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Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by:

1. The facility's Governing Body failed to provide oversight over the Nursing Department to ensure nursing staff followed the facility's policy and procedure regarding the timely activation of a Rapid Response Team (RRT, a team that responds to Rapid Response activation, team consists of a critical care nurse and a respiratory therapist) for two of 33 sampled patients (Patients 1 and 2). On 4/23/2025, Patient 1's RRT was activated forty (40) minutes (delay of 40 minutes) after displaying signs and symptoms of respiratory distress (difficulty breathing) and changes in baseline vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level). On 8/16/2025, Patient 2's RRT was activated over two (2) hours (delay of over 2 hours) after Patient 2 started displaying signs and symptoms of respiratory distress despite Hi-Flow oxygen (delivers heated, humidified air and oxygen at flow rates up to 60 L/min [liters per minute, a unit of measurement]) given since 12 a.m.

This deficient practice resulted in Patient 1 coding (loss of respirations and heart rate) two minutes after the activation of RRT and expiring during the Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when a patient stops breathing]) on 4/23/2025. In addition, on 8/16/2025, Patient 2 was intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing), transferred to the Intensive Care Unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care) and was made a DNR (Do Not Resuscitate, a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR] if the patient's heart stops beating or breathing stops). This lack of GB oversight also placed other patients at risk for a delayed RRT and had the potential for harm, serious injury, or death. (Refer to A-0063)

2. The facility's Governing Body failed to provide oversight on the facility's Quality Assurance Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) committee, to ensure that the QAPI identified an issue regarding a 40-minute delay in activating an RRT for Patient 1 on 4/23/2025 and ensure proactive implementation of an effective action plan to prevent the reoccurrence of another delayed activation of a RRT for Patient 2 on 8/16/2025, in accordance with the facility's performance improvement plan and bylaws (ensures that a hospital's medical professionals are appropriately qualified and set a standard of quality that assures patients they can receive safe and effective medical care).

This deficient practice regarding the lack of GB oversight resulted in the QAPI's inability to identify the delay in the activation of a RRT, on 4/23/2025, for Patient 1. In addition, it resulted in the implementation of an ineffective action plan which resulted in another delayed activation of a RRT for Patient 2 on 8/16/2025, which led in Patient 2 being intubated, being transferred to the ICU and consequently being made a DNR. This deficient practice also had the potential to affect other patients, who may encounter delayed RRT activation, which may result in patient harm and/or death. (Refer to A-0063)

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 Patient Rights was met, as evidenced by:

1. The facility failed to ensure one of 33 sampled patient's (Patient 3) husband (FM 1), was allowed into the waiting area of the Emergency Department (ED, a hospital department that provides immediate medical care for acute [sudden onset], life-threatening, or serious illnesses and injuries, such as heart attacks) for approximately two (2) hours, while waiting for Patient 3 to be called into the ED, in accordance with the facility's policy regarding Patient rights (a set of legal and ethical principles that protect and empower patients in healthcare decisions).

This deficient practice resulted in FM 1 waiting in the weapons screening area of the ED for approximately two (2) hours, instead of waiting in the waiting room, which had the potential for FM 1 not to hear when Patient 3 was called by the treatment team and may result in delay of treatment for Patient 3. (Refer to A-0129)

2. The facility failed to ensure that one of 33 sampled patients (Patient 6) was safely discharged (the process of releasing a patient from a healthcare facility to another appropriate care setting when they are medically stable, have a comprehensive plan for continued care, and possess the necessary support and resources to manage their health needs in the community) from the facility after being diagnosed with rectal bleeding (the passage of blood from the anus or rectum, the lower part of the large intestine) due to internal hemorrhoids (swollen veins located inside the rectum, rather than around the anus), in accordance with the facility's policy on patient rights regarding continuity of care after hospital discharge, when Patient 6 was discharged without receiving information regarding the need to follow-up with a colorectal surgeon (a medical specialist who diagnoses and treats conditions affecting the lower gastrointestinal tract, including the colon, rectum, and anus) as an outpatient and the importance of monitoring Patient 6's Hgb (Hemoglobin, transports oxygen in the blood) level due to rectal bleeding.

This deficient practice had the potential to result in Patient 6's health being compromised which could lead to readmission to the hospital and post-hospitalization complications such as recurrent rectal bleeding, organ failure (occurs when one or more vital organs in the body are unable to function properly), and even death. (Refer to A-0129)

3. The facility failed to ensure that translator services (professional interpreter services used to facilitate effective communication between healthcare providers and patients with limited English proficiency [LEP]) was used and properly documented, for one of 33 sampled patients (Patient 6), when discharge instructions were discussed with Patient 6 by the discharging physician and nurse, in accordance with the facility's policy regarding the use of interpreters.

This deficient practice had the potential for Patient 6 not to be informed (in their preferred language) about diagnosis, treatment plan, and post (after)-discharge instructions such as medication management, warning signs and symptoms that require urgent care, and potentially delay a follow-up appointment and treatments, which could worsen Patient 6's health outcomes. (Refer to A-0129)

4. The facility failed to ensure that one (1) of 33 sampled patients (Patient 24) and/or Patient 24 's daughter (the designated emergency contact) was supported and provided adequate information in making an informed decision (having enough information, in plain language, to decide about care) related to patient care, in accordance with the facility's policy regarding patient rights pertaining to receiving adequate information to make informed decision, when Patient 24 refused vital signs (temperature [a measure of body heat], heart rate [the number of times the heart beats in one minute], breathing rate [the number of breaths taken in one minute], and blood pressure [the force of blood pushing against the walls of the blood vessels]) to be taken on 12 occasions between 4/14/2025 and 5/2/2025. The medical record (MR, a comprehensive collection of documents that document a patient's health history) contained no documentation that patient education (information about the risks and implications of refusing vital signs) was provided to Patient 24 and/or Patient 24's daughter, and no documentation that the refusal of care was communicated to the provider (the physician or nurse practitioner responsible for the Patient 24's care).

This deficient practice had the potential to prevent Patient 24 and/or Patient 24's daughter from making a fully informed decision about refusal of care. This placed Patient 24 at risk for harm, including unrecognized complications such as internal bleeding, infection, or changes in heart or lung function. (Refer to A-0131)

5. The facility failed to ensure its physician (MD 6) provided the risks and benefits and alternative treatment options to one of 33 sampled patients (Patient 12), in accordance with the facility's policy and procedure regarding patient's rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) to receive adequate information to make an informed decision, when Patient 12 refused X rays (an imaging procedure to create detailed image of the body's internal structure such as bones, tissues and organs) to be taken for left leg fracture (broken bone) in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 7/26/2025.

This deficient practice had the potential to result in Patient 12 not being able to make an informed decision due to not fully understanding the need for X rays and treatment, thus leading to potential delay in receiving treatment including but not limited to splinting (a device used for temporary or definitive immobilization of an injured area, providing stability and support) which may potentially result in worsening of Patient 12's left leg fracture. (Refer to A-0131)

6. The facility failed to ensure fall (an unintentional descent of a patient to the ground, floor, or another lower surface) safety interventions were implemented, documented, and the physician was notified of the fall for one of 33 sampled patients (Patient 20), in accordance with the facility's policy regarding fall prevention and management, when Patient 20 fell on the ground in the ED (Emergency Department, a hospital service that provides immediate medical care for acute [sudden and severe onset] and life-threatening conditions) waiting area. Patient 20 had no post (after) fall nursing assessment and physician notification.

This deficient practice had the potential to result in delayed intervention to address possible injury post fall for Patient 20, which could have placed Patient 20 at risk for further falls and injury such as brain trauma (damage to the head), internal bleeding (bleeding within the body) and bone fractures (broken bones). (Refer to A-0144)

7. The facility failed to provide care in a safe setting for one (1) of 33 sampled patients (Patient 24) who sustained six (6) falls (unintended drops to the floor) during the hospital stay. Patient 24's medical record did not contain documented evidence that Patient 24 ambulated (walked) with the assistive device (such as a cane or walker, equipment that helps patients walk safely) that was recommended by the physical therapy services (treatments provided by specialists who help patients improve movement and safety; Physical therapists may recommend equipment, such as canes walkers to support safe walking and prevent falls). In one fall event, Patient 24 did not have on safe footwear (shoes or nonslip socks designed to reduce fall risk), in accordance with the facility's policy and procedures titled "Fall Prevention and Management."

This deficient practice had the potential for Patient 24 to continue sustaining falls, which increased the risk for serious injuries, such as broken bones (fractures, a break of a bone) or head injuries (damage to the skull or brain caused by impact). (Refer to A-0144)

8. The facility failed to provide care in a safe setting for two (2) of 33 sampled patients (Patient 28 and Patient 32). Both patients were assigned to line-of-sight observation (continuous visual monitoring where the patient must always be kept in direct view) for safety. However, one sitter (a staff member assigned to observe patients who need close monitoring)- Certified Nursing Assistant (CNA, a health care professional who provides basic patient care, such as assisting with daily living activities) 2-was assigned to observe both patients at the same time. While providing incontinence care (helping a patient who cannot control urination or bowel movements) for one patient, the sitter was unable to maintain continuous observation of the other patient, in accordance with the facility's policy regarding safety attendant (CNA) use pertaining to continuous visual observation of one designated patient.

This deficient practice had the potential to place Patient 28 and Patient 32 at risk for harm, including falls (unintentional coming to rest on the ground, floor, or other lower level), removal of medical equipment (such as intravenous [IV] lines, a thin catheter that goes in the vein to delivered medication or monitors), or self-injury (when patients harm themselves) during periods without required observation. (Refer to A-0144)

9. The facility failed to ensure one of 33 sampled patients (Patient 33), was physically and emotionally cared for within a safe and comfortable environment, when Patient 33's vocal cries from his (Patient 33) room, were not responded to by responsible staff in a timely manner.

This deficient practice had the potential to result in an unsafe care environment, poor clinical outcomes, and emotional harm for Patient 33. (Refer to A-0144)

10. The facility failed to ensure its nursing staff developed care plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided), in accordance with the facility's policy regarding plan of care for restraint use, for two (2) of 33 sampled patients (Patient 14 and 15), when violent behavioral (behavior placing patient or others in imminent danger) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) using hard locking restraints (a restraint device requires a key to unlock) applied to four (4) extremities (both wrist and both ankles), were used on Patient 14 on 6/14/2025 and on Patient 15 on 8/22/2025, in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential for inadequate monitoring and evaluation of Patient 14's and Patient 15's care progress and goals while being restrained, which may potentially lead to prolonged and unnecessary restraint use and may increase the risk of restraint use complications such as skin breakdown (damage to the skin due to prolonged pressure or friction [the force that opposes motion] on the skin) and impaired circulation (blood flow). (Refer to A-0166)

11. The facility failed to ensure nursing staff obtained renewal order, every 4 hours, for violent or self-destructive behavior (behavior placing patient or others in imminent danger) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 33 sampled patients (Patient 14), when Patient 14 was placed on hard locking 4-point restraints (a restraint device requires a key to unlock to all four (4) extremities [both wrists and both ankles]) on 6/14/2025 from 2:30 p.m. to 7:30 p.m.

This deficient practice resulted in Patient 14 being restrained without a physician order for 5 hours (from 2:30 p.m. to 7:30 p.m. on 6/14/2025) and could lead to possible unnecessary restraints use, which could result to complications such as psychosocial trauma for Patient 14. (Refer to A-0171)

12. The facility failed to ensure a physician (MD 7) performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after 24 hours, prior to extending a violent behavior (behavior placing patient or others in imminent danger) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order, for one of 33 sampled patients (Patient 14), in accordance with facility's policy regarding restraint use, when Patient 14 was placed on hard locking 4-point restraints (a restraint device requires a key to unlock to all four (4) extremities [both wrists and both ankles]) from 6/14/2025 at 10:36 a.m. to 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes), in the facility's Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in prolonged and unnecessary restraint use and may increase the risk of restraint use complications such as skin breakdown (damage to the skin due to prolonged pressure or friction [the force that opposes motion] on the skin) and impaired circulation (blood flow). (Refer to A-0172)

13. The facility failed to ensure proper skin check and circulations (blood flow) check were performed for two (2) of 33 sampled patients (Patients 14 and 16) in accordance with the facility's policy and procedure regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use when:

13.a. Nursing staff did not perform every fifteen (15) minutes skin check for Patient 14 on 6/14/2025 while Patient 14 was on violent behavioral (behavior placing patient or others in imminent danger) restraints

13.b. Nursing staff did not perform every 2 hours skin check for Patient 16 on 8/18/2025 from 8 a.m. to 8 p.m. while Patient 16 was on non-violent restraint

This deficient practice had the potential to cause injury such as skin tear, swelling and strangulation (occurs when a device, like a vest restraint or harness, applies pressure to a person's neck or body, obstructing their airway or blood flow to the brain, leading to asphyxia [when the body does not receive enough oxygen] or unconsciousness) for Patient 14 and Patient 16 while being restrained. (Refer to A-0175)

14. The facility failed to ensure its physicians conducted face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour, in accordance with the facility's policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, for two (2) of 33 sampled patients (Patient 14 and Patient 15), when violent behavioral (behavior placing patient or others in imminent danger) restraints with hard locking restraints (a restraint device requires a key to unlock) on four (4) extremities (both wrist and both ankles) were applied on Patient 14 on 6/14/2025 and on Patient 15 on 8/22/2025.

This deficient practice resulted in Patient 14 and Patient 15 not receiving physician assessment after restraint application to evaluate their (Patient 14 and Patient 15) responses to restraints and had the potential to result in prolonged and unnecessary restraints use. (Refer to A-0178)

15. The facility failed to ensure its physician documented face-to-face assessment, within an hour, for two (2) of 33 sampled patients (Patient 14 and Patient 15), in accordance with the facility's policy regarding restraints use, when violent behavioral (behavior placing patient or others in imminent danger) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) with hard locking restraints (a restraint device requires a key to unlock) applied to four (4) extremities (both wrist and both ankles), were used on Patient 14 on 6/14/2025 and Patient 15 on 8/22/2025.

This deficient practice regarding the lack of documented physician assessment or a clear record of interventions done )example: face to face assessment), had the potential to negatively impact the ability of healthcare staff to make informed decisions, by not having the necessary information, which may lead to inappropriate treatment such as unnecessary restraints use and other complications related to the use of restraints. (Refer to A-0184)

16. The facility failed to ensure one of seven sampled facility employees (RN 13) met the necessary training and competencies to provide safe nursing care in the facility, when RN 13's latest due annual restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use training and competency (the process of systematically evaluating a nurse's knowledge, skills, and behaviors to ensure they are proficient and safe in their role, contributing to positive patient outcomes) was not completed, in accordance with the facility's policy regarding restraints use and competency assessment and validation plan.

This deficient practice had the potential to result in RN 13 not being safely prepared for competence towards safe patient restraint use and application in the facility, which could have put patients in the facility at risk of harm. (Refer to A-0194)

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 the Condition of Participation (CoP) for Quality Assessment 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) was met, as evidenced by:

1. The facility's Quality Assessment 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) committee failed to review and monitor collected Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) and Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) data from the resuscitation (process of restoring vital life functions) committee (QAPI's subcommittee monitor code blue and RRT activities) in QAPI meetings, in order to identify opportunities for improvement to address the issue with delayed activation of emergency codes which affected two of 33 sampled patients (Patient 1 and Patient 2), in accordance with the facility's QAPI plan, when an unspecified time period of Code Blue and RRT data was discussed only one time (in June 2025) during a QAPI meeting from January 2025 to August 2025.

This deficient practice had the potential to result in breakdown in communication between QAPI and its subcommittee and resulted in lack of proper implementation of action plan to address the RRT activation delay on 4/23/2025 (there was a 40 minutes delay in calling RRT for Patient 1) to prevent future occurrence, hence leading to another RRT activation delay occurring on 8/16/2025 when a RRT call was delayed(over 2 hours) for Patient 2. Patient 2 suffered respiratory distress (difficulty breathing) requiring oral intubation (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and sent to ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) for further management. This deficient practice also had the potential to put other patients' safety at risk due to the delay of RRT activation. (Refer to A-0283)

2. The facility's Quality Assurance Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) committee failed to identify a 40-minute delay in activating a Rapid Response Team (RRT, a team that responds to Rapid Response activation, team consist of a critical care nurse and a respiratory therapist) for one of 33 sampled patients (Patient 1), when Patient 1 was having respiratory distress and a change of baseline vital signs. Patient 1 coded (respiratory and cardiac arrest [when the heart stops beating and the patient stops breathing]) two minutes after the RRT was activated and expired during the Code Blue (emergency code indicating patient needs immediate medical attention, usually due to a cardiac or respiratory arrest) on 4/23/2025. In addition, the QAPI failed to adequately track and analyze aggregate data pertaining to RRT and code blue calls and to implement an effective action plan to prevent the re-occurrence of another delayed activation of an RRT for Patient 2 on 8/16/2025, in accordance with the facility's performance improvement plan.

This deficient practice regarding the lack of a thorough investigation and implementation of an effective action plan resulted in QAPI's inability to identify the delay in the activation of a RRT, on 4/23/2025, for Patient 1, which resulted in Patient 1's death. In addition, the ineffective action plan resulted in another delayed activation of a RRT for Patient 2 on 8/16/2025, which resulted in Patient 2 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway), transferred to the Intensive Care Unit (a hospital department proving constant monitoring and life-sustaining treatment for patients with severe, life-threatening illness or injuries) and made into a DNR (a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR] if a patient's heart or breathing stops). This deficient practice also had the potential to place other patients at risk of a delayed RRT and had the potential to result in serious injury, harm or death. (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 one of 33 sampled patients (Patient 18) was provided peri-care (refers to cleaning and maintenance of the perineum, the area between the anus and the genitals) every shift, in accordance with the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice."

This deficient practice had the potential for putting Patient 18 at increased risk for infections (urinary tract [infection involving the urethra [tube where urine leaves the body] and the bladder, where urine is stored in the body]), skin break down (damage or injury to the skin, resulting in open wounds), and discomfort. (Refer to A-0395)

2. The facility failed to ensure one of 33 sampled patient's (Patient 3) vital signs (includes temperature, heart rate, blood pressure) were assessed, every two hours, in the Emergency Department (ED, a hospital service providing immediate, unscheduled medical care for severe illnesses or injuries that require urgent attention, 24 hours a day), in accordance with the facility's policies and procedures regarding assessment and reassessment in the ED.

This deficient practice had the potential for changes of condition to go unnoticed by nursing staff, which may lead to patient harm and/or death. (Refer to A-0395)

3. The facility failed to ensure one (1) of 33 sampled patients (Patient 24), received complete assessments after falls (unintentional coming to rest on the ground, floor, or other lower level), in accordance with the facility's policy and procedure, "Fall Prevention and Management." Patient 24 fell six (6) times during the hospital stay, but there was no documentation of post (after)-fall vital signs (basic measurements of body function: temperature [a measure of body heat], heart rate [the number of times the heart beats in one minute], breathing rate [the number of breaths taken in one minute], and blood pressure [the force of blood pushing against the walls of the blood vessels]) and no documentation of post-fall head-to-toe assessments (a full exam performed by a nurse after a fall to check for injury or change in condition).

This deficient practice had the potential to place Patient 24 at risk for harm; for delayed recognition of injuries or complications after a fall, such as bone fracture (a broken bone) or head injury (trauma of the skull or brain caused by impact), which may require urgent medical treatment. (Refer to A-0395)

4. The facility failed to ensure one of 30 sampled patient's (Patient 33's) nursing care plans (part of the nursing process, and is a set of goals, assessments, and interventions for each identified problem) were accurate, actionable, and reflected ongoing nursing assessment, in accordance with the facility's policy regarding care plans, when:

4.a. Patient 33's documented care plan titled, "POC (Plan of Care) Impaired Verbal Communication," inaccurately reflected that Patient 33's goal of "Communicate needs effectively," was achieved.

4.b. Patient 33's documented care plan titled, "POC Agitation (feelings of irritability and severe restlessness)," included the intervention "Patient Specific Interventions" that was incomplete and did not include the very specific nursing interventions for implementation.

These deficient practices resulted in Patient 33 not having an individualized goal-oriented plans of care for the identified problems of impaired verbal communication and agitation, which could have compromised ongoing interdisciplinary communication and coordination towards Patient 33's care. These deficient practices also had the potential for not appropriately addressing Patient 33's vulnerabilities, care needs, and risks. (Refer to A-0396)

5. The facility failed to ensure one of seven sampled facility employees (RN 3), met the necessary qualification to provide safe nursing care in the Emergency Department (ED, a hospital service providing immediate, unscheduled medical care for severe illnesses or injuries that require urgent attention, 24 hours a day), when RN 3's assessment and competency validation checklist (a document used in healthcare to assess and formally verify a nurse's ability to perform essential job functions and meet specific standards) was not completed within 90 days of hire, in accordance with the facility's policy regarding competency assessment and validation plan.

This deficient practice had the potential for RN 3 not being competent to perform patient care which had the potential to put patient safety at risk. (Refer to A-0397)

6. The facility failed to ensure that nursing care assignments were made and carried out in accordance with patient care and safety needs and the facility's policy and procedure titled, "Safety Attendant for Patient at Risk of Harm to Self or Others, for two (2) of 33 sampled patients (Patient 28 and Patient 32) located in the same room (Bed 1 and Bed 2). One sitter (a staff member assigned to observe patients who require close monitoring for safety)- Certified Nursing Assistance (CNA, a healthcare professional who provides basic patient care, such as assisting with daily living activities) 2, was assigned to observe both patients (Patient 28 and Patient 32) at the same time. Both patients were unable to use the call bell (a button patients press to call for staff assistance) and were incontinent (unable to control urination or bowel movements). Both patients (Patient 28 and Patient 32) also needed line-of-sight observation (continuous visual monitoring where the patients must remain in direct view).

