for proper management of identified multiple pressure injury on the buttocks (PI, localized injury to the skin or underlying tissue usually over a bony prominence), for one of 30 sampled patients (Patient 30)
This deficient practice has to potential for Patient 8's multiple PI on the buttocks to worsen and develop infection.

3. The facility failed to ensure the nurse adhered to the policy & procedure (P&P) for intravenous (IV - a way of administering fluids, medications, or nutrients directly into a vein) therapy for one of 30 sampled patients (Patient 16) by not labeling one of Patient 16's peripheral IV catheter (a short, flexible tube inserted into a vein, typically in the hand, arm, or foot to use for fluids or medication) sites.

This deficient practice had the potential for infection due to a compromised IV site.

4. The facility failed to ensure their staff adhered to the policy & procedure (P&P) for pain management by not documenting pain reassessment for two of 30 sampled patients (Patient 18 and Patient 20).

This deficient practice had the potential to result in ineffective pain management.

5. The facility failed to ensure their staff assessed and documented one of 30 sampled patient's (Patient 26) surgical dressing (protective covering applied to a surgical incision to help it heal and prevent infection) and vaginal packing (a surgical procedure involving inserting gauze or sponge material into the vaginal cavity, typically after pelvic reconstructive surgery or vaginal hysterectomy) upon admission to medical surgical unit (a specific area within a hospital or healthcare facility dedicated to providing comprehensive medical and surgical care to patients) and failed to document surgeon's (doctor who did the surgery) discharge which should have included the discharge instructions for Patient 26.

These deficient practices had the potential of failing to adequately monitor, identify and intervene complications immediately after surgery in the and after discharge of the patient which can lead to delayed healing, increased pain, and elevate patient risk of infection.

Findings:

1. A review of Patient 1's face sheet (a document that summarizes a patient's basic information for quick reference), dated 9/10/2023, indicated patient (Patient 1) arrived at the emergency department (ED) via ambulance for not breathing.
On 4/16/2025, at 1:22 p.m., during concurrent interview with director of emergency department (DED) and record review of Patient 1's Triage note (document which indicate how patient was sorted for urgency of care in the ED), dated 9/10/2023, DED stated Patient 1 was not assessed for pain, upon arrival to the ED, during triage, at 11:34 a.m. DED stated Patient 1 should have been assessed for pain according to facility's standards of care in the ED.

Concurrently, DED stated also the following:
- Patient 1 complained of knee pain, at 1:57 p.m., without the nurse determining the pain score for the intensity of patient's pain, per facility's policy and procedure.
- Patient 1 was given medication for pain at 2:34 p.m.
-Patient 1 was not reassessed for pain, after pain medication was given at 2:34 p.m., to assess for the effectiveness of the pain medication, after one hour following administration of pain medication, per facility's policy and procedure.
-Patient 1 was reassessed for pain, six hours after pain medication was administered, at 8:39 p.m., prior to discharge from the ED.

During a review of the medication administration record (MAR - a document which indicates the list of prescribed medication and when they were administered), dated 9/10/2023, the MAR indicated pain medication was given on 9/10/23 at 2:34 p.m.

A review of Emergency Department (ED) Standards of Care policy, dated 3/31/2023, indicated the following:
1. Patients will have a nursing assessment documented, including vital signs (VS - clinical measurements of a patient's essential body functions, including pulse rate, temperature, respiratory ate, and blood pressure), pulse oximetry, and pain assessment every two (2) hours.
2. Reassessment will be performed with any significant changes in patient's condition and on all patients to evaluate response to an intervention within an appropriate time frame.

A review of facility's Pain Management Standard of Care policy, dated 12/1/2020, indicated the following:
1. The patient's right to pain management included initial assessment and regular reassessment of pain.
2. To ensure all patients are assessed and treated appropriately, they will be assessed for pain using a pain scale.
3. All licensed staff will assess and monitor patient the presence of pain on admission, with each new report of pain, and immediately for sudden onset of new or intense pain.
All licensed staff will assess and monitor patient the presence of pain one hour after pain relieving intervention.

2. During an observation on 4/15/2025 at 2:40 PM, of the Patient 8's room and with Registered Nurse (RN 7), there were 3 folded layers of bed sheeting visible under Patient 8 as he (Patient 8) laid in bed on a low air loss mattress (air inflatable mattress designed to treat and prevent skin injury). Above the 3 layers of bed sheet, next to Patient 8's skin was a chuck (disposable, absorbent pad designed to protect mattresses from accidental leakage of stool or urine, usually blue in color).