This deficient practice had the potential to place Patient 28 and Patient 32 at risk for harm, including falls (unintentional coming to rest on the ground, floor, or other lower level), removal of medical equipment (such as IV lines [thin tubes inserted into a vein to deliver medication] or monitors), or self-injury (when patients harm themselves) due to periods without required observation (line of sight observation). (Refer to A-0397)

7. The facility failed to ensure one of seven sampled facility employees (RN 13) met the necessary qualifications and competencies to provide nursing care in the facility's Telemetry Unit (a hospital unit dedicated to the continuous, remote monitoring of patients whose cardiac [heart] conditions or other illnesses require constant observation, using portable equipment to track vital signs like heart rate and rhythm), when RN 13's latest due annual competency trainings and specialized EKG (electrocardiogram, a medical test that records the electrical activity of the heart by placing electrodes on the skin) testing, were not completed, in accordance with the facility's policy regarding competency assessment and Telemetry RN job description.

This deficient practice had the potential to result in RN 13 being unable to provide safe and effective patient care in the facility's Telemetry Unit, potentially putting patients in the facility at risk of harm. (Refer to A-0397)

8. The facility failed to ensure its staff activated a Rapid Response Team (RRT, an interdisciplinary team, critical care nurse and a respiratory therapist, that responds to RR activations throughout the hospital; purpose is to provide immediate, specialized care to patients who show signs of deteriorating health), in a timely manner, for two (2) of 33 sampled patients (Patients 1 and 2), who displayed a change of condition in respiratory (the process of breathing) status, in accordance with the facility's policy regarding RRT activation, when:

8.a. On 4/23/2025, the facility called Rapid Response Team (RRT) 40 minutes after Patient 1 started displaying signs and symptoms of respiratory distress (when breathing becomes difficult), oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) of 78 % (Normal: 95-100%), increased heart rate (156; Normal: 60 to 100 beats per minute [bpm]), and blood pressure (172/108; Normal: 120/90 millimeters of mercury [mm HG- a unit of measurement]). Two minutes later (after the RRT being called 40 minutes late from when Patient 1 started declining), a code blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when the patient stops breathing]) was subsequently called. Patient 1 expired.

8.b. On 8/16/2025, the facility called rapid response team (RRT) at 2:25 a.m. after Patient 2 started displaying signs and symptoms of respiratory distress with oxygen desaturation (a decrease in the amount of oxygen in the blood), increased respiratory rate (26; Normal: 12-20 breaths per minute) and increased breathing effort including use of accessory muscles (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) despite Hi-Flow oxygen (delivers heated, humidified air and oxygen at flow rates up to 60 L/min [liters per minute, a unit of measurement]) that was given since midnight of 8/16/2025. Patient 2 was intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) at 2:48 a.m. and was sent to the Intensive Care Unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care) for further management.

These deficient practices resulted in a delay in activating an RRT for Patients 1 and 2 and resulted in both patients being intubated. Patient 1 expired while the Code Blue was in progress. Patient 2 was transferred to the ICU for further management and was made a DNR (Do not resuscitate, a medical directive that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR, to maintain blood circulation and oxygen flow to vital organs during cardiac or respiratory arrest] if the patient's heart stops or breathing ceases) on 9/14/2025. (Refer to A-0398)

9. The facility failed to ensure nursing staff followed the facility's policy and procedure (P&P) titled, "Fall (an unintentional descent of a patient to the ground) Prevention and Management, for one of 33 sampled patients (Patient 20), when there was no assessment completed for possible injuries post (after) fall, when the physician was not notified regarding Patient 20's fall incident, and when a fall related event report was not completed.

This deficient practice had the potential for Patient 20 to suffer from delayed detection and treatment of potentially life threating injuries (such as fractures [broken bones]) and other conditions that may have contributed to the fall. Thus, potentially resulting in long-term disability or even death for Patient 20. (Refer to A-0398)

10. The facility failed to ensure that one of 33 sampled patient's (Patient 6), assessment regarding rectal bleeding finding (the passage of blood from the rectum [the final section of the large intestine, located just before the anus, and serves as a temporary storage site for feces]), was documented in the nursing flowsheet under gastrointestinal (GI, the stomach and intestines) assessment (evaluation of the digestive system, including the stomach, intestines, liver, and related structures; involves checking for signs and symptoms such as bleeding, and other indicators of GI health dysfunction) record, in accordance with the facility's policy regarding standards of nursing practice pertaining to assessment and documentation.

This deficient practice had the potential to impact Patient 6's safety and compromise care and discharge needs by potentially delaying treatment of the rectal bleeding, thus impairing accurate assessment of Patient 6's health status prior discharge. (Refer to A-0398)

11. The facility failed to ensure that three (3) of 33 sampled patients (Patient 29, Patient 30, and Patient 31), who had provider orders for continuous telemetry monitoring (a system that continuously tracks a patient's heart activity by using small sicky patches called electrodes that send signals to a central monitor, allowing staff to detect dangerous heart rhythms [the pattern and timing of your heartbeats] in real time), were placed on telemetry monitoring immediately and continuously. The facility also failed to ensure that Patients 29 and 31 received timely cardiovascular assessment (a nurse's evaluation of the patient's heart and circulation to establish a baseline [the patient normal rhythms] for comparison if changes occur), in accordance with the facility's policies regarding telemetry monitoring and nursing standards of practice pertaining to patient assessment.

This deficient practice had the potential to delay recognition and treatment of serious heart complications, such as such as arrhythmias (irregular heartbeats) or cardiac arrest (when the heart suddenly stops beating), which can lead to death if not treated promptly. (Refer to A-0398)

12. The facility failed to ensure that one of 33 sampled patients (Patient 3), was treated immediately with prescribed medications (Pepcid [famotidine, treats heartburn and other conditions caused by excess stomach acid] and Benadryl [diphenhydramine, treats allergy symptoms]), when Patient 3 presented to the Emergency Department (ED) with an allergic reaction of an itchy rash to both legs, in accordance with the physician's orders and the facility's policy and procedures regarding medication administration.

This deficient practice resulted in a delay in treatment for Patient 3 and resulted in Patient 3's symptoms being unrelieved for 3 hours. (Refer to A-0405)

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 the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by:

1. The facility failed to ensure that discharge instruction form was promptly signed by patient and properly filed and retained, for one of 33 sampled patients (Patient 4), in accordance with the facility's policy regarding documentation, when there was no copy of a signed Discharge instructions (personalized instructions given to a patient and/or their caregiver to guide them in continuing their care at home after leaving a hospital or other healthcare facility) form filed and retained by the facility to indicate that Patient 4 was provided the post (after) discharge care educational material and instructions and understood them.

This deficient practice had the potential for Patient 4 not to receive and/or understand the discharge instructions thus increasing the risk of compromised continuity of care, misunderstanding about the patient's (Patient 4) condition and recovery plan, and delayed follow-up and treatment after discharge. (Refer to A-0438)

2. The facility failed to ensure its nursing staff documented the reassessment and evaluation for one (1) of 33 sampled patient's (Patient 2) response to treatment and medications, given on 8/16/2025, , when there was a change of condition (a sudden change from the baseline condition requiring medical attention), in accordance with the facility's policy and procedure regarding standards of care pertaining to reassessment and documentation.

This deficient practice had the potential to result in other healthcare team members not being able to evaluate the cause of Patient 2's change of condition, response to treatment, which may potentially lead to delay of treatment and care. (Refer to A-0449)

3. The facility failed to ensure medical records were complete and accurate, in accordance with the facility's policy regarding rapid response team (RRT, a team that responds to Rapid Response activation, team consist of a critical care nurse and a respiratory therapist) documentation, for one of 33 sampled patients (Patient 1), when a Rapid Response Team was called for Patient 1. The RRT incident was not documented in the medical record. The time of the RRT documented in the nurse's notes was also inaccurate, when compared to the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) Log.

This deficient practice had the potential for wrong or misleading information, in the event that the RRT was under investigation and may also negatively impact the facility's ability to identify issues related to care, understand underlying causes, and implement improvement measures for patient safety. (Refer to A-0450)

4. The facility failed to ensure that for two of 33 sampled patients (Patient 4 and Patient 8), pertinent information necessary to monitor Patient 4's and Patient 8's condition, was documented in their (Patient 4 and Patient 8) medical records, in accordance with the facility' policy regarding core nursing standards of practice pertaining to documentation, when:

4.a. Vital signs (VS, measurements of key bodily functions such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation [an important indicator of oxygenation status]) were not obtained and promptly recorded for Patient 4 prior to Patient 4's discharge from the facility.

This deficient practice had the potential for Patient 4's key vital signs (VS) to be unmonitored prior to discharge, which could lead to undetected physiological instability, delayed recognition of worsening of Patient 4's condition, and increased risk of adverse events such as post-discharge complications. (Refer to A-0467)

4.b. Patient 8's daily weight was not obtained and recorded every day as ordered by the provider.

This deficient practice had the potential to negatively impact clinical-decision making and continuity of care, compromise Patient 8's quality of care, leading to inadequate monitoring of fluid status (the balance between how much fluid a person takes in and how much they lose, indicating if they are adequately hydrated or experiencing fluid overload [hypervolemia] or dehydration [hypovolemia]), including missed signs of worsening in Patient 8's condition, which may delay treatment. (Refer to A-0467)

5. The facility failed to ensure that for one of 33 sampled patients (Patient 4), a discharge summary (a medical document summarizing the patient's hospital's stay, including discharging diagnoses, treatments, outcomes, and follow-up plans), was recorded indicating a discussion of the outcome of Patient 4's hospitalization and arrangements for follow-up care, in accordance with the facility's medical rules and regulations pertaining to discharge summary documentation.

This deficient practice had the potential to increase risk of poor continuity of care for Patient 4, create misunderstandings about the patient's (Patient 4} condition and recovery plan, delay follow-up and treatment, and incomplete medical records, which could impact Patient 4's safety and the hospital's record keeping accuracy. (Refer to A-0468)

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, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to:

1. Provide oversight over the Nursing Department to ensure nursing staff followed the facility's policy and procedure regarding the timely activation of a Rapid Response Team (RRT, a team that responds to Rapid Response activation, team consist of a critical care nurse and a respiratory therapist) for two of 33 sampled patients (Patients 1 and 2). On 4/23/2025, Patient 1's RRT was activated forty (40) minutes (delay of 40 minutes) after displaying signs and symptoms of respiratory distress (difficulty breathing) and changes in baseline vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level). On 8/16/2025, Patient 2's RRT was activated over two (2) hours (delay of over 2 hours) after Patient 2 started displaying signs and symptoms of respiratory distress despite Hi-Flow oxygen (delivers heated, humidified air and oxygen at flow rates up to 60 L/min [liters per minute, a unit of measurement]) given since 12 a.m.

This deficient practice resulted in Patient 1 coding (loss of respirations and heart rate) two minutes after the activation of RRT and expiring during the Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when a patient stops breathing]) on 4/23/2025. In addition, on 8/16/2025, Patient 2 was intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing), transferred to the Intensive Care Unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care) and was made a DNR (Do Not Resuscitate, a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR] if the patient's heart stops beating or breathing stops). This lack of GB oversight also placed other patients at risk for a delayed RRT and had the potential for harm, serious injury, or death.

2. Provide oversight on the facility's Quality Assurance Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) committee, to ensure that the QAPI identified an issue regarding a 40-minute delay in activating an RRT for Patient 1 on 4/23/2025 and ensure proactive implementation of an effective action plan to prevent the reoccurrence of another delayed activation of a RRT for Patient 2 on 8/16/2025, in accordance with the facility's performance improvement plan and bylaws (ensures that a hospital's medical professionals are appropriately qualified and set a standard of quality that assures patients they can receive safe and effective medical care).

This deficient practice regarding the lack of GB oversight resulted in the QAPI's inability to identify the delay in the activation of a RRT, on 4/23/2025, for Patient 1. In addition, it resulted in the implementation of an ineffective action plan which resulted in another delayed activation of a RRT for Patient 2 on 8/16/2025, which led in Patient 2 being intubated, being transferred to the ICU and consequently being made a DNR. This deficient practice also had the potential to affect other patients, who may encounter delayed RRT activation, which may result in patient harm and/or death.

Findings:

1. During an interview on 9/19/2025 at 4:17 p.m. with the President (member of the Governing Body), the President stated the following: The Community Board (Governing Body, GB) was responsible for what happens in the hospital. The GB was responsible in providing oversight over various hospital departments (Example: Nursing, QAPI, Physical Environment), on treatment, care services, and quality of care delivered. GB had oversight on QPSC (Quality & Patient Safety Committee = QAPI [Quality Assurance Performance Improvement, a data-driven, proactive approach to improving the quality of care and services). The QPSC would present the QI (Quality Improvement)/PI (Performance Initiative) data for each year. QPSC would perform RCA (Root Cause Analysis, method to investigate significant adverse patient events or near misses to identify system-level vulnerabilities and develop corrective actions to prevent future harm) for any significant patient safety events such as the trach (tracheostomy, a surgical procedure that creates an opening in the trachea [windpipe] to allow air to enter and exit the lungs) dislodgement (involving Patient 1) and reports to the GB. QPSC would also report to GB anything reported to CDPH or other regulatory agencies. The code blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when a patient stops breathing])/RRT (Rapid Response Team, team consist of a critical care nurse and a respiratory therapist ) data were reported to QPSC, but the aggregated data (raw data from multiple sources that has been combined and summarized to provide a high-level view, often making it easier to understand trends, patterns, and insights that are not visible in individual data points) was not reported to the GB (by the QAPI; aggregated data is important in determining trends to ensure implementation of a comprehensive action plan for implementation).

During the same interview on 9/19/2025 at 4:17 p.m. with the President (member of the Governing Body), the President stated the following: The QPSC would report to the GB if there was any patient event or bad outcome related to the investigated incident. The trach event in April 2025 for Patient 1 was reported to GB. The board wanted to know what was done immediately after, in terms of patient safety. "We went through the timeline of the event, what happened? who was involved? What are we going to do about it? Was there any education done or policy change needed?" The President also stated the ICU physician and nursing staff were involved in the discussion. The team identified that the RRT should have been activated sooner because by the time the RRT team arrived, it was a full on code blue, for Patient 1. The President said "I Believe there was a policy change after the event." GB believed the implementation of the action plan was appropriate at that time (after Patient 1 incident, however another incident regarding a delay in calling an RRT happened which involved Patient 2). GB was aware of there was another patient (Patient 2) involved (when 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] was called on 9/18/2025 by the surveyors) in which a similar incident happened (delay in calling RRT on 8/16/2025). The President stated that the reason for ensuring the implementation of an effective action plan was to prevent similar events from happening and that the facility needed to continue to monitor the progress and outcome of what was implemented.

During an interview on 9/19/2025 at 4:35 p.m. with the President (a member of the GB), the President stated the following: The investigation, for Patient 1, did not capture the delay (in activating RRT). The President stated, "I am responsible for what happened from the hospital, and report to the board and tell them what happened." The President also said the GB relied on the Quality Team to present the data.

1.a. During a concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit (a hospital unit dedicated to the continuous, remote monitoring of patients whose cardiac [heart] conditions or other illnesses require constant observation, using portable equipment to track vital signs like heart rate and rhythm), Patient 1's medical record, was reviewed. The DOT stated the following: Per Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, Patient 1 was admitted for shortness of breath (difficulty breathing), intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and admitted to the intensive care unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care). Patient 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea to provide an airway and facilitate breathing) placement on 4/9/2025 and was transferred to the Telemetry unit on 4/20/2025.

During further concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, Patient 1's medical record, was reviewed. Per Nurse's Notes, dated 4/23/2025, Patient 1 was receiving oxygen at 10 L (liters, a unit of measurement), FiO2 (Fraction of Inspired Oxygen [concentration of oxygen in the air]) at 50 %, via T-piece (a medical device used to provide oxygen and ventilation to a patient with a tracheostomy). The Nurse's Notes indicated Patient 1 started displaying signs of respiratory distress (difficulty breathing) on 4/23/2025 at 12:10 a.m., after receiving trach (Tracheostomy) care. At 12:10 a.m., Patient 1's oxygen saturation (measurement of the amount of oxygen in the blood) was 78 % (normal is above 90%), Patient 1's heart rate increased to 156, and 146 (Normal is 60-100). Blood pressure increased to 172/108 (high; Normal is 120/90). Patient 1's nurse (RN 1) called the respiratory therapist (RT 1) to assess Patient 1. The RT 1 assessed and suctioned Patient 1. A Rapid Response Team (RRT, a team that responds to Rapid Response activation, team consists of a critical care nurse and a respiratory therapist) was called, per nurse's notes at 12:35 a.m., however, the documentation on the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log, indicated the RRT was called at 12:50 a.m. A Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when a patient stops breathing]) was called at 12:52 a.m. The DOT verified that Patient 1 met the criteria for an RRT, which included oxygen saturation of less than 90 % despite treatment, change in vital signs (HR, BP, O2 Sat). DOT said there was no evidence that RN 1 notified the physician of these changes. The DOT stated the RRT was called 40 minutes (at 12:50 a.m.) after Patient 1 started displaying signs of respiratory distress and changes in baseline vital signs. The DOT stated there was a delay in calling the RRT, which would trigger for a critical care nurse and a respiratory therapist to respond. At 12:52, a code blue was called. Patient 1 expired at 1:26 a.m. The DOT also verified there were no RRT notes documented in the medical record. In addition, the DOT was previously unaware of the 40-minute delay in activating the RRT.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, the H&P indicated Patient 1 had a past medical history of "multi-substance use, asthma (a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breathe), hypertension (high blood pressure), hypertension (high blood pressure) ...presented to the hospital due to worsening of shortness of breath (difficulty breathing), nausea (th urge to throw up), vomiting, altered mental status (a significant change in a person's level of consciousness [a person's degree of wakefulness and awareness of their surroundings and self, existing on a spectrum from fully alert to completely unresponsive], cognitive function [memory, attention, learning, perception, and decision-making], or behavior ) ...patient (Patient 1) is intubated ...in the Intensive Care Unit."

During a review of Patient 1's Vital Signs (VS) record, the VS record indicated the following:

-On 4/22/2025 at 8 p.m., Heart Rate (HR, reference range 51 - 119) was 93, Blood Pressure (BP) was 155/83 (high, reference range 91-139/51-89), Respiratory Rate (RR) 20 (normal, reference range 15 - 20), Temperature was 37 (normal).
-On 4/23/2025 at 12 a.m., HR was 78, Temperature 36.6 (normal)
-At 12:03 a.m., RR was 20, oxygen saturation was 95 % on FiO2 at 50% via T-Piece (a medical device used to provide oxygen and ventilation to a patient with a tracheostomy).
-At 12:08 a.m., HR was 108
-At 12:14 a.m., HR was 156 (high) and RR was 22 (high)
-At 12:15 a.m., BP was 172/108 (high)
-At 12:16 a.m., HR was 146 (high)

During a review of Patient 1's "Nursing Progress Note," dated 4/23/2025 at 6:37 a.m., the nursing progress notes indicated the following:

-At 12 a.m., "vital signs stable ...RT (respiratory therapist) came to do treatment for Patient 1."
-At 12:10 a.m., "went into Patient 1's room ...found patient having trouble breathing, checking Patient 1. RT was called to check trach tie. RT came and trach was examined, continues on showing very anxious (feeling of fear, dread, or uneasiness),"
-At 12:14 a.m., the heart rate went up to 156.
-At 12:16 a.m., Patient 1 remained short of breath, blood pressure went up to 172/108.
-At 12:35 a.m., RRT (Rapid Response Team) activated. (DOT verified, the time was inaccurate and the RRT was actually activated at 12:50 a.m., per PBX Rapid Response Log).
-At 12:50 a.m. Code Blue called. ICU team arrived at 12:52 a.m.
-At 1:26 a.m., Despite resuscitation (measures to help the heart keep beating and the patient breathing), Patient 1 expired (died).
-Addendum to the Notes, at 8 a.m. indicated the following:
-At 12:10 a.m., "After seeing RT do trach care, went inside patient's (Patient 1's) room to check, noted in respiratory distress oxygen saturation 78 % (Low, normal above 93 %), called RT to check the patient, titrated oxygen, suctioned the patient, (Patient 1) continued to have respiratory distress. Charge nurse came and called for RRT ...patient (Patient 1) remained in respiratory distress, no pulse noted. Code Blue team came and took over."

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:45 a.m., the Respiratory Note indicated the following: "Nurse called for RT (respiratory therapist), patient (Patient 1) had increased work of breathing. Arrived in room and patient suctioned with catheter. Catheter was passed though airway with no resistance. Inner cannula (a removable tube that fits inside the main tracheostomy tube [outer cannula, acting as a liner to make it easier to clean and prevent blockages from mucus buildup) was checked with no obstruction noted. Patient's )Patient 1's) saturation was checked and was noted to be falling below 90 % ...Rapid Response called. Bag (Manual resuscitator, to manually provide positive pressure ventilation and supplemental oxygen to patients who are not breathing effectively or have stopped breathing altogether) was connected to flowmeter on 100 % FiO2 and was provided to patient via trach ...Rapid Response team arrived with attending physician ...it was determined that the trach was dislodged ... minutes later a Code Blue was called."

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:55 a.m., the Respiratory Note indicated the following: "RRT called ...upon arrival, patient (Patient 1) was being bagged (manual resuscitation) on 100 % FiO2 via trach ...patient (Patient 1) appeared in respiratory distress ...It was determined the trach was dislodged. A few minutes later, a code blue was called due to the difficult airway ... Patient (Patient 1) was intubated by the Anesthesiologist ...After a long resuscitation effort, ROSC (return of spontaneous circulation, the resumption of the heart's ability to pump blood on its own after a cardiac arrest [heart stops beating]) was not obtained, and patient (Patient 1) was pronounced by the Attending Physician."

During a review of a PBX log titled, "Rapid Response," the PBX log indicated that on 4/23/2025 at 12:50 a.m., a code Rapid Response was called for Patient 1.

During a review of a PBX log titled, "Code Blue/White," the PBX log indicated that on 4/23/2025 at 12:52 a.m., a code blue was called for Patient 1.

During a review of the facility's policy and procedure (P&P) titled, "Adult Rapid Response Team," dated 8/24/2025, the P&P indicated the following: This policy allows patients, visitors, or employees to communicate an urgent need for rapid and timely intervention for a deteriorating person and for a critical care registered nurses (RN) to implement Standardized Procedures for adult patients ...The RRT: A Rapid Response Team is activated throughout the inpatient hospital. The composition of the team includes a critical care nurse and a respiratory care practitioner (RCP) ...
1. When a hospital staff member feels a patient warrants immediate assessment and intervention, they can activate the RRT dialing the hospital's Code line 77777 an specify the room and bed ...
Rapid Response Team Activation Criteria:
Some patient's condition that may warrant activation of the Rapid Response Team (RRT) include, but are not limited to;
-A general feeling or urgency that the patient is not doing well
-Oxygen saturation < 90% or acute changes despite oxygen supplementation ...
-Failure to respond to a treatment (i.e. fluid bolus, respiratory)
-Hemodynamic instability
-Acute change in vital signs or change from their baseline
Rapid Response Team Guidelines: include,
-Communication with the physician will begin immediately after the start of the RRT, throughout the RRT, as needed ...
Rapid Response Team Documentation:
-The assigned nurse or staff member who activated the rapid response and who was involved with the team's response will complete the RRT evaluation (debrief) tool and give it to the RRT lead nurse for review.
-The patient's assigned RN will document the time of code activation and the events leading to the activation.
-The Rapid Response Team lead nurse will document in the electronic health record and under Rapid Response Note ...

During a review of the facility's "Amended and Restated Bylaws of the Hospital Community Board ...," dated 2019, the Bylaws indicated the following: 8.2 Quality Assessment Performance Improvement, Patient Safety and Utilization Management. This Hospital Community Board is responsible for assuring that health care services provided at the Local Hospital are of high quality, safe, effective, efficient and consistent with community standards.

1.b. During a review of Patient 2's "Physician Note (physician progress notes)," dated 8/15/2025, the physician progress notes indicated, Patient 2 was admitted to the facility on 7/12/2025 with diagnoses including but not limited to acute hypoxic respiratory failure (a life-threatening condition where the lungs fail to adequately exchange oxygen from the air into the bloodstream, leading to low oxygen levels [hypoxemia] in the body), hepatic encephalopathy (a neuropsychiatric syndrome [These symptoms can affect a person's mood, behavior, cognition- the process of thinking and knowing, and physical health] that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (high blood sugar level), and acute kidney injury (a sudden decline in kidney function that leads to a buildup of waste products in the blood and an imbalance of fluids and electrolytes). The physician progress notes also indicated Patient 2 was receiving oxygen at three (3) liters per minute (LPM, how much oxygen delivered each minute) via nasal cannula (NC, a plastic flexible tube that provides oxygen through the nose).

During a review of Patient 2's physician order, dated 8/15/2025, the physician order indicated, Patient 2 was on continuous pulse oximetry monitoring (a noninvasive procedure that uses a small device to measure the percentage of oxygen saturation in the blood).

During a review of Patient 2's "Vital Signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) Flowsheet (VS flowsheet)," dated 8/15/2025, the VS flowsheet indicated, on 8/15/2025 at 8 p.m., Patient 2's oxygen saturation level (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) was 93 % (normal range 95-100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) with 18 respiratory rate (RR) per minute (normal respiratory rate range 12 - 20 per minute) on oxygen 3 LPM via nasal cannula.

During a review of Patient 2's "Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration [worsening]) Note (RRT notes)," dated 8/16/2025, the RRT notes indicated, "(on 8/16/2025) RRT called at 0223hr (2:23 a.m.) due to worsening hypoxemia (low oxygen level). Upon arrival, patient on high dose of oxygen, 100 % NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patient with severe respiratory distress [difficulty breathing] or hypoxia) and HFNC (High-Flow nasal Cannula [a medical device delivers a mixture of heated and humidified air and oxygen at high flow rates to treat respiratory failure) 60 Liters [per minute] (L/min, unit of measure)/ 91 % [FiO2](Fraction of Inspired Oxygen [concentration of oxygen in the air) with O2 Sat of 71 % (critical low oxygen saturation). Per primary RN (RN 13), patient (Patient 2) had been desaturating (the blood oxygen saturation level was dropping) to 87 % since midnight."

During further review of Patient 2's "Rapid Response Team" notes, dated 8/16/2025, the RRT notes indicated, "PMD [physician, MD 5] was informed with order of Lasix (medication to treat fluid overload [too much]) 40 mg (milligrams, unit of measure) IVP (Intravenous push, administered into a vein) given at 0027 (12:27 a.m.) and Bumex (medication to treat fluid retention, 40 times more potent than Lasix) 1 mg IVP & (and) Solu-Medrol (medication to treat inflammation [swelling] and breathing problem) 40 mg IVP given at 0207 (2:07 a.m.) which didn't show any improvement but instead patient (Patient 2) desaturated more to 69 %. Hence RRT was called ... RR 25, shallowing breathing ... patient (Patient 2) continued to desaturate as low as 55 % ... intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) at 0248hr (2:48 a.m.)." The RRT notes also indicated Patient 2 was transferred to the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) on a ventilator (an appliance for artificial respiration).

During an interview on 9/18/2025 at 10:58 a.m. with the Charge Nurse (CN) 10 of Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring), CN 10 stated the following: anyone could call rapid response team (RRT) when the patient had a change of condition including change in respiratory status, mentation (mental activity) changes and change in vital signs. Staff should call RRT also for extra help and to evaluate possible intubation when they were not able to maintain patient's oxygenation.

During a concurrent interview and record review on 9/18/2025 at 11:12 a.m. with the CN 10, the facility's "Daily Central Monitoring Log Sheet (tele log)," dated from 8/15/2025 to 8/16/2025, was reviewed. The tele log indicated "O2 Sat low" calls were made by the monitor tech (MT) 4 to Patient 2's primary nurse (RN 13) on 8/16/2025 at 12:13 a.m., 12:48 a.m., 1:14 a.m., and 2:07 a.m. The tele log also indicated RRT was called at 2:25 a.m. for Patient 2. CN 10 stated the following: as general rule, the monitor tech would notify the nurse when a patient's O2 Sat was below 90 %. The number of calls during the time span from 12:13 a.m. to 2:07 a.m. indicated Patient 2's O2 Sat was fluctuating (changing up and down) and not stable. CN 10 stated, "it is a long time (from onset time 12:13a.m. to RRT time 2:25 a.m.)." CN 10 further stated the following: the RRT was delayed. Even though there was communication with the physician and interventions provided, it should not take long to see an improvement. RN 13 took too long to call the RRT. Patient 2's condition could decompensate (a sudden or gradual worsening of a condition) and result in respiratory distress.

During a concurrent interview and record review on 9/18/2025 at 11:25 a.m. with the Manager (RM 1) of Respiratory, Patient 2's "Respiratory Treatment Form (RT notes)," dated 8/16/2025, was reviewed. The RT notes indicated, on 8/16/2025 at 00:25 (12:25) a.m. Patient 2 was noted to have shortness of breath light to moderate with or without activity, coarse crackles (loud, low-pitched, and longer-lasting "bubbling" or "rattling" discontinuous lung sounds) bilaterally (both lungs) and using accessory muscle (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) to breath. Patient 2 was on HFNC with liter flow rate of 50 L/min. Breathing treatment of Albuterol (bronchodilators [relax and open the air passage to the lungs to make breathing easier]) and Mucomyst (medication to break apart mucus in the lungs) were given. The oxygen flow rate of HFNC was increased to 55 L/min and Patient 2's respiration rate was 26. RM 1 stated RRT should have been called because Patient 2 was not getting better and was tachypneic (rapid breathing). There was a delay in calling the RRT. RM 1 further stated prolonged hypoxemia could cause damage to the brain and heart.

During a review of the facility's policy and procedure (P&P) titled, "Adult Rapid Response Team," dated 8/24/2025, the P&P indicated the following: This policy allows patients, visitors, or employees to communicate an urgent need for rapid and timely intervention for a deteriorating person and for a critical care registered nurses (RN) to implement Standardized Procedures for adult patients ...The RRT: A Rapid Response Team is activated throughout the inpatient hospital. The composition of the team includes a critical care nurse and a respiratory care practitioner (RCP) ...
1. When a hospital staff member feels a patient warrants immediate assessment and intervention, they can activate the RRT dialing the hospital's Code line 77777 an specify the room and bed ...
Rapid Response Team Actitation Criteria:
Some patient's condition that may warrant activation of the Rapid Response Team (RRT) include, but are not limited to;
-A general feeling or urgency that the patient is not doing well
-Oxygen saturation < 90% or acute changes despite oxygen supplementation ...
-Failure to respond to a treatment (i.e. fluid bolus, respiratory)
-Hemodynamic instability
-Acute change in vital signs or change from their baseline
Rapid Response Team Guidelines: include,
-Communication with the physician will begin immediately after the start of the RRT, throughout the RRT, as needed ...
Rapid Response Team Documentation:
-The assigned nurse or staff member who activated the rapid response and who was involved with the team's response will complete the RRT evaluation (debrief) tool and give it to the RRT lead nurse for review.
-The patient's assigned RN will document the time of code activation and the events leading to the activation.
-The Rapid Response Team lead nurse will document in the electronic health record and under Rapid Response Note ...

During a review of the facility's "Amended and Restated Bylaws of the Hospital Community Board ...," dated 2019, the Bylaws indicated the following: 8.2 Quality Assessment Performance Improvement, Patient Safety and Utilization Management. This Hospital Community Board is responsible for assuring that health care services provided at the Local Hospital are of high quality, safe, effective, efficient and consistent with community standards.

2. During a concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, Patient 1's medical record, was reviewed. The DOT stated the following: Per Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, Patient 1 was admitted for shortness of breath, intubated and admitted to the intensive care unit. Patient 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea to provide an airway and facilitate breathing) placement on 4/9/2025 and transferred to the Telemetry unit on 4/20/2025. The DOT also said Per Nurse's Notes, dated 4/23/2025, Patient 1 was receiving oxygen at 10 L, FiO2 at 50 %, via T-piece (a medical device used to provide oxygen and ventilation to a patient with a tracheostomy). Patient 1 started displaying signs of respiratory distress on 4/23/2025 at 12:10 a.m., after receiving trach care. At 12:10 a.m., Patient 1's oxygen saturation was 78 % (normal is above 90%), Patient 1's heart rate increased to 156, and 146. Blood pressure increased to 172/108 (high).

During further concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT stated the following: Patient 1's nurse (RN 1) called the respiratory therapist (RT 1) to assess Patient 1. The RT assessed and suctioned Patient 1. A Rapid Response Team (RRT) was called, per nurse's notes at 12:35 a.m., however, the documentation on the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log, indicated the RRT was called at 12:50 a.m. A Code Blue was called at 12:52 a.m. The DOT verified that Patient 1 met the criteria for an RRT, which included oxygen saturation of less than 90 % despite treatment, change in vital signs (HR, BP, O2 Sat). There was no evidence that RN 1 notified the physician of these changes. The DOT stated the RRT was called 40 minutes (at 12:50 a.m.) after Patient 1 started displaying signs of respiratory distress and changes in baseline vital signs. The DOT stated there was a delay in calling the RRT, which would trigger for a critical care nurse and a respiratory therapist to respond. At 12:52, a code blue was called. Patient 1 expired at 1:26 a.m. The DOT also verified there were no RRT notes documented in the medical record. In addition, the DOT was previously unaware of the 40-minute delay in activating the RRT.

During a concurrent interview and record review on 9/18/2025 at 11:12 a.m. with the CN 10, the facility's "Daily Central Monitoring Log Sheet (tele log)," dated from 8/15/2025 to 8/16/2025, was reviewed. The tele log indicated "O2 Sat low" calls were made by the monitor tech (MT) 4 to Patient 2's primary nurse (RN 13) on 8/16/2025 at 12:13 a.m., 12:48 a.m., 1:14 a.m., and 2:07 a.m. The tele log also indicated RRT was called at 2:25 a.m. for Patient 2. CN 10 stated the following: as general rule, the monitor tech would notify the nurse when a patient's O2 Sat was below 90 %. The number of calls during the time span from 12:13 a.m. to 2:07 a.m. indicated Patient 2's O2 Sat was fluctuating (changing up and down) and not stable. CN 10 stated, "it is a long time (from onset time 12:13a.m. to RRT time 2:25 a.m.)." CN 10 further stated the following: the RRT was delayed. Even though there was communication with the physician and interventions provided, it should not take long to see an improvement. RN 13 took too long to call the RRT. Patient 2's condition could decompensate and result in respiratory distress.

During an interview on 9/17/2025 at 3:28 p.m. with the Interim Quality Director (IQD, a part of the facility's QAPI), the IQD stated the following: The facility investigated Patient 1's death that occurred on 4/23/2025 by reviewing the nurse's and respiratory therapist's notes. The facility did not review the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log to determine the time the RRT was activated for Patient 1. The IDQ was not aware that there had been a forty (40) minute delay in activating an RRT, once Patient 1 met the criteria of an RRT. The IQD stated that the facility's preliminary recommendations for the incident included ensuring respiratory therapist follow trach care guidelines ... For nursing, preliminary reco

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

1. Ensure one of 33 sampled patient's (Patient 3) husband (FM 1), was allowed into the waiting area of the Emergency Department (ED, a hospital department that provides immediate medical care for acute [sudden onset], life-threatening, or serious illnesses and injuries, such as heart attacks) for approximately two (2) hours, while waiting for Patient 3 to be called into the ED, in accordance with the facility's policy regarding Patient rights (a set of legal and ethical principles that protect and empower patients in healthcare decisions).

This deficient practice resulted in FM 1 waiting in the weapons screening area of the ED for approximately two (2) hours, instead of waiting in the waiting room, which had the potential for FM 1 not to hear when Patient 3 was called by the treatment team and may result in delay of treatment for Patient 3.

2. Ensure that one of 33 sampled patients (Patient 6) was safely discharged (the process of releasing a patient from a healthcare facility to another appropriate care setting when they are medically stable, have a comprehensive plan for continued care, and possess the necessary support and resources to manage their health needs in the community) from the facility after being diagnosed with rectal bleeding (the passage of blood from the anus or rectum, the lower part of the large intestine) due to internal hemorrhoids (swollen veins located inside the rectum, rather than around the anus), in accordance with the facility's policy on patient rights regarding continuity of care after hospital discharge, when Patient 6 was discharged without receiving information regarding the need to follow-up with a colorectal surgeon (a medical specialist who diagnoses and treats conditions affecting the lower gastrointestinal tract, including the colon, rectum, and anus) as an outpatient and the importance of monitoring Patient 6's Hgb (Hemoglobin, transports oxygen in the blood) level due to rectal bleeding.

This deficient practice had the potential to result in Patient 6's health being compromised which could lead to readmission to the hospital and post-hospitalization complications such as recurrent rectal bleeding, organ failure (occurs when one or more vital organs in the body are unable to function properly), and even death.

3. Ensure that translator services (professional interpreter services used to facilitate effective communication between healthcare providers and patients with limited English proficiency [LEP]) was used and properly documented, for one of 33 sampled patients (Patient 6), when discharge instructions were discussed with Patient 6 by the discharging physician and nurse, in accordance with the facility's policy regarding the use of interpreters.

This deficient practice had the potential for Patient 6 not to be informed (in their preferred language) about diagnosis, treatment plan, and post (after)-discharge instructions such as medication management, warning signs and symptoms that require urgent care, and potentially delay a follow-up appointment and treatments, which could worsen Patient 6's health outcomes.

Findings:

1. During a review on 9/18/2025 beginning at 1:48 p.m. with the Manager of Security (MOS) and the Director of Security (DOS), and Nurse Manager (NM 2) of the ED, the video footage, dated 1/29/2025, which captured Patient 3's ED visit, was reviewed. The MOS, DOS, and NM 2 verified the following that took place in the video footage on 1/29/2025:

-At 6:46 p.m., Patient 3 entered the Emergency Department (ED)
-At 6:47 p.m., Patient 3 was at the Nurse Desk (first look by nurse to determine urgency of patient condition)
-At 6:52 - 6:57 p.m., Patient 3 at Registration Desk
-From 6:58 p.m., to 7:03 p.m., Patient 3 observed waiting in the ED waiting room (area), and stood on the opposite side of glass divider where Security Officer (SO 3) conducted weapons screening.
-At 7:04 p.m., Patient 3 exited the ED.
-At 7:13 p.m., Husband (FM 1, husband of Patient 3) entered the ED weapon's screening area located inside the building, adjacent to the waiting room (area), went to Nurse's desk, then waited on the opposite side of the glass from Security Officer weapons screening.
-At 7:38 p.m., FM 1 exited the ED.
-At 7:42 p.m., Patient 3 Re-Entered the ED, went to Registration Window.
-At 7:44 p.m., Patient 3 entered Triage (process used to prioritize and categorize patients based on the severity of their condition and their need for immediate medical attention) Room # 3
-At 7:50 p.m., Patient 3 exited Triage Room # 3 and waited in the ED waiting room (WR).
-At 7:54 p.m., Patient 3 entered Triage Room # 1.
-At 8:02 p.m. Patient 3 exited Triage Room # 1 and sat on a chair next to Triage Room # 2.
-At 8:24 p.m., Patient 3 exited the ED.
-At 8:32 p.m. - 10:27 p.m., FM 1 returned to the Security Officer's (SO 3) weapons screening area and remained behind the glass divider in the weapons screening area. Other patients and visitors were observed entering the waiting room, and there were empty seats available in the waiting room (area).
-At 10:28 p.m., Security Officer (SO 4) screened FM 1 for weapons and allowed FM 1 to enter the waiting room (area). FM 1 sat down on an empty chair.
-At 10:37 p.m., FM 1 exited the ED waiting room area.
-At 10:43 p.m., Patient 3 re-entered the ED waiting room, went to nurse desk (first look) and Patient 3 was then taken inside the ED.

During an interview on 9/18/2025 at 2:37 p.m. with the MOS, the MOS verified the following: Patient 3 entered the Emergency Department (ED) waiting room on 1/29/2025 at 6:46 p.m. and exited the ED at 7:04 p.m. FM 1 entered the Emergency Department waiting room on 1/29/2025 at 7:13 p.m., and exited the waiting room at 7:38 p.m. Patient 3 returned to the ED waiting area at 7:42 p.m., and exited at 8:24 p.m. FM 1 returned to ED weapons screening area at 8:32 p.m., however Security Officer (SO) 3 did not allow FM 1 to enter in the ED waiting room, instead FM 1 waited in the weapons screening area for almost 2 hours from 8:32 p.m. to 10:37 p.m. SO 3 was not available for interview, however, prior to SO 3 leaving, SO 3 was asked the reason for which SO 3 did not allow FM 1 to enter the ED waiting room. Per MOS, SO 3 stated the reason FM 1 was not allowed in the waiting room was due to crowd control and for FM 1's safety, as there were sick people in the waiting room. MOS stated that SO 3 did not have the authority to implement crowd control. Crowd control should be implemented in collaboration with nursing personnel and should be a coordinated response.

During an interview on 9/18/2025 at 2:37 p.m. with the DOS, the DOS stated the following: Patient rights apply to everyone, patients and visitors. SO 3 initially allowed FM 1 to enter the waiting room at 7:13 p.m., then denied FM 1 access to the waiting room at 8:32 p.m. Empty seats were available in the waiting room on 1/29/2025 and SO 3 should have granted FM 1 access to the ED waiting room (to hear if patient 3 was being called by the treatment team since Patient 3 was outside the ED and FM 1 stayed inside the ED). FM 1 was allowed into the waiting room only at 10:28 p.m., by Security Officer (SO) 4, two hours later, at the change of shift.

During an interview on 9/18/2025 at 2:37 p.m with NM 2, NM 2 stated that Security Officers needed to collaborate with nursing staff for crowd control and infection control purposes. Patients were entitled to have visitors and denying entry was a violation of patient rights.

During a review of Patient 3's "ED Triage - Text," dated 1/29/2025 at 7:53 p.m., the Text indicated Patient 3 was triaged and assigned an ESI (Emergency Severity Index, a five-level triage system used in emergency departments [ED] to classify patients by acuity and resource needs, from Level 1 [most urgent] to Level 5 [least urgent]) Level 4 (semi-urgent condition, that is not immediately life-threatening). Patient 3's chief complaint "was allergic reaction, itchy rash to bilateral (both) legs, started this morning (1/29/2025) ...denies shortness of breath (difficulty breathing) or airway swelling ..."

During a review of Patient 3's "MSE (Medical Screening Examination, purpose of an MSE is to determine, with "reasonable clinical confidence," whether or not a person who comes to the ED has an emergency medical condition (EMC) Screening - Text," dated 1/29/2025 at 7:59 p.m., the Text indicated MSE Screening was initiated - Patient 3 "presents for C/C (chief complaint) of pruritic (itchy) rash only on legs since this morning (1/29/2025). Started taking Augmentin (an antibiotic used to treat bacterial infections) and Flagyl (an antibiotic used to treat infections caused by bacterial and parasites) yesterday (1/28/2025), Currently, breastfeeding. No acute distress (patient appears stable and is not exhibiting signs of severe or sudden suffering, discomfort, or difficulty), unlabored respirations (normal, effortless breathing). Orders placed, further evaluation by definitive provider."