During an interview on 4/15/2025 at 2:42 PM, in Patient 8's room with RN 7, RN 7 stated the reason there were multiple layers under Patient 8 was because Patient 8 urinates frequently (incontinence), has multiple PI on his buttocks, and multiple layers were necessary to keep him (Patient 8) dry.

During an interview on 4/17/2025 at 10:40 AM, with the Physical Therapist, the Physical Therapist stated a comfort glide (single layered repositioning device placed under the patient to help prevent pressure injury) ideally would be placed under the patient with one chuck to help prevent wetness under the patient's skin. Subsequently, the Physical Therapist stated other devices used to help reposition to reduce occurrence of PI were foam wedges and unwrinkled linen underlayment. Wrinkled linens should be straightened out to prevent friction against the patient's skin and cause PI. The Physical therapist then stated staff were given quarterly training regarding reduction of pressure injury.

During a review of the 'Pressure Injury - Prevention and Treatment Policy' policy 13575541, indicated one individualized plan of skin care for incontinent patients is to avoid tension and skin wrinkles which may further damage skin. This document also indicated that a urinary catheter (hollow tube inserted into the blader to collect urine) may be considered for a short period of time to prevent contamination of the skin injury.

3. During a review of Patient 16's History & Physical (H&P - a formal and complete assessment of the patient and the problem), dated 4/14/2025, the H&P indicated Patient 16 was admitted to the facility to undergo bypass graft surgery (a procedure to bypass blocked or narrowed arteries in the heart, improving blood flow to the heart muscle).

During a concurrent observation and interview with the Nurse Manager of the Telemetry unit (NM 1), on 4/15/2025, at 2:31 p.m., Patient 16 was observed with two peripheral IV sites: one on the left hand and one on the right hand. The left hand peripheral IV site did not have a date or time labelled on the dressing (a specialized adhesive covering used to protect and secure the area where an IV is inserted). NM 1 stated that IV sites are supposed to be labelled with the date and time they were inserted.

During a review of the facility's policy & procedure (P&P) titled, "Intravenous Therapy for Adults and Pediatrics," last revised 7/3/2024, the P&P indicated, "PIV [peripheral IV] site care and maintenance: All IV sites will be changed only as clinically warranted based on integrity and patency of the site and labeled with initiation date and time."

4.a. During a review of Patient 18's "History & Physical" (H&P - a formal and complete assessment of the patient and the problem), dated 4/11/2025, at 6:07 a.m., the H&P indicated Patient 18 was admitted to the facility for a Cesarean section (C-section - surgery to deliver a baby through an incision in the abdomen).

During a concurrent interview and record review on 4/17/2025, at 3:56 p.m., with Registered Nurse (RN) 1, Patient 18's "Pain Assessment" flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 4/12/2025, was reviewed. The flowsheet indicated that Patient 18 reported pain intensity of four out of 10 on the numeric pain scale (a method of measuring pain intensity by asking a patient to rate their pain on a scale from zero, which is no pain, to ten, which is the worst possible pain) at 4:46 a.m. on 4/12/2025. The flowsheet also indicated that Patient 18's pain was not reassessed until 6:31 a.m., one hour and 43 minutes later. RN 1 confirmed that Patient 18's pain reassessment was not documented until 6:31 a.m.

In the same concurrent interview and record review, Patient 18's "Medication Administration Record" (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 4/12/2025, was reviewed. The MAR indicated Patient 18 was given acetaminophen (a type of pain medication) at 4:46 a.m. RN 1 stated that Patient 18's pain should have been reassessed 30 minutes after the medication was given.

During a review of the facility's policy & procedure (P&P), titled "Pain Management Standard of Care," last revised 12/1/2020, the P&P indicated, "All licensed staff will: 1. Assess and monitor patients for presence of pain: ... d. One hour after pain relieving intervention"

4.b. During a review of Patient 20's H&P, dated 4/11/2025, at 5:13 p.m., the H&P indicated Patient 20 was admitted to the facility for a C-section.

During a concurrent interview and record review on 4/17/2025, at 4:13 p.m., with RN 1, Patient 20's "Pain Assessment" flowsheet, dated 4/11/2025, was reviewed. The flowsheet indicated that Patient 20 reported pain intensity of three out of 10 on the numeric pain scale at 4:07 a.m. on 4/11/2025. The flowsheet also indicated that Patient 20's pain was not reassessed until 8:00 a.m., three hours and 53 minutes later. RN 1 confirmed that Patient 20's pain reassessment was not documented until 8:00 a.m.