During a review of Patient 3's "Consultation" notes, dated 1/29/2025 at 11:33 p.m., the Consultation notes indicated the following: Patient 3 "...PPD (post-partum date, days after childbirth) # 8, s/p (status post) NSVD (normal spontaneous vaginal delivery), presented yesterday for increased abdominal pain and diagnosed with urinary tract infection (UTI, an infection that affects part of the urinary system) and endometritis (an inflammatory condition that affects the lining of the uterus [a hollow, muscular organ located in the female pelvis that plays a crucial role in pregnancy and childbirth)). Got prescription for ...Augmentin and Flagyl which...now is back today for bilateral erythematous (redness) leg rash..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2024 the P&P indicated the following ...All staff provide care, treatment, and services to patients that demonstrates respect for our patients' rights. The facility as defined patient's rights as the following:
A. Considerate and respectful care, and to be made comfortable...
R. Designate a support person as well as visitors of your choosing, if your have decision making capacity, whether or not the visitor is related by blood, marriage, or registered domestic partner status ...

2. During a review of Patient 6's History and Physical (H&P, the most formal assessment of the patient and the problem), dated 1/22/2025, the H&P indicated that Patient 6 was admitted to the facility [on 1/22/2025] with a diagnosis of rectal bleeding (refers to fresh, red blood visible in the stool or coming from the anus, indicating bleeding from the lower gastrointestinal [GI, relating to the digestive system tract, such as the colon, rectum, or anus] tract).

During a review of Patient 6's "Gastroenterology (a branch of medicine that focuses on the diagnosis, treatment, and prevention of disorders affecting the digestive system) Consultation Note," dated 1/23/2025, the note indicated that Patient 6 was evaluated (by gastroenterology) due to continued rectal bleeding. The note also indicated that Patient 6 reported having rectal bleeding on and off for 3 years, and that Patient 6 was taking medications for anemia (not having enough red blood cells in the body to carry oxygen [a chemical element necessary for breathing] throughout), prescribed to Patient 6's by a medical provider in Mexico (a country in North America).

During further review of Patient 6's "Gastroenterology Consultation Note," dated 1/23/2025, the note indicated that Patient 6 was found to be anemic (someone with anemia, a condition characterized by a lower-than-normal number of healthy red blood cells or hemoglobin, which impairs the body's ability to transport sufficient oxygen to its tissues and organs) with hemoglobin (Hgb, a protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels of 6 (normal Hgb level for males is 14 to 18 grams/deciliter [g/dl, a unit of measurement] and that for females is 12 to 16 g/dl. When the hemoglobin level is low, the patient has anemia), in which Patient 6 received two units of blood transfusions (to replace blood lost during surgery, trauma, or childbirth, or to treat chronic conditions like severe anemia) to keep Hgb levels at 7 g/dl or higher.

During a review of Patient 6's "Consult Note-Surgery (evaluation for a possible surgical intervention)," dated 1/25/2025, the note indicated that on 1/25/2025, Patient 6 underwent diagnostic procedures and was diagnosed with internal hemorrhoids which required a surgical evaluation consultation for hemorrhoidectomy (surgical removal of hemorrhoids [swollen and inflamed veins in the rectum and anus]). The note further indicated that on 1/25/2025, Patient 6 reported that the rectal bleeding had stopped; and that Patient 6 was determined to be "not a candidate for urgent or emergent surgical intervention (requiring immediate medical intervention such as surgery)," during the admission (from 1/22/2025 to 1/26/2025). The note also indicated that Patient 6 could benefit from an outpatient evaluation by the colorectal surgeon (a medical specialist who focuses on the diagnosis and treatment of diseases and conditions affecting the colon, rectum, and anus) for further treatment options.

During an interview on 9/15/2025, at 3:01 p.m. with Patient 6, Patient 6 said the following, "After being discharged from the hospital on 1/26/2025, I felt very dizzy and continued to bleed heavily. Nobody asked me in the hospital if I was still bleeding when I got discharged. I was told I was bleeding internally, due to internal hemorrhoids ad that there was nothing that could be done for me in the hospital." Patient 6 then said that after continuing to bleed for two days, he [Patient 6] did not know what else to do, bought tickets to fly to another state, to be with the family, where Patient 6 got admitted to the hospital and was given a blood transfusion and had an emergency surgery to stop the bleeding.

During a review of Patient 6's "Physician Note-Surgery," dated 1/26/2025, the note indicated that on 1/26/2025, the nurse reported to the physician that Patient 6 experienced bright red rectal bleeding overnight and the physician rounded with the nurse on Patient 6.

During a concurrent interview and record review, on 9/17/2025, at 11:20 a.m., with clinical educator (CE 1), Patient 6's Physician Note-Surgery," dated 1/26/2025, was reviewed. CE 1 said that the note was written by the medical student and co-signed by the trauma-surgeon "on call" (MD 3) that day (a surgeon who is designated to be available to respond to medical emergencies, perform urgent surgical procedures, or provide consultations outside of their regular working hours), MD 3 co-signed the note, attesting to its validity. CE 1 verified that the note did not contain any documented assessment of the active rectal bleeding on 1/26/2025 and did not indicate whether Patient 6 continued to experience rectal bleeding or dizziness on 1/26/2025 or the bleeding had stopped prior to discharge.

During a review of Patient 6's Discharge Summary (clinical document provided at the end of a patient's hospital stay, summarizing their condition, treatments, diagnoses, medications, and follow-up instructions to ensure a smooth transition to home care and subsequent care by primary care physicians and other specialists), dated 1/26/2025, the discharge summary indicated that Patient 6 was discharged with a recommendation to follow a high fiber diet (also known as roughage or bulk, includes all parts of plant foods that your body can't digest or absorb), perform sitz baths (a shallow bath where the individual sits in warm water up to their hips, which helps to relieve discomfort associated with hemorrhoidal pain), and to follow-up with the primary care physician in 5-7 days. The discharge summary also indicated that Patient 6 did not require urgent or emergent surgery of hemorrhoids.

During an interview on 9/19/2025 at 10:33 a.m. with trauma surgeon (MD 3), MD 3 stated that Patient 6 was not a candidate for surgery or a surgical intervention because the surgeon who initially evaluated Patient 6 [on 1/25/2025] had determined that the patient had hemorrhoids and was not actively bleeding (experiencing ongoing blood loss). MD 3 also added that they [MD 3] followed up with Patient 6 on 1/26/2025, prior to Patient 6's discharge to home. MD 3 also said that since MD 3 was not the primary surgeon (who initially evaluated Patient 6), he [MD 3] was not responsible for the decision not to operate on Patient 6. MD 3 further said, "I asked the patient if he (Patient 6) was bleeding, and he said he was not bleeding. The recommendation after discharge was for the patient [Patient 6] to follow-up with a colorectal surgeon (a medical specialist who diagnoses and treats conditions affecting the lower gastrointestinal tract [digestive system], including the colon, rectum, and anus) as an outpatient.

During the same interview on 9/19/2025 at 10:33 a.m. with trauma surgeon (MD 3), MD 3 said that the criteria for urgent or emergent surgery would include ongoing bleeding. MD 3 said, "If the patient [Patient 6] was still bleeding, I would call the primary surgeon and inform them that the patient might still need surgery so they could re-evaluate."

During an interview on 9/19/2025 at 10:57 a.m. with Physician's Assistant (PA, who initially evaluated Patient 6 and determined that surgery was not indicated), said the following: "Patient (Patient 6) was consulted by surgery after diagnostic testing by gastroenterology (GI) was completed, with the recommendation to perform removal of hemorrhoids. When I saw the patient (Patient 6) (on 1/25/2026), he [Patient 6] was not actively bleeding, and was stable after receiving blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient). Surgery decided that the patient (Patient 6) was stable enough to be discharged and to follow up with the outpatient colorectal surgeon. All recommendations from surgery were discussed with the attending physician, who was responsible for the overall well-being of the patient."

During an interview on 9/19/2025 at 11:22 a.m. with the physician advisor (MD 4), MD 4 said the following regarding Patient 6's discharge summary, dated 1/26/2025: "This discharge summary contains no documentation of the use of the interpreter [since Patient 's preferred language was Spanish]; there was also no record of a discussion with the patient about the need to follow-up with a colorectal surgeon as an outpatient as recommended by surgery and gastroenterology. While it is always important for the patient to follow up with the appropriate specialist, it is also important to make sure the patient understands discharge instructions and recommendations. I can only speculate, what discussion took place between the discharging physician and the patient [Patient 6]; but this discharge summary does not reflect any documentation that such discussion took place; it's not very clear whether a follow-up with a colorectal surgeon was discussed with the patient and if patient was aware about the need to monitor the CBC (a complete blood count test, that measures and evaluates the different types of cells in your blood, including red blood cells). Ideally, the discharge plans and any discussions about follow-up care should be clearly documented in the discharge summary, but they are not."

During a review of the facility's policy and procedure (P&P) titled,
"Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare decisions) and Responsibilities," last revised 6/2024, the P&P indicated that the patient has the right to:
"D. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.
E. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment ...
O. Reasonable continuity of care and to know in advance the time and location of appointments ...
P. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from the hospital. You have the right to be involved in the development and implementation of your discharge plan ...."

During a review of the facility's policy and procedure (P&P) titled, "Limited English Proficiency (LEP): Language Access for Patient and Companions," dated 4/2023, the P&P indicated, "Patients and companions who are Limited English Proficient (LEP) shall have information and services provided to them in their primary language while receiving healthcare services at all [Name] facilities ... Staff shall provide culturally and linguistically appropriate care ... 5. Providing Interpreter Services for Meaningful Access
a. Interpreter services will be provided for any patient who has Limited English Proficiency. b. Interpreter services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge.

During a review of the facility medical rules and regulations (R&R), dated 6/2024, the R&R indicated the following: "The attending practitioner or his physician designate shall make adequate admitting notes, progress notes, and discharge summary on each record of a patient under his care. The discharge summary must contain:
a. All relevant diagnoses and operative procedures performed;
b. Reason for hospitalization;
c. Significant findings;
d. Procedures performed and treatment rendered;
e. Condition of patient on discharge;
f. Specific instructions given to the patient and/or family, particularly in relation to physical activity, medication diet and follow-up care;
The condition on discharge of the patient should be stated in terms that permit a specific measurable comparison with the condition on admission, avoiding the use of-' vague, relative terminology such as "improved. When preprinted instructions are given to the patient or family, the record should so indicate and a sample of the instruction sheet in use at the time should be on file in the Health Information Management Department."

3. During a review of Patient 6's History and Physical (H&P, the most formal assessment of the patient and the problem), dated 1/22/2025, the H&P indicated that Patient 6 was admitted to the facility (on 1/22/2025) with a diagnosis of rectal bleeding (refers to fresh, red blood visible in the stool or coming from the anus, indicating bleeding from the lower gastrointestinal [GI, relating to the digestive system tract, such as the colon, rectum, or anus] tract).

During a review of Patient 6's Face-sheet (a summary page that includes key patient information such as address, admission information, and language), for the admission dates from 1/22/2025 through 1/26/2025, the Face-sheet indicated that Patient 6's preferred language (the language the patient prefers for communication, including speaking and understanding) was Spanish only. This information was verified with Clinical Educator (CE 1) on 9/17/2025 at 11:01 a.m.

During an interview on 9/17/2025, at 11:11 a.m. with Clinical Educator (CE 1), CE 1 stated that, after reviewing Patient 6's physician's progress notes for the admission from 1/22/2025 through 1/26/2025, the only documentation of interpreter services use was found in the History and Physical (H&P), where an identification (ID) number of the interpreter service was documented on 1/23/2025 by the admitting physician. CE 1 then confirmed that no other physician notes contained documentation of interpreter services used. CE 1 also said that the facility staff can utilize the following interpreter services available within the facility: an iPad (a tablet device that can be used to connect to professional interpreter services) and hired interpreters (professional interpreters employed or contracted by the facility to assist with language translation).

During a concurrent interview and record review on 9/17/2025 at 11:37 a.m. with Clinical Educator (CE 1), Patient 6's Discharge Instructions (personalized guidelines provided by nurses to patients before leaving a healthcare setting), dated 1/26/2025, was reviewed. The discharge instructions did not contain documentation of interpreter service use when the discharge instructions were provided to Patient 6 prior to discharge on 1/26/2025. CE 1 said the following, "To ensure the patient (Patient 6) understood the discharge instructions, the nurse should have documented the use of interpreter services in the progress notes, and event note [specific note used to record significant events or interventions during a patient's care]) or directly in the discharge instructions, but the nurse did not."

During a concurrent interview and record review on 9/18/2025 at 10:01 a.m. with clinical educator (CE 1), Patient 6's Discharge Summary (clinical document provided at the end of a patient's hospital stay, summarizing their condition, treatments, diagnoses, medications, and follow-up instructions to ensure a smooth transition to home care and subsequent care by primary care physicians and other specialists), dated 1/26/2025, was reviewed. The CE 1 said that the discharge summary indicated that no interpreter identification (ID) number was documented in the discharge summary on 1/26/2025 and confirmed, that the discharging physician did not speak Spanish.

During a concurrent interview and record review on 9/18/2025, at 10:37 a.m. with the clinical educator (CE 1), Patient 6's "Consult Note-Surgery (evaluation for a possible surgical intervention)," dated 1/25/2025, was reviewed. The CE 1 confirmed that the consult note did not indicate whether the physician's assistant (PA, who recorded the note) used the interpreter services, and it was unclear whether the PA could speak Spanish.

During an interview on 9/19/2025 at 10:57 a.m. with Physician's Assistant (PA, who initially evaluated Patient 6 and determined that surgery was not indicated), the PA said the following: "Patient (Patient 6) was consulted by surgery after diagnostic testing by gastroenterology (GI) was completed, with the recommendation to perform removal of hemorrhoids. I used the interpreter services with Patient 6 during my consultation, but I did not document the use of interpreter services in my notes. This was a serious case, and I wanted to ensure that Patient 6 could understand the information discussed."

During an interview on 9/19/2025 at 11:22 a.m. with the physician advisor (MD 4), MD 4 said the following regarding Patient 6's discharge summary, dated 1/26/2025: "This discharge summary contains no documentation of the use of the interpreter (since Patient 6's preferred language was Spanish); there was also no record of a discussion with the patient about the need to follow-up with a colorectal surgeon as an outpatient as recommended by surgery and gastroenterology. While it is always important for the patient to follow up with the appropriate specialist, it is also important to make sure the patient understands discharge instructions and recommendations. I can only speculate, what discussion took place between the discharging physician and the patient (Patient 6); but this discharge summary does not reflect any documentation that such discussion took place; it's not very clear whether a follow-up with a colorectal surgeon was discussed with the patient and if patient was aware about the need to monitor the CBC (a complete blood count test, that measures and evaluates the different types of cells in the blood, including red blood cells). Ideally, the discharge plans and any discussions about follow-up care should be clearly documented in the discharge summary, but they are not."

During an interview on 9/19/2025 at 1:44 p.m. with staff registered nurse (RN 15), RN 15 said the following, "The patient's preferred language is obtained and documented upon admission. We always want to communicate with the patient in a language they understand. We document the use of interpreter services, which includes recording the name and identification number of the interpreter services used, as well as what was discussed during the translation. This documentation is important because it directly impacts patient safety. Patients need to understand their plan of care, what actions we are going to take, the next steps, and how we will support their recovery. Ensuring effective communication helps the patient to get better and allows them to ask any questions they may have."

During a review of the facility's policy and procedure (P&P) titled,
"Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare decisions) and Responsibilities," last revised 6/2024, the P&P indicated that the patient has the right to:
"D. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care.

During a review of the facility's policy and procedure (P&P) titled, "Limited English Proficiency (LEP): Language Access for Patient and Companions," dated 4/2023, the P&P indicated, "Patients and companions who are Limited English Proficient (LEP) shall have information and services provided to them in their primary language while receiving healthcare services at all [Name] facilities ... Staff shall provide culturally and linguistically appropriate care ... 5. Providing Interpreter Services for Meaningful Access
a. Interpreter services will be provided for any patient who has Limited English Proficiency. b. Interpreter services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge.
7. Documentation of Services
a. The documentation of the provision of interpreter services shall be recorded in the patient medical record and shall include the following:
1) Name of requestor.
2) Date and time of interpretation.
3) Name of [Name] Qualified Medical Interpreter or vendor company name and interpreter name, or telephonic interpreter ID number, as applicable; and a 4) Brief description of content interpreted.

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

1. Ensure that one (1) of 33 sampled patients (Patient 24) and/or Patient 24 's daughter (the designated emergency contact) was supported and provided adequate information in making an informed decision (having enough information, in plain language, to decide about care) related to patient care, in accordance with the facility's policy regarding patient rights pertaining to receiving adequate information to make informed decision, when Patient 24 refused vital signs (temperature [a measure of body heat], heart rate [the number of times the heart beats in one minute], breathing rate [the number of breaths taken in one minute], and blood pressure [the force of blood pushing against the walls of the blood vessels]) to be taken on 12 occasions between 4/14/2025 and 5/2/2025. The medical record (MR, a comprehensive collection of documents that document a patient's health history) contained no documentation that patient education (information about the risks and implications of refusing vital signs) was provided to Patient 24 and/or Patient 24's daughter, and no documentation that the refusal of care was communicated to the provider (the physician or nurse practitioner responsible for the Patient 24's care).

This deficient practice had the potential to prevent Patient 24 and/or Patient 24's daughter from making a fully informed decision about refusal of care. This placed Patient 24 at risk for harm, including unrecognized complications such as internal bleeding, infection, or changes in heart or lung function.

2. Ensure its physician (MD 6) provided the risks and benefits and alternative treatment options to one of 33 sampled patients (Patient 12), in accordance with the facility's policy and procedure regarding patient's rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) to receive adequate information to make an informed decision, when Patient 12 refused X rays (an imaging procedure to create detailed image of the body's internal structure such as bones, tissues and organs) to be taken for left leg fracture (broken bone) in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 7/26/2025.

This deficient practice had the potential to result in Patient 12 not being able to make an informed decision due to not fully understanding the need for X rays and treatment, thus leading to potential delay in receiving treatment including but not limited to splinting (a device used for temporary or definitive immobilization of an injured area, providing stability and support) which may potentially result in worsening of Patient 12's left leg fracture.

Findings:

1. During a review of Patient 24's "Face sheet (a summary document containing demographic, contact, insurance, and medical information)," undated, the form indicated Patient 24's emergency contact person was her daughter, with a phone number listed.

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/23/2025, the "H&P" indicated, Patient 24 was admitted from a skilled nursing facility (a healthcare facility that provides 24-hour medical and rehabilitation services) after a fall (an unintentional, sudden descent of a patient's body to the floor or another lower surface). The H&P further indicated Patient 24's medical history included alcoholic cirrhosis (a chronic liver disease caused by long-term alcohol use), hypertension (chronic high blood pressure, defined as a systolic blood pressure [top number] of 130 mmHg [a unit of measurement] or higher), diabetes (a chronic condition that affects how the body uses glucose [sugar] for energy), and blindness in the right eye (significant loss of vision not correctable by glasses or surgery).

During a concurrent interview and record review on 9/17/2025 at 10:40 a.m. with the Stroke Program Coordinator (SPC) 1, Patient 24's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" report, dated from 4/14/2025 through 5/2/2025, was reviewed. The report indicated the following refusals of vital signs (temperature [a measure of body heat], heart rate [the number of times the heart beats in one minute], breathing rate [the number of breaths taken in one minute], and blood pressure [the force of blood pushing against the walls of the blood vessels]):

- On 4/14/2025 at 4:00 p.m. Patient 24 refused vital signs check.
- On 4/15/2025 at 4:00 a.m. Patient 24 refused vital signs check.
-On 4/16/2025 at 10:00 a.m. Patient 24 refused vital signs check.
-On 4/20/2025 at 9:00 a.m. Patient 24 refused vital signs check.
-On 4/21/2025 at 8:00 a.m. Patient 24 refused vital signs check.
-On 4/22/2025 at 4:00 a.m. Patient 24 refused vital signs check.
-On 4/23/2025 at 8:00 a.m. Patient 24 refused vital signs check.
-On 4/24/2025 at 4:00 p.m. Patient 24 refused vital signs check.
-On 4/25/2025 at 4:00 p.m. Patient 24 refused vital signs check.
-On 4/25/2025 at 8:00 p.m. Patient 24 refused vital signs check.
-On 4/27/2025 at 3:32 p.m. Patient 24 refused vital signs check. (Report also indicated, "Patient (Patient 24) received on the floor in the shower room while being helped to get up by staff." SPC confirmed that this was a fall event).
- On 5/2/2025 at 7:00 a.m. Patient 24 refused vital signs check.
- On 5/2/2025 at 10:00 p.m. Patient 24 refused vital signs check.

During the same interview on 9/17/2025 at 10:40 a.m. with the Stroke Program Coordinator (SPC) 1, SPC 1 confirmed there was no documentation that Patient 24 or her (Patient 24) daughter, was educated about the risks of refusing vitals signs check, and no documentation that the refusals were communicated to the provider.

During the same concurrent interview and record review on 9/17/2025 at 10:40 a.m. with the Stroke Program Coordinator (SPC) 1, Patient 24's "Vital Signs" flow sheet, dated 4/27/2025, was reviewed. The flow sheet indicated, on 4/27/2025, there were no vital signs documented after the fall that occurred 4/27/2025 at 3:32 p.m. SPC 1 also confirmed that there were no documented vitals for 12:00 a.m. SPC 1 stated that there were no documented evidence within the vital flowsheet, "Nursing Progress Notes," or the "Clinical Events Result report" indicating that education explaining the risk and benefits regarding the importance of checking vital signs or the refusal, was provided, to Patient 24 or Patient 24 daughter.

During a concurrent interview and record review on 9/17/2025 at 11:05 a.m. with the Stroke Program Coordinator (SPC) 1, Patient 24's "Nursing Progress Note," dated 5/2/2025, was reviewed. The note indicated, on 5/2/2025 at 11:55 p.m., "Patient fall: PT (Patient 24) was ambulating with the 1:1 sitter (is a staff member who provides continuous, undivided attention to a single patient to ensure their safety and prevent harm, falls, or harmful actions). PT (Patient 24) dragged her right foot, missed a step and knees buckled, fell knees first." SPC 1 confirmed that the Nursing Progress Note indicated that Patient 24 fell on 5/2/2024 at 11:55 pm.

During the same concurrent interview and record review on 9/17/2025 at 11:05 a.m. with SPC 1, Patient 24's "Vital Signs" flowsheet, was reviewed. The flowsheet indicated on 5/2/2025 at 8:00 a.m., 12:00 p.m., and 8 p.m. there were no vital signs taken. SPC 1 stated there should be vital signs taken every 4 hours. SPC 1 also stated that there should be vital signs taken at 8:00 a.m., 12:00 p.m., 4:00 p.m., and at 8:00 p.m., for the day shift. SPC 1 stated when patient refuses care it should be documented in the form called, "Refusal of Care Form." SPC 1 stated this form required that the name of the provider that was notified of the refusal of care, must be documented.

During the same concurrent interview and record review on 9/17/2025 at 11:05 a.m. with SPC 1, Patient 24's medical record (MR, a comprehensive collection of documents that document a patient's health history) section titled, "Refusal of Care Form," dated 4/27/2025 and 5/2/2025, were reviewed. SPC 1 confirmed that there was no documentation that education was provided or that the provider was notified (regarding Patient 24's refusal to have vital signs checked).

During an interview on 9/17/2025 at 10:55 a.m. with SPC 1, SPC 1 stated that when a patient refuses vital signs, the nurse should educate the patient or the patient's representative, document the education provided, and notify the provider. SPC 1 confirmed this was not documented for Patient 24.

During an interview on 9/17/2025 at 10:55 a.m. with the Director of Clinical Education (DIR) 4, DIR 4 stated when a patient refuses vitals, the nurse must educate the patient on the risk and benefits, and this should be documented. DIR 4 also stated that the provider should be notified, and the name of the provider should be documented in the patient's MR, as well.

During an interview on 9/17/2025 at 3:19 p.m. with the Interim Quality Director (IQD), the IQD stated although Patients may refuse care, the provider must be notified so the provider can explain the risks and alternatives.

During an interview on 9/19/2025 at 9:57 a.m. with the Nurse Manager of Medical Surgical Unit (NM) 5, NM 5 stated that after a fall, a head-to-toe assessment (a systemic exam of the body, including vital signs) must be completed and the provider notified. NM 5 stated that when patients refuse vital signs, nurses must educate them on the risks so they can make an informed decision.

During an interview on 9/19/2025 at 11:25 a.m. with Certified Nursing Assistant, a healthcare professional who provides basic patient care, such as assisting with daily living activities (CNA) 4, CNA 4 stated if a patient refuses vials signs, the CNA must report it to the nurse, who then educates the patient and notifies the provider.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibility," dated 6/2024, the P&P indicated, "(Name of the Facility) has defined patient's rights as the following: Patients have the right to receive information about their health status, participate in their plan of care, and make informed decisions, including the right to refuse treatment after receiving adequate information.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "Care Coordination - The registered nurse coordinates care delivery. The registered nurse: Assists the patient to identify options for care ... Health Teaching and Promotion - The registered nurse employs strategies to promote health and a safe environment ... Uses health promotion and health teaching methods in collaboration with the patient's values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status. Uses feedback and evaluations from the patient to determine the effectiveness of the employed strategies ... Documents health teaching and promotion a minimum of once per shift.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent for Operations, Diagnostic or Therapeutic Procedure Core Nursing Standards of Practice," dated 8/2024, the P&P indicated, "Patient's Rights: Patients must be informed of the nature, risks, benefits, and alternatives of any purposed treatment of procedure in order to give informed consent or refusal.

2. During a review of Patient 12's "Emergency Department Physician Notes (ED physician notes, medical notes completed by Emergency Department [hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician), dated 7/26/2025, the ED physician notes indicated, Patient 12 came from a skilled nursing facility (SNF, a nursing facility with the staff and equipment to give skilled nursing care and skilled rehabilitative services and other related health services) for left leg injury after getting caught in a shower chair in the morning of 7/26/2025 and had an outpatient X ray (an imaging procedure to create detailed image of the body's internal structure such as bones, tissues and organs) studies notable for an acute (new onset) spiral tibia and fibula fracture (a type of fracture [broken bone] that occurs when the tibia [shinbone] and fibula [calf bone] in the lower leg are twisted apart, creating a spiral-like pattern). The ED physician notes also indicated Patient 12's left lower leg had swelling with contusion (bruise).

During an interview on 9/16/2025 at 12:29 p.m. with a Registered Nurse (RN) 5 at ED, RN 5 stated the ED providers would explain the risk and benefits of receiving care and treatment (to the patient or designated patient representative) when a patient refused care.

During a concurrent interview and record review on 9/17/2025 at 11:10 a.m. with the Director (DED) of Emergency Department, Patient 12's ED physician notes, dated 7/26/2025, was reviewed. The ED physician notes indicated, "Working diagnosis includes but is not limited to fractures, concussion (a mild traumatic brain injury (TBI) caused by a blow or jolt to the head that temporarily disrupts brain function), acute dislocation (a traumatic event where the bones in a joint are suddenly forced out of their normal position), musculoskeletal injury (injuries that affect the muscles, bones, tendons, ligaments, and nerves of the body), abrasions (a superficial wound of the skin caused by rubbing or scraping against a rough surface), contusions (a medical term for a bruise) or hematomas (a localized collection of blood ) ... X-ray studies were ordered in the emergency department to determine fracture type and intervention however patient was refusing any imaging studies or care of any kind ... Definitive fracture care cannot be completed or determined because patient is refusing any imaging studies. Imaging report provided by facility (Patient 12's skilled nursing facility), however patient is also refusing any intervention including splinting (a device used for temporary or definitive immobilization of an injured area, providing stability and support) ..."

During the same concurrent interview and record review on 9/17/2025 at 11:10 a.m. with the Director (DED) of Emergency Department, Patient 12's ED physician notes, dated 7/26/2025, was reviewed and indicated "The plan has been discussed in detail, and they (Patient 12) are aware of the specific conditions for emergent return, as well as the importance of follow-up ... Patient (Patient 12) was discharged in stable condition." The DED stated the following: the ED physician notes did not indicate any discussion about risk and benefits and alternative treatment options with Patient 12 when Patient 12 refused care and treatment. It was the ED provider's responsibility to explain the risks and benefits of receiving treatment and to provide the patient with alternate treatment options in a way Patient 12 could understand. DED further stated without the explanation, Patient 12 would not understand the reason for getting the X ray and splint, hence patient (Patient 12) may refuse, and this could cause delay of care.

During an interview on 9/18/2025 at 2:34 p.m. with the ED Medical Director, EDMD stated the ED provider should explain the risk and benefits of getting care and the treatment options including the need for immobilization of the fractured leg when Patient 12 refused X ray and care so Patient 12 could understand and make informed decision regarding the care. EDMD stated complications for untreated fracture included nonunion (failure of the bones to heal properly), arthritis (swelling and tenderness of the joints) development and the need for surgery.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2024, the P&P indicated, "It is the policy of [the facility] to identify every patient's rights by doing the following ... All staff provide care, treatment, and services to patients that demonstrates respect for our patients' rights ... Patient's Rights ... D. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care ... E. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment."

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

1. Ensure fall (an unintentional descent of a patient to the ground, floor, or another lower surface) safety interventions were implemented, documented, and the physician was notified of the fall for one of 33 sampled patients (Patient 20), in accordance with the facility's policy regarding fall prevention and management, when Patient 20 fell on the ground in the ED (Emergency Department, a hospital service that provides immediate medical care for acute [sudden and severe onset] and life-threatening conditions) waiting area. Patient 20 had no post (after) fall nursing assessment and physician notification.

This deficient practice had the potential to result in delayed intervention to address possible injury post fall for Patient 20, which could have placed Patient 20 at risk for further falls and injury such as brain trauma (damage to the head), internal bleeding (bleeding within the body) and bone fractures (broken bones).

2. Provide care in a safe setting for one (1) of 33 sampled patients (Patient 24) who sustained six (6) falls (unintended drops to the floor) during the hospital stay. Patient 24's medical record did not contain documented evidence that Patient 24 ambulated (walked) with the assistive device (such as a cane or walker, equipment that helps patients walk safely) that was recommended by the physical therapy services (treatments provided by specialists who help patients improve movement and safety; Physical therapists may recommend equipment, such as canes walkers to support safe walking and prevent falls). In one fall event, Patient 24 did not have on safe footwear (shoes or nonslip socks designed to reduce fall risk), in accordance with the facility's policy and procedures titled "Fall Prevention and Management."

This deficient practice had the potential for Patient 24 to continue sustaining falls, which increased the risk for serious injuries, such as broken bones (fractures, a break of a bone) or head injuries (damage to the skull or brain caused by impact).

3. Provide care in a safe setting for two (2) of 33 sampled patients (Patient 28 and Patient 32). Both patients were assigned to line-of-sight observation (continuous visual monitoring where the patient must always be kept in direct view) for safety. However, one sitter (a staff member assigned to observe patients who need close monitoring)- Certified Nursing Assistant (CNA, a health care professional who provides basic patient care, such as assisting with daily living activities) 2-was assigned to observe both patients at the same time. While providing incontinence care (helping a patient who cannot control urination or bowel movements) for one patient, the sitter was unable to maintain continuous observation of the other patient, in accordance with the facility's policy regarding safety attendant (CNA) use pertaining to continuous visual observation of one designated patient.

This deficient practice had the potential to place Patient 28 and Patient 32 at risk for harm, including falls (unintentional coming to rest on the ground, floor, or other lower level), removal of medical equipment (such as intravenous [IV] lines, a thin catheter that goes in the vein to delivered medication or monitors), or self-injury (when patients harm themselves) during periods without required observation.

4. Ensure one of 33 sampled patients (Patient 33), was physically and emotionally cared for within a safe and comfortable environment, when Patient 33's vocal cries from his (Patient 33) room, were not responded to by responsible staff in a timely manner.

This deficient practice had the potential to result in an unsafe care environment, poor clinical outcomes, and emotional harm for Patient 33.

Findings:

1. During a review of Patient 20's, "ED (Emergency Department, a hospital service that provides immediate medical care for acute [sudden and severe onset] and life-threatening conditions) Triage (process used to prioritize and categorize patients based on the severity of their condition and their need for immediate medical attention)" notes, dated 7/29/2025, the ED triage note indicated Patient 20 presented to the facility's ED at 8:23 p.m. with chief complaint of dizziness and triage assessment also indicated Patient 20 was unsteady on feet and unsure if Patient 20 had a seizure (sudden burst of electrical activity in the brain).

During a concurrent observation and interview on 9/18/2025 at 2:46 p.m. with the Emergency Department Manager (NM 2) and the Manager of Security (MOS), the facility's ED security footage dated 7/30/2025 at 12:58 a.m., was reviewed. Patient 20 was observed sitting in the chair in the ED lobby waiting area and tried to get up. Patient 20 was observed leaning toward the left side, lost balance, and fell to the ground. Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 20 (RN 20) was the only staff present at the time of fall and approached Patient 20 after the fall. RN 20 and Patient 20's family representative was observed helping Patient 20 get back in the chair. MOS stated Patient 20 left the ED lobby about 1:42 a.m.

During a concurrent interview and record review on 9/18/2025 at 3:10 p.m. with NM 2, Patient 20's, "Event flow sheet," dated 7/30/2025, was reviewed. NM 2 stated Patient 20 left AMA (against medical advice, choosing to leave the hospital before the treating physician recommends discharge) and left the signed AMA paper at 1:45 a.m. NM 2 stated Patient 20 should have been assessed for possible injury after the fall. NM 2 also stated a provider should have been informed after the fall.

During the same interview on 9/18/2025 at 3:10 p.m. with NM 2, NM 2 stated the nurse (RN 20) seen in the security footage (on 7/30/2025) could have assessed Patient 20 since it appeared that the RN (RN 20) was talking to Patient 20. However, this cannot be confirmed since there was no documentation made by the RN (RN 20) regarding post fall nursing assessment or physician notification after the fall incident.

During an interview 9/18/2025 at 3:29 p.m. with the Director of Education (DOE), DOE stated there was a potential risk for undiagnosed injury for Patient 20 when Patient 20 did not get evaluated after the fall. The DOE further said, "patient safety was what we want."

During a concurrent interview and record review on 9/19/2025 at 9:36 a.m. with NM 2 and Clinic Educator (CE 2), Patient 20's "ED Triage," note, dated 7/29/2025, was reviewed. NM 2 stated Patient 20 was a risk for fall based on presenting symptoms of dizziness and unsteady gait upon arrival to the ED.

During the same interview on 9/19/2025 at 9:36 a.m. with NM 2 and CE 2, CE 2 confirmed there was no event report generated regarding Patient 20's fall. NM 2 stated it was important to track documentation regarding fall incidents and an event report should have been completed by the nurse. NM 2 stated Patient 20 did not have a fall screening (brief evaluation that identifies individuals at a higher risk of falling) because Patient 20 was still waiting for an ED room and an assigned nurse. NM 2 stated based on Patient 20's presented symptoms in ED such as dizziness and unsteady on feet, Patient 20 was at risk for fall.

During a review of the facility's policy & procedure (P&P) titled, "Fall Prevention and Management," effective date 7/2018, the P&P indicated, "Post Fall Management ...Immediately perform and document complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries ...Monitor patient for any effects of the fall ...Reassess patient as appropriate, including physical and neuro status ...Notify the Licensed Independent Provider immediately at the time of the fall ...Assessment of the patient's condition, patient's explanation of what happened, name and time the Licensed Independent Provider and family (if appropriate) was notified ...Complete an online event report ...Fall data is monitored and tracked for trends and reported through the facility Patient Safety/Quality processes."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," effective date 6/2001, the P&P indicated "Receive care in a safe setting ..."

2. During a review of Patient 24's "History and Physical (H&P, History and Physical)," dated 3/23/2025, the "H&P" indicated, Patient 24 was admitted from a skilled nursing facility (a healthcare facility that provides 24-hour medical and rehabilitation services) after a fall (an unintentional descent of a patient to the ground). The H&P further indicated Patient 24's medical history included alcoholic cirrhosis (a chronic liver disease caused by long-term alcohol use), hypertension (chronic high blood pressure, defined as a systolic blood pressure [top number] of 130 mmHg [a unit of measurement] or higher), diabetes (a chronic condition that affects how the body uses glucose [sugar] for energy), and blindness in the right eye (significant loss of vision not correctable by glasses or surgery).

During a review of Patient 24's medical record (MR, a comprehensive collection of documents that document a patient's health history) titled, "Johns Hopkins Fall Assessment (JHFRAT, tool used to systematically assess a patient's likelihood of falling, as the threshold for high risk is any score greater than 13)" report, dated from 3/23/2025 through 6/6/2025, the report indicated, Patient 24 had a score greater than 13, with scores as high as 34 meeting the criteria for high fall risk.

During a concurrent interview and record review on 9/17/2025 at 10:27 a.m. with the Stroke Program Coordinator (a healthcare leader responsible for the overall management and continuous improvement of a hospital's stroke [a medical condition that occurs when blood flow to the brain is interrupted] program) (SPC) 1, Patient 24's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" report, dated 4/21/2025 through 6/2/2025, was reviewed. The report indicated the following:

-On 4/21/2025 at 8:00 p.m., indicated, "Spoke to (name of provider), made her aware patient (Patient 24) fell, landed on her left side."

- On 4/25/2025 at 12:00 a.m., indicated, "MD notified that patient fell in hallway while ambulating with safety sitter (is a staff member who provides continuous, undivided attention to a single patient to ensure their safety and prevent harm, falls, or harmful actions) beside her."

-On 4/27/2025 at 3:32 p.m., indicated, "Patient (Patient 24) received on the floor in the shower while being helped to get up by staff. Patient assisted back to room."

-On 5/2/2025 at 11:55 p.m., indicated in Nursing Progress Note, "Patient (Patient 24) ambulating with 1:1 sitter, missed a step, knees buckle, fell knees first."

-On 5/11/2025 at 9:20 a.m. indicated, "Patient (Patient 24) fell ambulating to bathroom with sitter. Patient lost balance and fell to the ground and landed on her back and bottom."

-On 5/31/2025 at 8:50 p.m. indicated, "Patient (Patient 24) had unassisted fall to floor claiming to put out cigarette." SPC stated that Patient 24 did not have cigarettes. SPC 1 confirmed that according to documented evidence in Patient 24's medical record, Patient 24 fell six (6) times.

During an interview on 9/19/2025 at 11:36 a.m. with charge nurse (CN) 5, CN 5 stated patients with high fall risk should not ambulate (to walk) without the recommended assistive devices. CN 5 stated if a patient refuses, staff must educate patient and inform the charge nurse. CN 5 said that, at a minimum, patients assessed as having unsteady gait (a person's manner of walking), should ambulate with a gait belt.

During a concurrent interview and record review on 9/19/2025 at 1:53 p.m. with the Director of Medical Surgical Unit (DOM), Patient 24's "Activity and Daily Living (ADL, an individual's daily care activity including bathing, dressing, and getting in and out of bed or a chair, and walking)" record, dated from 4/21/2025 through 5/3/2025, was reviewed. The ADL record indicated the following:

- On 4/21/2025 Patient 24 ambulated 20 feet without an assistive device.
-On 4/25/2025 Patient 24 ambulated 51-149 feet without an assistive device.
-On 4/27/2025 Patient 24 ambulated 11-20 feet without an assistive device.
-On 5/3/2025 Patient 24 ambulated 150-299 feet without an assistive device.
-On 5/31/2025 Patient 24 ambulated 51-149 feet without an assistive device.

During the same interview on 9/19/2025 at 1:53 p.m. with the DOM, the DOM stated Patient 24 was impulsive (actions that are taken without considering the consequences or potential risks) and did not want to use the recommended assistive device; however, staff were responsible for ensuring the patient used it safely and for documenting education, provider notification, and escalation if the patient refused. DOM confirmed there was no documented evidence that staff used a gait belt on Patient 24 during ambulation.

During a concurrent interview and record review on 9/17/2025 at 2:20 p.m. with Director of Physical Therapy (DIR) 5, Patient 24's "Physical Therapy Daily Progress Note," dated 4/21/2025, was reviewed. DIR 5 stated the note indicated Patient 24 required "moderate assistance for ambulation (need staff support to walk safely). The therapist recommended a front-wheeled walker (a walking aid with wheels to improve stability) and use of a gait belt (a belt fastened around a patient's waist to provide a secure grip point for caregivers assisting with movement) that helps "break the fall" if the patient loses balance.

During a concurrent interview and record review on 9/19/2025 at 2:30 p.m. with the Director of Medical Surgical Unit (DOM), Patient 24's, "Mobility Assessment Tool (BMAT)" record, dated 4/20/2025 through 5/20/2025, was reviewed. The BMAT (a standardized test used to determine safe mobility and needed equipment for walking) indicated, from 4/20/2025 through 5/20/2025, Patient 24's score was a 3, which required the use of an assistive device such as a walker. DOM confirmed that Patient 24 required the use of an assistive device for ambulation and was at high fall risk due to multiple falls.

During the same interview on 9/19/2025 at 2:30 p.m. with the DOM, Patient 24's internal incident report (documented record of an unexpected or unplanned event that affects a patient, visitor, or staff member), dated 4/24/2025, was reviewed. DOM confirmed Patient 24 wore her (Patient 24) own mismatched slippers when she (Patient 24) tripped and fell while walking with a sitter. DOM stated although patients may refuse facility-provided footwear, nursing staff must document that education was provided and escalate concerns through the chain of command. DOM confirmed that this was not done.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2024, the P&P indicated, "The basic rights of human beings for independence of expression, decision, action and concern for personal dignity in human relationships are all of great importance. Thus, the prime responsibility is to ensure that patient's rights are preserved ... (Name of the facility) has define patient's rights as the following: Patient's Receive care in a safe setting."

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Management," dated 6/2022, the P&P indicated, "Review Bedside Mobility Assessment Level (BMAT) with consideration of appropriate mobility equipment recommendations when patient identified to be at risk for fall. Document fall interventions on the appropriate fall risk assessment tool or fall injury screen section ...Document education/instructions given to the patient/family ...for Fall Risk Score greater than 14, implement basic safety measures: Provide fall prevention education to patient and family in particular to call for assistance when getting out of bed ( e.g., wearing well-fitting, flat footwear with nonskid soles) Provide yellow slippers or non-skid footwear ...Consider hip protectors/helmet/gait belt ..."

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "The registered nurse should screen patients for falls, mobility ...Precautions/interventions should be implemented according to the results of the screenings. The following Screenings should be completed: Fall Risk, Patient Mobility/Safe Lift ...The registered nurse analyzes assessment data to determine actual or potential nursing diagnoses, patient problems and issues. The registered nurse: Identifies actual or potential risks to the patient's health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural or environmental circumstances ...The registered nurse employs strategies to promote health and a safe environment."

During a review of the facility's policy and procedure (P&P) titled, "Chain of Command (COC): Communication of Patient Care Concerns," dated 2/28/2028, the P&P indicated: "Patient care should not be delayed ...An effective Chain of Command clearly defines a line of authority and responsibility through which concerns can be escalated ...All hospital and medical staff should take whatever action is necessary and appropriate to ensure that patients receive quality care. Communication regarding patient care concerns should be timely, complete, and accurate and follow the Chain of Command to achieve resolution."