In the same concurrent interview and record review, Patient 20's MAR, dated 4/11/2025, was reviewed. The MAR indicated Patient 18 was given ibuprofen (a type of pain medication) at 4:07 a.m. RN 1 stated that Patient 20's pain should have been reassessed 30 minutes after the medication was given.

During a review of the facility's policy & procedure (P&P), titled "Pain Management Standard of Care," last revised 12/1/2020, the P&P indicated, "All licensed staff will: 1. Assess and monitor patients for presence of pain: ... d. One hour after pain relieving intervention"

5. During a review of Patient's 26 "History and Physical - Interval Note", dated 4/15/2025, the record indicated that Patient had been seen pre-operative (before surgery) for surgery for rectovaginal fistula (an abnormal connection between the rectum and vagina). It was noted that the case was discussed in detail and patient agreed with the plan for rectovaginal fistula repair surgery (involves surgically closing the abnormal connection between the last section of the large intestine, and it connects the colon to the anus and vagina).

During a review of Patient 26's "PACU Note", dated 04/15/2025 10:17 a.m., the record indicated that the Patient was received from operating room (OR, a designated area within a hospital where surgical procedures are performed) to the post anesthesia care unit (PACU, a specialized area in a hospital or surgical center where patients are monitored and cared for immediately after surgery) on 04/15/25 at 9:00 a.m., Patient came with an abdominal dressing and vaginal packing in the PACU. Patient was then transferred to 7 North medical surgical unit at 10:30 a.m.

During a concurrent interview and record review on 04/17/2025 at 10:30 a.m. of Patient 26's medical record titled, "Skin Parameters," dated 04/15/2025, and interview with Senior Director 1 (SD1), the record had no documentation of an initial assessment of the surgical dressing and vaginal packing in the medical surgical unit. SD1 stated that the admitting nurse failed to assess and document patients surgical dressing and vaginal packing. Patient was discharged same day 4/15/25, and it was noted that patient was discharged with a surgical dressing but no documentation or any reference to vaginal packing was noted on discharge. SD 1 said the surgical wound and its dressing should have been assessed and documented on all patient admission, transfer and discharge.

During a concurrent interview and record review on 04/17/2025 at 10:40 a.m., of Patient 26's medical record titled, "Discharge Note," dated 04/15/2025, and interview with Senior Director 1 (SD1), the record had no documentation of assessment, intervention, or discharge teaching on patient's (Patient 26) vaginal packing.

During an interview on 04/18/25, at 1:52 P.M. with Registered Nurse 10 (RN 10), RN1 stated that she (RN 10) admitted and discharged Patient 26 on 4/15/25 in the medical surgical unit. RN10 received Patient 26 from PACU, admitted Patient 26 around 11:00 a.m. and discharged Patient 26, 4 hours later. According to RN 10, Patient 26 was awake on admission, came with abdominal dressing and vaginal packing. RN 10 also said she received a call from Surgeon 1 (S1), and S1 gave order for nursing to inform patient - "Ok for patient to remove vaginal packing next morning." RN 10 added that she deemed it as an instruction to patient and not as telephone order. Patient was just verbally informed of this instruction and was not included or documented in the patient's printed discharge instruction.

During an interview on 04/18/25, at 3:00 P.M., with the Vice President of Regulatory Affairs (VPRA). VPRA stated that it was not right for RN10 to deem the telephone order from S1 as a patient instruction. VPRA said RN10 failed to input the surgeon's order - "Ok for patient to remove vaginal packing next morning" as a telephone order in the medical record and failed to document it on patient's discharge instruction.

During a review of the Policy and Procedure titled "Admission, Care of, Transfer and Discharge of Post anesthesia Care Patient" (Policy No.: E.74270.500), with last revised date of 5/24/2021, the document indicates the following:
A. Initial assessment and documentation will include:
- Dressings, visible incisions, drainage tubes, catheters, and other receptacles will be assessed for type, drainage amount, patency, and securement. Surgeon is to be notified of excessive bleeding.
- Patient/caregiver will be provided with instructions for discharge, medications (if applicable), and management of any postoperative issues/complications.

During a review of the Policy and Procedure titled "Physicians' Orders" (Policy No.: E.87200.638), with last revised date of 1/23/2025, the document indicates the following:
A. Registered Nurse (RN) is responsible for coordination and implementation of diagnostic and therapeutic orders of medical staff members.
B. All verbal/telephone orders will be entered into MR

Based on observation, interview, and record review, the facility failed to ensure two of 7 facility personnels (FM, Facility Manager and FS, Facility Supervisor) had a city-required license to operate steam boilers to maintain adequate operation and maintenance of the steam boiler (a critical part of healthcare facilities, providing the steam necessary for heating, sterilization, and other essential functions).