3.a. During a concurrent observation and interview on 9/16/2025 at 2:15 p.m. with Certified Nursing Assistant (CNA) 2, in the presence of the Director for Medical Surgical Unit (DOM), in Patient 28 and Patient 32's room (shared room), CNA 2 was sitting in the back of the room. Patient 32 was sleeping. Patient 28 did not respond when greeted. CNA 2 stated Patient 28 was not oriented (confused and unable to recognize people, places, or time). CNA 2 also stated both patients were unable to use the call bell (a device that allows patients to alert staff when they need help) and required total assistance with incontinence care. CNA 2 demonstrated that when cleaning Patient 28, he (CNA 2) would leave the privacy curtain slightly open so he could turn around and observe Patient 32 at the same time. CNA 2 confirmed that he (CNA 2) could not immediately intervene if Patient 32's safety was at risk while he was assisting Patient 28.

During a review of Patient 28's "History and Physical (H&P, comprehensive document that includes a patient's medical history and findings on admission)," dated 9/8/2025, the "H&P" indicated, Patient 28 was admitted to the facility for lethargy (severe drowsiness of lack of energy), confusion (inability to think clearly or understand surroundings), hypotension (low blood pressure), generalized weakness (overall loss of strength in the body).

During a review of Patient 28's "Nursing Progress Note," dated 9/8/2025, the note indicated, "Patient refuses telemetry monitoring (a system that continuously tracks heart activity using small sticky patches called electrodes, which are placed on the skin), patient self-removed IV (intravenous line, a thin tube inserted into a vein to deliver medication), patient is confused trying to get out of bed."

During a review of Patient 28's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" record, dated 9/8/2025, the record indicated, Patient 28 was "Getting out of bed. Combative (aggressive and physically resisting care). Swinging arms at nurse while report given. Pulling IV out. Charge nurse notified for safety sitter (one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others)."

During a review of Patient 28's "Observation/Intervention," record, dated from 9/16/2025, the record indicated, the "Reason for Observation: 1:1 Observation (one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others) and Safety intervention by staff: Direct observation (a healthcare worker who provides continuous, direct observation and supervision of a single patient to ensure their safety)."

During a concurrent interview and record review on 9/16/2025 at 2:30 p.m. with the DOM, the "Nursing Assignment Schedule," dated 9/16/2025, was reviewed. The Nursing Assignment Schedule indicated CNA 2 was scheduled as the 1:1 sitter for both Patient 28 and Patient 32. DOM stated both patients (Patient 28 and Patient 32) were placed on a line-of-sight observation (requires a designated staff member to maintain constant, unobstructed visual contact with a patient to prevent harm to themselves or others) for safety risk. DOM confirmed that while changing an incontinent (involuntary loss of urine or stool) patient, the sitter may not be able to immediately intervene if the other patient's safety was at risk, but other staff could be called to assist. DOM stated placing patients on one-to-one observation (safety monitoring requiring one dedicated staff member per patient) was based on the nursing assessment and did not require a provider order.

During an interview on 9/19/2025 at 11:36 a.m. with the Nurse Manager (NM) 6, NM 6 stated it was not safe to assign one sitter to two patients on a line-of-sight observation, because line-of-sight required continuous, direct visual monitoring. NM 6 stated patients on a line-of-sight observation may be confused, at high risk for falls, or at risk for self-harm, and if the sitter was occupied with one patient, they (the staff) could not immediately intervene for the other patient.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2024, the P&P indicated, "The basic rights of human beings for independence of expression, decision, action and concern for personal dignity in human relationships are all of great importance. Thus, the prime responsibility is to ensure that patient's rights are preserved ... (Name of the facility) has define patient's rights as the following: Patient's Receive care in a safe setting."

During a review of the facility's policy and procedure (P&P) titled, "Safety Attendant for Patients at Risk of Harm to Self or Others on a Unit other than behavioral health unit," dated 10/2021, the P&P indicated, "The implementation of a Safety Attendant will be used to provide a safe environment with interventions to allow for close monitoring and observation of the environment and behaviors of the patient. One-to-one Observation - means one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others. This requires continuous visual observation of one designated patient."

3.b. During a concurrent observation and interview on 9/16/2025 at 2:15 p.m. with CNA 2, in the presence of the Director for Medical Surgical Unit (DOM), in Patient 28 and Patient 32's room, CNA 2 was observed sitting in the back of the room. Patient 32 was sleeping. Patient 28 did not respond when greeted. CNA 2 stated Patient 28 was not oriented (confused and unable to recognize people, places, or time). CNA 2 also stated both patients were unable to use the call bell (a device that allows patients to alert staff when they need help) and required total assistance with incontinence care. CNA 2 demonstrated that when cleaning Patient 28, he (CNA 2) would leave the privacy curtain slightly open so he (CNA 2) could turn around and observe Patient 32 at the same time. CNA 2 confirmed that he (CNA 2) could not immediately intervene if Patient 32's safety was at risk while he (CNA 2) was assisting Patient 28.

During a review of Patient 32's "History and Physical (H&P)," dated 7/28/2025, the "H&P" indicated Patient 32 was admitted to the facility after falling 10-15 feet from a tree. The H&P further indicated Patient 32 sustained a large laceration (deep cut or tear in the skin) to the left arm and left knee region.

During a review of Patient 32's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" record, dated 9/15/2025, the record indicated, "Patient (Patient 32) crying in bed for his dad," and "Patient (Patient 32) yelling in the room."

During a review of Patient 32's "Activity of Daily Living (ADL, basic self-care tasks such as bathing, dressing, eating, and walking)" record, dated 9/16/2025, the record indicated Patient 32 required total assistance with ADLs (a person is completely dependent on another person to perform all aspects of a basic personal care task, such as feeding, bathing, or dressing, because they are unable to participate in the activity at all).

During a review of Patient 32's "Observation/Intervention," record, dated 9/16/2025, the record indicated, "Reason for Observation: Safety. Safety Intervention by Safety Attendant: Direct Observation (one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others) and Safety intervention by staff: Direct observation (a healthcare worker who provides continuous, direct observation and supervision of a single patient to ensure their safety)."

During a concurrent interview and record review on 9/16/2025 at 2:30 p.m. with the DOM, the "Nursing Assignment Schedule," dated 9/16/2025, was reviewed. The Nursing Assignment schedule indicated CNA 2 was scheduled as the 1:1 sitter for both Patients (Patient 28 and Patient 32). DOM stated both patients were placed on a line-of-sight observation (requires a designated staff member to maintain constant, unobstructed visual contact with a patient to prevent harm to themselves or others) for safety risk. DOM confirmed that while changing an incontinent patient, the sitter may not be able to immediately intervene if the other patient's safety was at risk, but other staff could be called to assist. DOM stated placing patients on one-to-one observation (safety monitoring requiring one dedicated staff member per patient) was based on the nursing assessment and did not require a provider order.

During an interview on 9/19/2025 at 11:36 a.m. with the Nurse Manager (NM) 6, NM 6 stated it was not safe to assign one sitter to two patients on a line-of-sight observation, because line-of-sight required continuous, direct visual monitoring. NM 6 stated patients on a line-of-sight observation may be confused, at high risk for falls, or at risk for self-harm, and if the sitter was occupied with one patient, they (the staff) could not immediately intervene for the other.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2024, the P&P indicated, "The basic rights of human beings for independence of expression, decision, action and concern for personal dignity in human relationships are all of great importance. Thus, the prime responsibility is to ensure that patient's rights are preserved ...(Name of the facility) has define patient's rights as the following: Patient's Receive care in a safe setting."

During a review of the facility's policy and procedure (P&P) titled, "Safety Attendant for Patients at Risk of Harm to Self or Others on a Unit other than behavioral health unit," dated 10/2021, the P&P indicated, "The implementation of a Safety Attendant will be used to provide a safe environment with interventions to allow for close monitoring and observation of the environment and behaviors of the patient. One-to-one Observation - means one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others. This requires continuous visual observation of one designated patient."

4. During a review of Patient 33's "History and Physical (H&P)," dated 8/20/2025, the "H&P" indicated the facility admitted Patient 33 on 8/20/2025, after Patient 33 presented to the facility's Emergency Department (ED) with shortness of breath (SOB). Patient 33 had a medical history of tobacco, methamphetamine (a powerful stimulant that can lead to muscle injury), and fentanyl (a powerful drug to relieve pain) use.

During an observation on 9/16/2025 at 2:00 p.m., while touring the 7th floor unit hallways, loud moaning and vocal sounds (no clear verbalizations) were heard coming from inside Patient 33's room. As Patient 33's room was approached from the unit hallway, a "Fall Risk" sign was noted on Patient 33's room doorway and no staff were observed to be present nor attending to Patient 33.

During an observation on 9/16/2025 at 2:14 p.m., from just outside of Patient 33's room, yelling out continued to be heard from inside Patient 33's room. Patient 33's yelling was audible from the unit hallway and the nurse station nearby - no staff were present nor were any staff observed to be responding to Patient 33's room. Upon entering Patient 33's room, Patient 33 was observed to be on his (Patient 33) bed, facing forward but slumped down in his bed mattress, leaning towards his left-side and towards the bed side-rails on his left-side, with the head of bed (HOB) at an approximate 45-degree angle and a concave-shaped (shaped like a bowl) mattress in-use. Patient 33 continued to yell out loudly in the presence of the surveyors as they entered his room, indicating apparent discomfort with his bodily position on his bed. At least five minutes had passed from 2:14 p.m. through 2:19 p.m., and there was still no staff response to Patient 33's yelling out from inside his (Patient 33) room.

During a concurrent observation and interview on 9/16/2025 at 2:19 p.m., with Patient 33 at his bedside area, Patient 33 continued to yell out and appear to be in discomfort. Throughout the encounter with Patient 33, the following events were observed:
-Patient 33 was unable to demonstrate the ability to activate his call light (a communication device in healthcare settings, typically a corded button or pendant, that allows patients or residents to signal staff for assistance).
-Upon observing Patient 33's inability to activate his call light, Patient 33 was asked if he would like assistance from staff, and Patient 33 responded, "Yes."
-The surveyor then stepped outside of Patient 33's room and verbally requested facility staff to assist Patient 33 in his room, and only then did staff respond to Patient 33's room and bedside to attend to Patient 33.
-After Patient 33 was assisted and repositioned by staff in privacy, Patient 33's yelling out loud had nearly ceased.
-Upon presenting to Patient 33's bedside after staff provided assistance and repositioning for Patient 33, Patient 33 no longer appeared to be in distress or discomfort and was no longer yelling out loud.

During an observation on 9/16/2025 at 2:21 p.m. with Charge Nurse (CN) 1 at Patient 33's bedside area, Patient 33 was still unable to independently access and/or activate his call light, even upon multiple requests. CN 1 physically demonstrated for Patient 33 how to use his special "hand squeeze" call light (an alternative call light system that is different from the common button-activated call light system), but Patient 33 was still unable to demonstrate his ability to independently activate his call light.

During an interview on 9/16/2025 at 2:25 p.m. with Patient 33, Patient 33 stated he would "holler" if he needed help from staff. Patient 33 presented with confusion and was unable to participate in a meaningful conversation beyond "yes" and "no" responses to surveyors' questions.

During an interview on 9/16/2025 at 2:28 p.m. with Registered Nurse (RN) 2, RN 2 stated that Patient 33 was confused and "not all there."

During an interview on 9/16/2025 at 2:45 p.m. with RN 2, RN 2 stated that Patient 33 was admitted for congested heart failure (CHF - when the heart becomes weak and does not pump blood through the body normally) and was only oriented to his name. RN 2 stated, Patient 33 had weakness on the right side of his body, and Patie

Based on interview and record review, the facility failed to ensure its nursing staff developed care plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided), in accordance with the facility's policy regarding plan of care for restraint use, for two (2) of 33 sampled patients (Patient 14 and 15), when violent behavioral (behavior placing patient or others in imminent danger) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) using hard locking restraints (a restraint device requires a key to unlock) applied to four (4) extremities (both wrist and both ankles), were used on Patient 14 on 6/14/2025 and on Patient 15 on 8/22/2025, in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential for inadequate monitoring and evaluation of Patient 14's and Patient 15's care progress and goals while being restrained, which may potentially lead to prolonged and unnecessary restraint use and may increase the risk of restraint use complications such as skin breakdown (damage to the skin due to prolonged pressure or friction [the force that opposes motion] on the skin) and impaired circulation (blood flow).

Findings:

During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to facility's ED for danger to self with chief complaint of possible psychiatric (relating to mental illness or its treatment) issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) was placed in the chart at 10:36 a.m. [indicating] to place [apply] the restraint."

During a review of Patient 14's physician order, dated 6/14/2025, the physician order indicated physician (MD 7) ordered violent/self-destructive restraint use in which Patient 14 had hard locking restraints (a restraint device requires a key to unlock) applied to all four (4) extremities (both wrists and both ankles) for violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During a review of Patient 15's "ED physician notes," dated 8/22/2025, the ED physician notes indicated Patient 15 was brought to the facility's ED for bizarre (very strange and unusual) behavior and altered mental status (AMS, disruption in how the brain works that causes a change in behavior).

During a review of Patient 15's physician order, dated 8/22/2025, the order indicated physician (MD 8) ordered violent/self-destructive restraint allowing Patient 15 to be placed on hard locking restraints applied to all four (4) extremities for violent/aggressive behavior.

During a review of Patient 15's "Restraint Flowsheet," dated 8/22/2025, the restraint flowsheet indicated Patient 15's restraint started on 8/22/2025 at 12:40 p.m. and removed at 1:45 p.m. (1 hour and 5 minutes).

During an interview on 9/18/2025 at 2:30 p.m. with the Director (DED) of Emergency Department, DED stated it was not an ED nursing staff practice to develop any care plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for patients in the ED. DED stated there were no care plans developed for Patient 14 and Patient 15 during the ED stay.

During a concurrent interview and record review on 9/18/2025 at 2:32 p.m. with DED, the Code of Federal Regulation Title 42 (federal regulations), "Condition of Participation: Patient's Rights," dated 2/2020, was reviewed. The federal regulations indicated, "§482.13(e)(4) - The use of restraint or seclusion must be -- (i) in accordance with a written modification to the patient's plan of care." DED stated she (DED) was not aware of such requirement.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Documentation: A. The Plan of Care reflects restraints."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department Nursing Standards of Practice," dated 8/2024, the P&P indicated, "Standard IV (Roman numeral system meaning number four [4]) - Planning: The emergency registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes ... 2. Prioritize elements of the plan based on the assessment of the patient's safety needs to include benefits, risks and alternatives ... Standard V (Roman numeral system meaning number five [5]) - Implementation: The emergency registered nurse implements the identified plan ... 4. Documents implementation and any modifications, including changes or omissions, of the identified plan ... Standard VI (Roman numeral system meaning number six [6]) - Evaluation: The emergency registered nurse will evaluate the progress toward attainment of outcomes and goals ... 2. Collaborates and shares evaluation data and conclusions with the patient and other stakeholders in accordance with federal and state regulations."

Based on interview and record review, the facility failed to ensure nursing staff obtained renewal order, every 4 hours, for violent or self-destructive behavior (behavior placing patient or others in imminent danger) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 33 sampled patients (Patient 14), when Patient 14 was placed on hard locking 4-point restraints (a restraint device requires a key to unlock to all four (4) extremities [both wrists and both ankles]) on 6/14/2025 from 2:30 p.m. to 7:30 p.m.

This deficient practice resulted in Patient 14 being restrained without a physician order for 5 hours (from 2:30 p.m. to 7:30 p.m. on 6/14/2025) and could lead to possible unnecessary restraints use, which could result to complications such as psychosocial trauma for Patient 14.

Findings:

During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to facility's ED for danger to self with chief complaint of possible psychiatric (relating to mental illness or its treatment) issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints was placed in the chart at 10:36 a.m. to place [apply] the restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)."

During a review of Patient 14's physician order, dated 6/14/2025, the order indicated physician (MD 7) ordered violent/self-destructive restraint and to place Patient 14 on hard locking restraints (a restraint device requires a key to unlock) to all four (4) extremities (both wrists and both ankles) for violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During a concurrent interview and record review on 9/19/2025 at 11:32 a.m. with the Director of Emergency Department, Patient 14's physician orders for restraints, dated on 6/14/2025, were reviewed. The physician orders indicated violent behavioral restraint was ordered on 6/14/2025 at 10:36 a.m. with a time limit of 4 hours, then the violent behavioral order was renewed at 7:30 p.m. DED stated the following: two (2) renewal orders were missing (at 2:30 p.m. and 6:30 p.m.) Patient 14 was restrained without a valid physician order from 2:30 p.m. to 7:30 p.m. (5 hours). Physician renewal order was needed every four (4) hours for violent behavioral restraint continuation to see if there was a continued need for restraints or if patient's restraint could be removed.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Table 1: Restraint Orders/Documentation/Monitoring ... Violent or self-destructive behavior - adult 18 and older ... renewal orders: every 4 hours up to 24 hours."

Based on interview and record review, the facility failed to ensure a physician (MD 7) performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after 24 hours, prior to extending a violent behavior (behavior placing patient or others in imminent danger) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order, for one of 33 sampled patients (Patient 14), in accordance with facility's policy regarding restraint use, when Patient 14 was placed on hard locking 4-point restraints (a restraint device requires a key to unlock to all four (4) extremities [both wrists and both ankles]) from 6/14/2025 at 10:36 a.m. to 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes), in the facility's Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in prolonged and unnecessary restraint use and may increase the risk of restraint use complications such as skin breakdown (damage to the skin due to prolonged pressure or friction [the force that opposes motion] on the skin) and impaired circulation (blood flow).

Findings:

During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to the facility's ED for danger to self with chief complaint of possible psychiatric issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints was (relating to mental illness or its treatment) placed in the chart at 10:36 a.m. to place [apply] the restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)."

During a review of Patient 14's physician order, dated 6/14/2025, the order indicated physician (MD 7) ordered violent/self-destructive restraint and to place Patient 14 on hard locking restraints (a restraint device requires a key to unlock) to all four (4) extremities (both wrists and both ankles) for violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During an interview on 9/18/2025 at 2:43 p.m. with the Medical Director (MDED) of ED, MDED stated the following: all ED providers should know they (ED providers) needed to perform face-to-face assessment when a patient was placed on violent behavioral restraint. The ED provider would see and speak with the patient to assess if the restraint was still necessary or not. The goal was to release the restraint as early as possible.

During a concurrent interview and record review on 9/19/2025 at 11:32 a.m. with the Director (DED) of Emergency Department, Patient 14's Physician orders dated from 6/14/2025 to 6/15/2025, were reviewed. The physician orders indicated the first violent behavioral order was placed on 6/14/2025 at 10:26 a.m. The physician orders also indicated the violent behavioral restraint was continued and renewed the next day on 6/15/2025 at 7:22 a.m. and 11:43 a.m. by MD 7.

During a concurrent interview and record review on 9/19/2025 at 11:44 a.m. with the DED, Patient 14's "ED Note Addendum," dated 6/15/2025 at 10:26 a.m., was reviewed. The "ED Note Addendum" indicated, "Received sign-out, patient (Patient 14) still requiring agitation PRN (as needed) meds (medication) and restraints ... no acute events, just agitation (feeling of irritability or severe restlessness)." DED stated there was no physician assessment in the "ED Note Addendum." DED stated there was no face-to-face assessment for Patient 14 prior to renewing the violent behavioral restraint after being placed on restraints for 24 hours. DED further stated physician reassessment was needed to determine if Patient 14 still met the criteria for restraint use.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Criteria or Indications for Restraints ... B. Violent or self-destructive behavior: the use of restraint may be necessary to protect the patient from injury to self or others, or property because of a primary behavioral health or an emotional disorder such as a result of substance use disorder or withdrawal from non-prescription drugs ... Medical Orders for Restraint. For the purpose of this policy only a physician or licensed practitioner may order restraint ... The note from the prescribing provider should describe the findings that support continued use of restraint ... Table 1: Restraint Orders/Documentation/Monitoring ... Violent or self-destructive behavior - Adult 18 or older ... 2. Face-to-face assessment and order by MD or practitioner (nurse practitioner or physician assistant) within one (1) hour. If the patient remains in restraint 24 hours after the original order the ordering provider must conduct another face-to-face assessment before entering a new order for a behavioral restraint. Note: greater than 24 hours is considered extreme with potential for serious harm."

Based on interview and record review, the facility failed to ensure proper skin check and circulations (blood flow) check were performed for two (2) of 33 sampled patients (Patients 14 and 16) in accordance with the facility's policy and procedure regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use when:

1. Nursing staff did not perform every fifteen (15) minutes skin check for Patient 14 on 6/14/2025 while Patient 14 was on violent behavioral (behavior placing patient or others in imminent danger) restraints

2. Nursing staff did not perform every 2 hours skin check for Patient 16 on 8/18/2025 from 8 a.m. to 8 p.m. while Patient 16 was on non-violent restraint

This deficient practice had the potential to cause injury such as skin tear, swelling and strangulation (occurs when a device, like a vest restraint or harness, applies pressure to a person's neck or body, obstructing their airway or blood flow to the brain, leading to asphyxia [when the body does not receive enough oxygen] or unconsciousness) for Patient 14 and Patient 16 while being restrained.

Findings:

1. During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to the facility's ED for danger to self with chief complaint of possible psychiatric (relating to mental illness or its treatment) issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) was placed in the chart at 10:36 a.m. to place [apply] the restraint."

During a review of Patient 14's physician order, dated 6/14/2025, the order indicated physician (MD 7) ordered violent/self-destructive restraint and place Patient 14 on hard locking restraints (a restraint device requires a key to unlock) applied to all four (4) extremities (both wrists and both ankles) for violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During an interview on 9/19/2025 at 11:22 a.m. with the Director (DED) of Emergency Department, DED stated skin assessment and monitoring should be done every fifteen (15) minutes while a patient was on violent behavioral restraint to make sure the restraint was not too tight to cause skin tear, swelling or affecting circulation (blood flow) under the restraint device. DED stated, "you do not want patient on restraints end up with injury."

During a concurrent interview and record review on 9/19/2025 at 11:25 a.m. with the Director of Emergency Department (DED), Patient 14's restraint flowsheet, dated on 6/14/2025, was reviewed. The restraint flowsheet indicated for the period from10:45 a.m. to 7:45 p.m. on 6/14/2025, restraint monitoring check was done at 10:45 a.m., 1:30 p.m., 1:45 p.m., 3:50 p.m. 5:30 p.m., 7 p.m. and 7:45 p.m. DED stated the assessment for Patient 14 was not done every 15 minutes.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Table 1: Restraint Orders/Documentation/Monitoring ... Violent or self-destructive behavior - adult 18 or older ... RN will document in the violent/self-destructive reassessment approximately every 15 minutes as specified in the HER table 4 ... Table 4: visual/safety observation, skin..."

2. During a review of Patient 16's "History and Physical (H&P)," dated 7/24/2025, the H&P indicated, Patient 16 was admitted to the facility on 7/24/2025 with diagnoses including but not limited to acute (new onset) respiratory failure (a serious condition that makes it difficult to breathe on your own) and pneumonia (lung infection).

During a review of Patient 16's physician order, dated 8/18/2025, the physician order indicated Patient 16 was placed on non-violent/non-destructive restraint with bilateral (both) mittens to both hands due to pulling lines, tubes or dressings.

During a concurrent interview and record review on 9/17/2025 at 3:23 p.m. with the Director (DOT) of Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring), Patient 16's restraint flowsheet, dated 8/18/2025, was reviewed. The restraint flowsheet indicated restraint skin check and monitoring was done on 8/18/2025 at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 8 a.m., 12 p.m., 4 p.m., 8 p.m. and 10 p.m. DOT stated the following: the skin monitoring was done incorrectly from 8 a.m. to 8 p.m. (12 hours). The nursing staff should have performed skin monitoring to check for skin integrity (the overall health of the skin as a complete, sound, and undamaged barrier) and circulation every two (2) hours instead of every four (4) hours from 8 a.m. to 8 p.m. The purpose of skin check was to make sure the restraint was not causing any skin breakdown or strangulation (occurs when a device, like a vest restraint or harness, applies pressure to a person's neck or body, obstructing their airway or blood flow to the brain, leading to asphyxia [when the body does not receive enough oxygen] or unconsciousness) for patient.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Table 1: Restraint Orders/Documentation/Monitoring ... Non-violent or non-self-destructive ... Patient monitoring ... adult & youth (age 9 -17) Staff (RN, LVN, CNA or EMT) will document the non-violent restraint flowsheet approximately every 2 hours as specified in the HER Table 3 ... Table 3: Restraint: Monitor restrained patient for skin, circulation of immobilized limb, level of consciousness ..."

Based on interview and record review, the facility failed to ensure its physicians conducted face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour, in accordance with the facility's policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, for two (2) of 33 sampled patients (Patient 14 and Patient 15), when violent behavioral (behavior placing patient or others in imminent danger) restraints with hard locking restraints (a restraint device requires a key to unlock) on four (4) extremities (both wrist and both ankles) were applied on Patient 14 on 6/14/2025 and on Patient 15 on 8/22/2025.

This deficient practice resulted in Patient 14 and Patient 15 not receiving physician assessment after restraint application to evaluate their (Patient 14 and Patient 15) responses to restraints and had the potential to result in prolonged and unnecessary restraints use.

Findings:

1. During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to the facility's ED for danger to self with chief complaint of possible psychiatric (relating to mental illness or its treatment) issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints was placed in the chart at 10:36 a.m. to place the restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)."

During a review of Patient 14's physician order, dated 6/14/2025, the order indicated physician (MD 7) ordered violent/self-destructive restraint and place hard locking restraints (a restraint device requires a key to unlock) on all four (4) extremities (both wrists and both ankles) of Patient 14 due to violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During a concurrent interview and record review on 9/18/2025 at 2:23 p.m. with the Director (DED) of Emergency Department (ED), Patient 14's "ED physician notes," dated 6/14/2025, was reviewed. The "ED physician notes" indicated, "Reexamination/Reevaluation - 1032 (10:32 a.m.): notified patient noncooperative, masturbating in the room. 1036 (10:36 a.m.): restraints placed, code gray (hospital security code meaning a combative person is on the premises requiring additional staff to assist and de-escalate the situation). 1044 (10:44 a.m.): Geodon (medication to treat acute (new onset) agitation [a state of severe excitement and restlessness]) given." DED stated there was no face-to-face assessment documented after Patient 14 was placed on violent behavioral restraint (at 10:36 a.m.).

During an interview on 9/18/2025 at 2:43 p.m. with the Medical Director (MDED) of ED, MDED stated the following: all ED providers should know they (ED providers) needed to perform face-to-face assessment when a patient was placed on violent behavioral restraint. The ED provider would see and speak with the patient to assess if the restraint was still necessary or not. The goal was to release restraint as early as possible. The face-to-face assessment should be documented in the ED physician notes.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Initiation of Restraints ... Violent or self-destructive behavior restraint ... the physician or licensed practitioner must conduct and document a face-to-face assessment within one (1) hour of initiation of the restraints for violent or self-destructive behavior. This evaluation shall include: A. The patient's immediate situation; B. The patient's reaction to the intervention; C. The patient's medical and behavioral condition; and D. The need to continue or terminate the restraint."

2. During a review of Patient 15's "ED physician notes," dated 8/22/2025, the ED physician notes indicated Patient 15 was brought to the facility's ED for bizarre (very strange and unusual) behavior and altered mental status (AMS, disruption in how the brain works that causes a change in behavior).

During a review of Patient 15's physician order dated 8/22/2025, physician (MD 8) ordered violent/ self-destructive restraint and to place Patient 15 on hard locking restraints applied to all four (4) extremities for violent/aggressive behavior.

During a review of Patient 15's "Restraint Flowsheet," dated 8/22/2025, the "Restraint Flowsheet" indicated Patient 15's restraint started on 8/22/2025 at 12:40 p.m. and removed at 1:45 p.m. (1 hour and 5 minutes).

During a concurrent interview and record review on 9/18/2025 at 2:15 p.m. with the Director (DED) of Emergency Department (ED), Patient 15's "Restraint Flowsheet," dated 8/22/2025, was reviewed. The "Restraint Flowsheet" indicated, RN 19 performed face-to-face assessment for Patient 15 on 8/22/2025 at 12:40 p.m. DED stated face-to-face assessment could only be performed by a provider not by a RN.

During a concurrent interview and record review on 9/18/2025 at 2:16 p.m. with DED, Patient 15's "ED physician notes," dated 8/22/2025, was reviewed. The "ED physician notes" indicated, a reassessment was done noting Patient 15's vital signs were stable and discharged in police custody. DED stated it was unknown what time the reassessment was performed.

During an interview on 9/18/2025 at 2:43 p.m. with the Medical Director (MDED) of ED, MDED stated the following: all ED providers should know they (ED providers) needed to perform face-to-face assessment when a patient was placed on violent behavioral restraint. The ED provider would see and speak with the patient to assess if the restraint was still necessary or not. The goal was to release restraint as early as possible.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Initiation of Restraints ... Violent or self-destructive behavior restraint ... the physician or licensed practitioner must conduct and document a face-to-face assessment within one (1) hour of initiation of the restraints for violent or self-destructive behavior. This evaluation shall include: A. The patient's immediate situation; B. The patient's reaction to the intervention; C. The patient's medical and behavioral condition; and D. The need to continue or terminate the restraint."

Based on interview and record review, the facility failed to ensure its physician documented face-to-face assessment, within an hour, for two (2) of 33 sampled patients (Patient 14 and Patient 15), in accordance with the facility's policy regarding restraints use, when violent behavioral (behavior placing patient or others in imminent danger) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) with hard locking restraints (a restraint device requires a key to unlock) applied to four (4) extremities (both wrist and both ankles), were used on Patient 14 on 6/14/2025 and Patient 15 on 8/22/2025.

This deficient practice regarding the lack of documented physician assessment or a clear record of interventions done )example: face to face assessment), had the potential to negatively impact the ability of healthcare staff to make informed decisions, by not having the necessary information, which may lead to inappropriate treatment such as unnecessary restraints use and other complications related to the use of restraints.

Findings:

1. During a review of Patient 14's "ED physician notes (medical notes completed by Emergency Department [ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated 6/14/2025, the ED physician notes indicated Patient 14 was brought to the facility's ED for danger to self with chief complaint of possible psychiatric (relating to mental illness or its treatment) issue. The ED physician notes also indicated, "Patient (Patient 14) engaged in verbally and physically threatening behavior to the ED staff ... An order for physical restraints was placed in the chart at 10:36 a.m. to place the restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)."

During a review of Patient 14's physician order, dated 6/14/2025, physician (MD 7) ordered violent/self-destructive restraint and to place Patient 14 on hard locking restraints (a restraint device requires a key to unlock) applied to all four (4) extremities (both wrists and both ankles) for violent/aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior.

During a review of Patient 14's "Restraint Flowsheet (restraint flowsheet, documentation of nursing assessment and monitoring while patient was on restraint)," dated from 6/14/2025 to 6/15/2025, the restraint flowsheet indicated Patient 14's restraints started on 6/14/2025 at 10:36 a.m. and was removed on 6/15/2025 at 12:15 p.m. (25 hours and 39 minutes).

During a concurrent interview and record review on 9/18/2025 at 2:23 p.m. with the Director (DED) of Emergency Department (ED), Patient 14's "ED physician notes," dated 6/14/2025, was reviewed. The "ED physician notes" indicated, "Reexamination/Reevaluation - 1032 (10:32 a.m.): notified patient noncooperative, masturbating in the room. 1036 (10:36 a.m.): restraints placed, code gray (hospital security code meaning a combative person is on the premises requiring additional staff to assist and de-escalate the situation). 1044 (10:44 a.m.): Geodon (medication to treat acute (new onset) agitation [a state of severe excitement and restlessness]) given." DED stated there was no face-to-face assessment documented by the physician, after Patient 14 was placed on violent behavioral restraint (at 10:36 a.m.).

During an interview on 9/18/2025 at 2:43 p.m. with the Medical Director (MDED) of ED, MDED stated the following: all ED providers should know they (ED providers) needed to perform face-to-face assessment when a patient was placed on violent behavioral restraint. The ED provider would see and speak with the patient to assess if the restraint was still necessary or not. The goal was to release the restraints as early as possible. The face-to-face assessment should be documented in the ED physician notes.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Initiation of Restraints ... Violent or self-destructive behavior restraint ... the physician or licensed practitioner must conduct and document a face-to-face assessment within one (1) hour of initiation of the restraints for violent or self-destructive behavior. This evaluation shall include: A. The patient's immediate situation; B. The patient's reaction to the intervention; C. The patient's medical and behavioral condition; and D. The need to continue or terminate the restraint."

2. During a review of Patient 15's "ED physician notes," dated 8/22/2025, the ED physician notes indicated Patient 15 was brought to the facility's ED for bizarre (very strange and unusual) behavior and altered mental status (AMS, disruption in how the brain works that causes a change in behavior).

During a review of Patient 15's physician order, dated 8/22/2025, physician (MD 8) ordered violent/ self-destructive restraint to place Patient 15 on hard locking restraints applied to all four (4) extremities for violent/aggressive behavior.

During a review of Patient 15's "Restraint Flowsheet," dated 8/22/2025, the "Restraint Flowsheet" indicated Patient 15's restraints started on 8/22/2025 at 12:40 p.m. and removed at 1:45 p.m. (1 hour and 5 minutes).

During a concurrent interview and record review on 9/18/2025 at 2:15 p.m. with the Director (DED) of Emergency Department (ED), Patient 15's "Restraint Flowsheet," dated 8/22/2025, was reviewed. The "Restraint Flowsheet" indicated, RN 19 performed face-to-face assessment for Patient 15 on 8/22/2025 at 12:40 p.m. DED stated face-to-face assessment could only be performed by a provider not by a RN.

During a concurrent interview and record review on 9/18/2025 at 2:16 p.m. with DED, Patient 15's "ED physician notes," dated 8/22/2025, was reviewed. The "ED physician notes" indicated, a reassessment was done noting Patient 15's vital signs were stable and discharged in police custody. DED stated it was unknown what time the reassessment (face to face assessment) was performed.

During an interview on 9/18/2025 at 2:43 p.m. with the Medical Director (MDED) of ED, MDED stated the following: all ED providers should know they (ED providers) needed to perform face-to-face assessment when a patient was placed on violent behavioral restraint. The ED provider would see and speak with the patient to assess if the restraint was still necessary or not. The goal was to release the restraints as early as possible.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Purpose: to define guidelines for appropriate therapeutic and safe use of restraint that preserves the patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... Initiation of Restraints ... Violent or self-destructive behavior restraint ... the physician or licensed practitioner must conduct and document a face-to-face assessment within one (1) hour of initiation of the restraints for violent or self-destructive behavior. This evaluation shall include: A. The patient's immediate situation; B. The patient's reaction to the intervention; C. The patient's medical and behavioral condition; and D. The need to continue or terminate the restraint."

Based on interview and record review, the facility failed to ensure one of seven sampled facility employees (RN 13) met the necessary training and competencies to provide safe nursing care in the facility, when RN 13's latest due annual restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use training and competency (the process of systematically evaluating a nurse's knowledge, skills, and behaviors to ensure they are proficient and safe in their role, contributing to positive patient outcomes) was not completed, in accordance with the facility's policy regarding restraints use and competency assessment and validation plan.

This deficient practice had the potential to result in RN 13 not being safely prepared for competence towards safe patient restraint use and application in the facility, which could have put patients in the facility at risk of harm.

Findings:

During a concurrent interview and record review on 9/19/2025 at 11:15 a.m. with the Director of Human Recourses (DHR), Registered Nurse 13's (RN 13) "Offer of employment letter," was reviewed. The letter indicated that RN 13 was hired to the facility's Telemetry Unit as a Registered Nurse on 4/3/2023. This finding was confirmed by the DHR.

During a concurrent interview and record review on 9/19/2025 at 1:21 p.m. with the Director of Education (DOE), the DOE was unable to provide documentation to reflect that RN 13 completed their (RN 13) latest annual nursing competency training, which also included RN 13's due restraint use and application training. The DOE stated, the latest due annual competency included the following subject matter: "Restraints/SI (Suicidal Ideation [thoughts of taking one's own life]/Ligature (a flexible item, such as a rope, cord, or bedding, used in a self-harm attempt by binding it to a fixed object ["ligature point"] to cause asphyxiation [when the body does not receive enough oxygen] or impede blood flow) Assessment and Risk."

During an interview on 9/19/2025 at 1:25 p.m. with the DOE, the DOE stated that RN 13's latest annual competency was due prior to December 31, 2024. The DOE stated that the expectation was that all nurses were to complete their global competencies that included both classroom instruction and psychomotor (the relationship and interaction between mental processes and physical motor activities) skills demonstration. The DOE stated restraint use was covered during every annual competency and was always required. The DOE stated that a message was sent to the direct management of RN 13, but a follow-up was not completed to capture RN 13's lapse in their (RN 13) latest due annual competencies.

During an interview on 9/19/2025 at 1:48 p.m. with the DOE, the DOE stated, when the nurses do not complete their annual competencies, this posed a risk for not ensuring the nurses were prepared for doing their jobs.

During a review of the facility's "Telemetry RN Job Description," dated 10/10/2024, the document indicated, "... 16. General Competencies: 16.1 Job Standards: Maintains compliance with all mandatory licensure, certification and regulations, Completes annual safety, health, education, compliance and HIPPA requirements on time..."

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2025, the P&P indicated, "... STAFF EDUCATION & COMPETENCY TRAINING: Competency and validation in restraint use must be provided both during initial orientation and ongoing. Periodic in-service training to all staff who have direct patient contact and others that may be involved in the application of restraint devices. Staff members must have documented demonstrated competence in restraint techniques. Education/training will include:
A. Restraint Use Policy and related documentation review
B. Assessment/Reassessment processes and timelines
C. Proper and safe restraint application methods
D. Alternative approaches
E. Providing care to patients in restraints
F. Discontinuation of restraints
G. Documentation requirements"

During a review of the facility's policy and procedure (P&P) titled, "Competency Assessment and Validation Plan," dated 6/2023, the P&P indicated, "... POLICY: A. Each employee shall participate in a continuous assessment of competency, which will begin at the point of hire and continue through the annual performance appraisal. B. Key department/job classification competencies including age-specific and all mandated requirements will be assessed annually at the time of performance appraisal... H. The components and process of competency assessment in the department are as follows: ... 4. Initial assessments of department and/or job classification key competencies completed during and/or at the end of Department Orientation Assessment will be accomplished by verbal and written post-testing, job-related simulations and direct observation of performance... 6. Documentation records of mandatory, in-service and continuing education classes completed..."

Based on interview and record review, the facility's Quality Assessment 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) committee failed to review and monitor collected Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) and Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) data from the resuscitation (process of restoring vital life functions) committee (QAPI's subcommittee monitor code blue and RRT activities) in QAPI meetings, in order to identify opportunities for improvement to address the issue with delayed activation of emergency codes which affected two of 33 sampled patients (Patient 1 and Patient 2), in accordance with the facility's QAPI plan, when an unspecified time period of Code Blue and RRT data was discussed only one time (in June 2025) during a QAPI meeting from January 2025 to August 2025.

This deficient practice had the potential to result in breakdown in communication between QAPI and its subcommittee and resulted in lack of proper implementation of action plan to address the RRT activation delay on 4/23/2025 (there was a 40 minutes delay in calling RRT for Patient 1) to prevent future occurrence, hence leading to another RRT activation delay occurring on 8/16/2025 when a RRT call was delayed(over 2 hours) for Patient 2. Patient 2 suffered respiratory distress (difficulty breathing) requiring oral intubation (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and sent to ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) for further management. This deficient practice also had the potential to put other patients' safety at risk due to the delay of RRT activation.

Findings:

During an interview on 9/19/2025 at 11:56 a.m. with the Patient Safety Risk Manager (PSRM), PSRM stated the facility's QAPI program (Quality Assessment and Performance Improvement, 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) was responsible for measuring progress, and ongoing monitoring of performance improvement initiatives and to ensure all other subcommittees reported to the Quality and Patient Safety Committee.

During an interview on 9/19/2025 at 3:20 p.m. with the Patient Safety Risk Manager (PSRM), PSRM stated the following: the resuscitation (process of restoring vital life functions) committee was responsible for collecting all RRT (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) and Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) data and report to Quality and Patient Safety Committee monthly.

During a concurrent interview and record review on 9/19/2025 at 3:32 p.m. with PSRM, the facility's QAPI minutes titled, "Quality & Patient Safety Committee (QAPI minutes)," from January 2025 to August 2025, were reviewed. The QAPI minutes indicated the RRT and Code Blue data was discussed only in meeting on 6/11/2025. The QAPI minutes dated 6/11/2025 indicated, "(the minutes did not specify what month of data [was] being presented) RRT activity highlighted crowd control issues and communication breakdowns. Staff are reminded only essential personnel should remain during events ..." There was no other RRT and Code Blue data reporting found in other QAPI minutes. PSRM stated the RRT and Code Blue data gathered on a monthly basis was not included in the QAPI minutes and the QAPI minutes did not reflect what specific month was the RRT and Code Blue data pertain to.

During an interview on 9/19/2025 at 3:40 p.m. with the Director (DIR 2) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), DIR 2 stated the resuscitation committee met monthly and reviewed the numerical data of code blue and RRT. There was a debriefing form (an evaluation form completed after an event to identify area of improvement) for each code blue and RRT to evaluate if all elements were met including the timeliness of the responding team to the code blue and RRT. The debriefing did not evaluate if the Code Blue or RRT was activated in a timely manner or not. It focused on what happened after the Code Blue or if RRT was activated. The resuscitation committee reported the data to QAPI on a quarterly basis (data is aggregated for tracking and analysis to form the basis of a comprehensive action plan to address identified concerns and prevent re-occurrence of the same issue).

During a concurrent interview and record review on 9/19/2025 at 4 p.m. with DIR 2, the facility's QAPI minutes titled, "Quality & Patient Safety Committee (QAPI minutes)," from January 2025 to August 2025, were reviewed. The QAPI minutes indicated the RRT and Code Blue data was discussed only in the June meeting on 6/11/2025. DIR 2 stated she (DIR 2) had no control of what was on the QAPI minutes. DIR 1 also stated QAPI was the central body to drive the quality measure to make sure everyone was doing the right thing and to ensure that areas of concern (such as the delay in activating RRT) were promptly identified and action plans were properly implemented.

1.a. During a concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit (a hospital unit that provides constant electronic monitoring of a patient's vital signs, such as heart rate, rhythm, and blood pressure), Patient 1's medical record, dated 4/26/2025, was reviewed. The DOT stated the following: Patient 1 was admitted on 3/25/2025 for shortness of breath (difficulty breathing), intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and admitted to the intensive care unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care). Patient 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to allow air to enter the lungs) placement on 4/9/2025 and was transferred to the Telemetry unit on 4/20/2025. Patient 1 was receiving oxygen at 10 Liters, FiO2 (Fraction of inspired oxygen, used to determine if a patient is receiving adequate oxygen) at 50 %, via T-piece (a medical device used to provide oxygen and ventilation to patients with a tracheostomy).