This deficient practice had the potential for the steam boilers to fail which are needed for heating and sterilization needs of the hospital.

Findings:

During an interview with the Director of Facilities/Construction (DFC), on 4/18/2025, at 8:52 a.m., the DFC stated that the facility has two working boilers with each rated at 400 horsepower (a unit of measurement of power, or the rate at which work is done). The Stationary Engineers (the staff at the facility responsible for maintenance and operation of generators, boilers, HVAC [Heating, Ventilating, and Air Conditioning] equipment, and water treatment systems) operate the boilers and are licensed to operate boilers as required by the city, based on the total number of horsepower of the boilers; however, if there was no Stationary Engineer available due to call-outs or emergencies, then the Facilities Manager (FM) and Facilities Supervisor (FS) operate the boilers as a temporary solution until a licensed operator can arrive.

During an interview with the DFC, on 4/18/2025, at 9:39 a.m., the DFC confirmed that the FM and FS do not have the license to operate the boilers as required by the city.

During a concurrent observation and interview, on 4/18/2025, at 10:16 a.m., with the DFC, pictures of the name plates affixed to both boilers was observed. Boiler #1's name plate indicated it had 400 horsepower. Boiler #2's name plate indicated it had 400 horsepower.

During a review of a facility-provided document titled "City of Los Angeles Department of Building and Safety, Examination Information, Steam Engineers and Boiler Operators," last revised 4/2022, the document indicated, "A valid Boiler Operator License or Steam Engineer License is required by the City of Los Angeles for a person to operate, within city limits, one or more high pressure boilers rated above 5 horsepower - L.A.M.C. [Los Angeles Municipal Code] Sec. 97.0201."

Based on interview and record review the facility failed to perform an initial discharge plan evaluation for one of 30 sampled patients (Patient 14). This deficient practice may delay the discharge of the patient and may affect the needs for discharge and final disposition of the patient.

Findings:

During an interview on 4/17/2025 at 3:00 PM, Social Worker (SW1) stated that social services staff see patients in the hospital within 24 to 48 hours of admission. SW1 then said there was no documentation of any conversation with Patient 14's daughter regarding Patient 14's plan after discharge but stated Patient 14's daughter verbally agreed to home health once discharged. SW1 subsequently stated if a patient has an objection to the discharge plan, the objection would be noted in the patient's medical record and forwarded to the treating physician. SW1 then said it was expected from the social services staff to perform an initial assessment and document social services assessment. SW 1 acknowledged an initial assessment had not been performed and documented while Patient 14 was in this facility.

During a review of the 'Physician Discharge Summary,' dated 11/28/2024, the discharge summary indicated Patient 14 presented to the hospital with left sided pain.

During her stay, Patient 14 received consultation and treatment from a cardiologist (medical doctor specializing in diagnosing and treating diseases and conditions of the heart and blood vessels); lab results for thyroid (organ in the neck producing hormones that regulate growth and development) function indicated an abnormality was discovered during Patient 14's stay and an endocrinologist (physician specializing in treatment of patients with disorders of organs that produce hormones such as the thyroid) evaluated and treated Patient 14.
This document indicated Patient 14 felt safe to be discharged from the hospital. Patient 14 was agreeable with visiting her primary care physician in 1 week, obtaining referral to a cardiologist, and follow up with endocrinology regarding her thyroid findings.

During a review of the 'Care Management Progress Note' regarding Patient 14, dated 11/28/2024, the progress note indicated DME (durable medical equipment, medical devices intended for repeated use over an extended period, e.g., wheelchairs and crutches) had been finalized. There were no barriers to home health care; home health including Registered Nurse care, Physical Therapy (treatment that uses exercises, stretches, and other physical techniques to help people improve their physical function and reduce pain), Occupational therapy (treatment focusing on helping individuals perform daily living activities by adapting their environment, skills, and cognitive abilities) had been arranged.

During a review of the 'Discharge Planning - E.83600.601' policy #10149656, this policy indicated "care management staff will document the discharge planning evaluation in the patient's medical record to help facilitate communications among the healthcare team working with the patient in order to develop and implement an appropriate discharge plan, Documentation will include the initial assessment and progress notes, outlining the subsequent planning process." This policy also indicated documentation should include any difficulty encountered with patients/family uncooperative with or refusing discharge planning services.