During the same interview on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT said Patient 1 started displaying signs of respiratory distress (when breathing becomes difficult) on 4/23/2025 at 12:10 a.m., after receiving trach (tracheostomy) care. At 12:10 a.m., Patient 1's oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) was 78 % (normal is above 90%), Patient 1's heart rate increased to 156, and 146 (Normal: 60-100). Blood pressure increased to 172/108 (high; Normal is 120/90). Patient 1's nurse (RN 1) called the respiratory therapist (RT 1) to assess Patient 1. The RT assessed and suctioned Patient 1. A Rapid Response Team (RRT) was called, per nurse's notes at 12:35 a.m., however, the documentation on the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log, indicated the RRT was called at 12:50 a.m. A Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when the patient stops breathing]) was called at 12:52 a.m.

During the same interview on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT verified that Patient 1 met the criteria for a RRT, which included oxygen saturation of less than 90 % despite treatment, change in vital signs (HR, BP, O2 Sat). There was no evidence that RN 1 notified the physician of these changes. The DOT stated the RRT was called 40 minutes (at 12:50 a.m.) after Patient 1 started displaying signs of respiratory distress and changes in baseline vital signs. The DOT stated there was a delay in calling the RRT, which would trigger for a critical care nurse and a respiratory therapist to respond. At 12:52, a code blue was called. Patient 1 expired at 1:26 a.m. The DOT also verified there were no RRT notes documented in the medical record.

During an interview on 9/17/2025 at 3:28 p.m. with the Interim Quality Director (IQD), the IQD stated the following: The facility investigated Patient 1's death that occurred on 4/23/2025 by reviewing the nurse's and respiratory therapist's notes. The facility did not review the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log to determine the time the RRT was activated for Patient 1. The IDQ was not aware that there had been a forty (40) minute delay in activating an RRT, once Patient 1 met the criteria of an RRT. The IQD stated that the facility's preliminary recommendations for the incident included ensuring respiratory therapist follow trach care guidelines ... For nursing, preliminary recommendations included investigating the rationale for discontinuation of the pulse oximetry, consider formulating/revising the needs of and safety considerations for patient with artificial airways prior to being moved out of critical care environments. Evaluate handoff communication between RN and RT. Assess whether the patient should have a sitter and reviewing staffing ratios (There was no mention of how to address the delay in RRT activation). The IQD stated she would check the QAPI meeting minutes for additional interventions.

During a second interview on 9/18/2025 at 8:45 a.m. with the IDQ, the IDQ stated she (IDQ) reviewed the "Performance Improvement (PI)" minutes and could not find evidence of additional actions to be taken by nursing personnel addressing a delayed RRT response.

During an interview on 9/19/2025 at 1:41 p.m. with the Patient Safety Risk Manager (PSEM), the PSRM stated that Patient 1's death was investigated. The facility determined there was an issue with the ability to call for help, as the Registered Nurse (RN 1) was there. In addition, Patient 1 had difficult airway, which included a swollen tongue and a large goiter (an enlargement of the thyroid gland, located at the neck). After tracheostomy care, Patient 1 signaled to RN 1 that Patient 1 was unable to breathe. RN 1 called the respiratory therapist (RT 1) to return. RT 1 returned to Patient 1 and both RN 1 and RT 1 were trouble shooting trying to increase Patient 1 oxygen saturation. The attending physician attempted to intubate Patient 1 but was unsuccessful due to the difficult airway and trach dislodgment. The anesthesiologist intubated the patient. Patient 1 expired during the Code Blue.

During the same interview on 9/19/2025 at 1:41 p.m. with the Patient Safety Risk Manager (PSEM), the PSRM stated the RRT was activated at 12:35 a.m. on 4/23/2025 and verified there was no RRT note documented in the medical record. The PSRM was not aware that PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log indicated the RRT for Patient 1 was activated on 4/23/2025 at 12:50 a.m., not 12:35 a.m. The PSRM stated that a Code Blue should have been activated instead of an RRT. As a result, the facility implemented ongoing training which included mock codes (simulation exercise with a mannequin/human patient simulator that has no respiratory effort and/or no carotid pulse). In addition, part of the action plan indicated to develop a brief, mandatory education modules that clarify: Criteria for Rapid Response, Indicators for impending cardiopulmonary arrest, and when and how to escalate to a Code Blue. There was no action plan addressing the delay in activating an RRT.

During a review of the facility's policy and procedure (P&P) titled, "Performance Improvement Plan (PI Plan), dated 4/2022, the P&P indicated, "The purpose of the organizational Performance Improvement Plan (PI Plan) at [the facility] is to ensure that the Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making), medical staff, and patient care services staff demonstrate a consistent endeavor to deliver safe, effective, patient-centered, timely, efficient and equitable care and services ... Findings of the Quality & Patient Safety Committee, continuous performance improvement activities of the medical staff and all appropriate department/services and disciplines that affect patient care and safety are reviewed, assessed and evaluated at scheduled meetings. At a minimum the organization collects data on measures ... including ... 6. Resuscitation and rapid response events and outcomes ... Quality & Patient Safety Committee ... this committee establishes priorities, goals, objectives and all other design components of the PI Program ... this is accomplished through the following activities ... 5. Receiving, reviewing and acting upon reports regarding PI activities. 6. Actively participating in the planning and implementation of information systems and data management processes to support measurement, assessment and improvement activities. 7. Developing and participating in mechanisms to facilitate communication regarding PI priorities, plans goals, objectives and activities. 8. Overseeing the design and effective implementation of the PI Program, Patient Safety Program and Risk Management Plan ..."

1.b. During a review of Patient 2's "Physician Note (physician progress notes)," dated 8/15/2025, the physician progress notes indicated, Patient 2 was admitted to the facility on 7/12/2025 with diagnoses including but not limited to acute hypoxic respiratory failure (a life-threatening condition where the lungs fail to adequately exchange oxygen from the air into the bloodstream, leading to low oxygen levels [hypoxemia] in the body), hepatic encephalopathy (a neuropsychiatric syndrome [These symptoms can affect a person's mood, behavior, cognition- the process of thinking and knowing, and physical health] that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (high blood sugar level) and acute kidney injury (a sudden decline in kidney function that leads to a buildup of waste products in the blood and an imbalance of fluids and electrolytes). The physician progress notes also indicated Patient 2 was receiving oxygen at three (3) liters per minute (LPM, how much oxygen delivered each minute) via nasal cannula (NC, a plastic flexible tube that provides oxygen through the nose).

During a review of Patient 2's physician order, dated 8/15/2025, the physician order indicated, Patient 2 was on continuous pulse oximetry monitoring (a noninvasive procedure that uses a small device to measure the percentage of oxygen saturation in the blood).

During a review of Patient 2's "Vital Signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) Flowsheet (VS flowsheet)," dated 8/15/2025, the VS flowsheet indicated, on 8/15/2025 at 8 p.m. Patient 2's oxygen saturation level (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) was 93 % (normal range 95-100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) with 18 respiratory rate (RR) per minute (normal respiratory rate range 12 - 20 per minute) on oxygen 3 LPM via nasal cannula.

During a concurrent interview and record review on 9/19/2025 at 4:02 p.m. with DIR 2, Patient 2's "Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration [worsening]) Note (RRT notes)," dated 8/16/2025, was reviewed. The RRT notes indicated, "(on 8/16/2025) RRT called at 0223hr (2:23 a.m.) due to worsening hypoxemia (low oxygen level). Upon arrival, patient on high dose of oxygen, 100 % NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patient with severe respiratory distress [difficulty breathing] or hypoxia) and HFNC (High-Flow nasal Cannula [a medical device delivers a mixture of heated and humidified air and oxygen at high flow rates to treat respiratory failure) 60 Liters [per minute] (L/min, unit of measure)/ 91 % [FiO2](Fraction of Inspired Oxygen [concentration of oxygen in the air) with O2 Sat of 71 % (critical low oxygen saturation)."

During a concurrent interview and record review on 9/19/2025 at 4:02 p.m. with DIR 2, DIR 2 said per primary RN (RN 13) notes, "patient (Patient 2) had been desaturating (the blood oxygen saturation level was dropping) to 87 % since midnight. PMD [physician, MD 5] was informed with order of Lasix (medication to treat fluid overload [too much]) 40 mg (milligrams, unit of measure) IVP (Intravenous push, administered into a vein) given at 0027 (12:27 a.m.) and Bumex (medication to treat fluid retention, 40 times more potent than Lasix) 1 mg IVP & (and) Solu-Medrol (medication to treat inflammation [swelling] and breathing problem) 40 mg IVP given at 0207 (2:07 a.m.) which didn't show any improvement but instead patient (Patient 2) desaturated more to 69 %. Hence RRT was called ... RR 25, shallowing breathing ... patient (Patient 2) continued to desaturate as low as 55 % ... intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) at 0248hr (2:48 a.m.)." The RRT notes also indicated Patient 2 was transferred to the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) on a ventilator (an appliance for artificial respiration). DIR 2 stated the nurse should have activated RRT when Patient 2's O2 Sat was at 71 %."

During an interview on 9/19/2025 at 4:15 p.m. with DIR 2, Patient 2's RRT debriefing form, dated 8/16/2025, was reviewed. The RRT debriefing form did not indicate any issue or concern from the RRT. DIR 2 stated Patient 2's RRT was delayed and would qualify for a case review.

During a review of the facility's policy and procedure (P&P) titled, "Performance Improvement Plan (PI Plan), dated 4/2022, the P&P indicated, "The purpose of the organizational Performance Improvement Plan (PI Plan) at [the facility] is to ensure that the Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making), medical staff, and patient care services staff demonstrate a consistent endeavor to deliver safe, effective, patient-centered, timely, efficient and equitable care and services ... Findings of the Quality & Patient Safety Committee, continuous performance improvement activities of the medical staff and all appropriate department/services and disciplines that affect patient care and safety are reviewed, assessed and evaluated at scheduled meetings. At a minimum the organization collects data on measures ... including ... 6. Resuscitation and rapid response events and outcomes ... Quality & Patient Safety Committee ... this committee establishes priorities, goals, objectives and all other design components of the PI Program ... this is accomplished through the following activities ... 5. Receiving, reviewing and acting upon reports regarding PI activities. 6. Actively participating in the planning and implementation of information systems and data management processes to support measurement, assessment and improvement activities. 7. Developing and participating in mechanisms to facilitate communication regarding PI priorities, plans goals, objectives and activities. 8. Overseeing the design and effective implementation of the PI Program, Patient Safety Program and Risk Management Plan ..."

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 identify a 40-minute delay in activating a Rapid Response Team (RRT, a team that responds to Rapid Response activation, team consist of a critical care nurse and a respiratory therapist) for one of 33 sampled patients (Patient 1), when Patient 1 was having respiratory distress and a change of baseline vital signs. Patient 1 coded (respiratory and cardiac arrest [when the heart stops beating and the patient stops breathing]) two minutes after the RRT was activated and expired during the Code Blue (emergency code indicating patient needs immediate medical attention, usually due to a cardiac or respiratory arrest) on 4/23/2025. In addition, the QAPI failed to adequately track and analyze aggregate data pertaining to RRT and code blue calls and to implement an effective action plan to prevent the re-occurrence of another delayed activation of an RRT for Patient 2 on 8/16/2025, in accordance with the facility's performance improvement plan.

This deficient practice regarding the lack of a thorough investigation and implementation of an effective action plan resulted in QAPI's inability to identify the delay in the activation of a RRT, on 4/23/2025, for Patient 1, which resulted in Patient 1's death. In addition, the ineffective action plan resulted in another delayed activation of a RRT for Patient 2 on 8/16/2025, which resulted in Patient 2 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway), transferred to the Intensive Care Unit (a hospital department proving constant monitoring and life-sustaining treatment for patients with severe, life-threatening illness or injuries) and made into a DNR (a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR] if a patient's heart or breathing stops). This deficient practice also had the potential to place other patients at risk of a delayed RRT and had the potential to result in serious injury, harm or death.

Findings:

During an interview on 9/17/2025 at 3:28 p.m., with the Interim Quality Director (IQD), the IQD stated the following: The facility investigated Patient 1's death that occurred on 4/23/2025 by reviewing the nurse's and respiratory therapist's notes. The facility did not review the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log to determine the time the RRT was activated for Patient 1. The IDQ was not aware that there had been a forty (40) minute delay in activating a RRT, once Patient 1 met the criteria of an RRT. The IQD stated that the facility's preliminary recommendations for the incident included ensuring respiratory therapist follow trach care guidelines ... For nursing, preliminary recommendations included investigating the rationale for discontinuation of the pulse oximetry (a small, non-invasive medical device that measures the oxygen saturation [amount of oxygen in the blood] level in the blood), consider formulating/revising the needs of and safety considerations for patient with artificial airways prior to being moved out of critical care environments. Evaluate handoff communication between RN (Registered Nurse) and RT (Respiratory Therapist). Assess whether the patient should have a sitter (a dedicated staff member or sometimes a nurse who provides continuous, observation and direct support to a patient) and reviewing staffing ratios (The recommendations did not include measures to address the delay in activating RRT or Code Blue). The IQD stated she (IQD) would check the QAPI (Quality Assurance Performance Improvement, a data-driven, proactive approach to improving the quality of care and services) minutes check for additional interventions.

During a second interview on 9/18/2025 at 8:45 a.m. with the IDQ, the IDQ stated she (IDQ) reviewed the "Performance Improvement (PI)" minutes, and could not find evidence of additional actions to be taken by nursing personnel to address the delayed activation of the RRT.

During an interview on 9/19/2025 at 1:41 p.m., with the Patient Safety Risk Manager (PSEM), the PSRM stated that Patient 1's death was investigated. The facility determined there was an issue with the ability to call for help, as the Registered Nurse (RN 1) was there. In addition, Patient 1 had difficult airway, which included a swollen tongue and a large goiter (an enlargement of the thyroid gland, located at the neck). After tracheostomy care, Patient 1 signaled to RN 1 that Patient 1 was unable to breathe. RN 1 called the respiratory therapist (RT 1) to return. RT 1 returned to Patient 1 and both RN 1 and RT 1 were trouble shooting trying to increase Patient 1's oxygen saturation. The attending physician attempted to intubate Patient 1 but was unsuccessful due to the difficult airway and trach dislodgment. The anesthesiologist intubated the patient. Patient 1 expired during the Code Blue.

During the same interview on 9/19/2025 at 1:41 p.m. with the Patient Safety Risk Manager (PSEM), the PSRM stated the RRT was activated at 12:35 a.m. (40 minutes delay) and verified there was no RRT note documented in the medical record. The PSRM was not aware that PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log indicated the RRT for Patient 1 was activated on 4/23/2025 at 12:50 a.m., not 12:35 a.m. The PSRM stated that a Code Blue should have been activated instead of a RRT. As a result, the facility implemented ongoing training which included mock codes (simulation exercise with a mannequin/human patient simulator that has no respiratory effort and/or no carotid pulse). In addition, part of the action plan indicated to develop a brief, mandatory education modules that clarify: Criteria for Rapid Response, Indicators for impending cardiopulmonary arrest (when the heart stops beating), and when and how to escalate to a Code Blue.

During a concurrent interview and record review on 9/19/2025 at 4 p.m. with DIR 2, the facility's QAPI minutes titled, "Quality & Patient Safety Committee (QAPI minutes)," from January 2025 to August 2025, were reviewed. The QAPI minutes indicated the RRT and Code Blue data was discussed only in the June meeting on 6/11/2025. DIR 2 stated she (DIR 2) had no control of what was on the QAPI minutes. DIR 1 also stated QAPI was the central body to drive the quality measure to make sure everyone was doing the right thing and to ensure that areas of concern were promptly identified (by tracking, analyzing data aggregate such as RT/Code blue data) and action plans were properly implemented.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, the H&P indicated Patient 1 had a "past medical history of multi-substance use, asthma (a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breathe), hypertension (high blood pressure) ...presented to the hospital due to worsening of shortness of breath (difficulty breathing), nausea (the urge to throw up), vomiting, altered mental status (a significant change in a person's level of consciousness [a person's degree of wakefulness and awareness of their surroundings and self, existing on a spectrum from fully alert to completely unresponsive], cognitive function [memory, attention, learning, perception, and decision-making], or behavior ) ...patient (Patient 1) is intubated ...in the Intensive Care Unit."

During a review of Patient 1's Vital Signs (VS, (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) record, the VS record indicated the following:

-On 4/22/2025 at 8 p.m., Heart Rate (HR, reference range 51 - 119) was 93, Blood Pressure (BP) was 155/83 (high, reference range 91-139/51-89), Respiratory Rate (RR) 20 (normal, reference range 15 - 20), Temperature was 37 (normal).
-On 4/23/2025 at 12 a.m., HR was 78, Temperature 36.6 (normal)
-At 12:03 a.m., RR was 20, oxygen saturation was 95 % on FiO2 (Fraction of Inspired Oxygen [concentration of oxygen in the air]) at 50% via T-Piece (a medical device used to provide oxygen and ventilation to patients with a tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to allow air to enter the lungs).
-At 12:08 a.m., HR was 108
-At 12:14 a.m., HR was 156 (high) and RR was 22 (high)
-At 12:15 a.m., BP was 172/108 (high)
-At 12:16 a.m., HR was 146 (high)

During a review of Patient 1's "Nursing Progress Note," dated 4/23/2025 at 6:37 a.m., the nursing progress notes indicated the following:

-At 12 a.m., "vital signs stable ...RT (respiratory therapist) came to do treatment for patient (Patient 1)."
-At 12:10 a.m., "went into patient's (Patient 1's) room ...found patient having trouble breathing, checking patient (Patient 1). RT was called to check trach tie. RT came and trach was examined, continues on showing very anxious (feeling of fear, dread, uneasiness),"
-At 12:14 a.m., the heart rate went up to 156.
At 12:16 a.m., Patient- (Patient 1) remained short of breath, blood pressure went up to 172/108.
--At 12:35 a.m., RRT (Rapid Response Team) called. (However, the PBX log titled, "Rapid Response," indicated that on 4/23/2025 at 12:50 a.m., a code Rapid Response was called for Patient 1., this was verified by the Director of the Telemetry [DOT]).
-At 12:50 a.m. Code Blue called. ICU team arrived at 12:52 a.m.
-At 1:26 a.m., Despite resuscitation, Patient 1 expired.
-Addendum to the Nursing Progress Note, at 8 a.m. indicated the following:
-At 12:10 a.m., "After seeing RT do trach care, went inside patient's (Patient 1's) room to check, noted in respiratory distress oxygen saturation 78 % (Low, normal above 93 %), called RT to check the patient, titrated oxygen, suctioned the patient, continued to have respiratory distress. Charge nurse came and called for RRT ...patient (Patient 1) remained in respiratory distress, no pulse noted. Code Blue team came and took over."

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:45 a.m., the Respiratory Note indicated the following: Nurse called for RT (respiratory therapist), "patient (Patient 1) had increased work of breathing. Arrived in room and patient suctioned with catheter. Catheter was passed though airway with no resistance. Inner cannula (a removable tube that fits inside the main tracheostomy tube [outer cannula, acting as a liner to make it easier to clean and prevent blockages from mucus buildup) was checked with no obstruction noted. Patient's (Patient 1's) saturation was checked and was noted to be falling below 90 % ...Rapid Response called. Bag (Manual resuscitator, to manually provide positive pressure ventilation and supplemental oxygen to patients who are not breathing effectively or have stopped breathing altogether) was connected to flowmeter on 100 % FiO2 and was provided to patient via trach ...Rapid Response team arrived with attending physician ...it was determined that the trach was dislodged ... minutes later a Code Blue was called."

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:55 a.m., the Respiratory Note indicated the following: "RRT called ...upon arrival, patient (Patient 1) was being bagged (manual resuscitation) on 100 % FiO2 via trach ...patient (Patient 1) appeared in respiratory distress ...It was determined the trach was dislodged. A few minutes later, a code blue was called due to the difficult airway ...patient (Patient 1) was intubated by the Anesthesiologist ...After a long resuscitation effort, ROSC (return of spontaneous circulation, the resumption of the heart's ability to pump blood on its own after a cardiac arrest [heart stops beating]) was not obtained and" Patient 1 was pronounced (declared dead) by the Attending Physician.

During a review of a PBX log titled, "Rapid Response," the PBX log indicated that on 4/23/2025 at 12:50 a.m., a code Rapid Response was called for Patient 1.

During a review of a PBX log titled, "Code Blue/White," the PBX log indicated that on 4/23/2025 at 12:52 a.m., a code blue was called for Patient 1.

During a review of Patient 2's "Physician Note (physician progress notes)," dated 8/15/2025, the physician progress notes indicated, Patient 2 was admitted to the facility on 7/12/2025 with diagnoses including but not limited to acute hypoxic respiratory failure (a life-threatening condition where the lungs fail to adequately exchange oxygen from the air into the bloodstream, leading to low oxygen levels [hypoxemia] in the body), hepatic encephalopathy (a neuropsychiatric syndrome [These symptoms can affect a person's mood, behavior, cognition- the process of thinking and knowing, and physical health] that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (high blood sugar level) and acute kidney injury (a sudden decline in kidney function that leads to a buildup of waste products in the blood and an imbalance of fluids and electrolytes). The physician progress notes also indicated Patient 2 was receiving oxygen at three (3) liters per minute (LPM, how much oxygen delivered each minute) via nasal cannula (NC, a plastic flexible tube that provides oxygen through the nose).

During a review of Patient 2's physician order, dated 8/15/2025, the physician order indicated, Patient 2 was on continuous pulse oximetry monitoring (a noninvasive procedure that uses a small device to measure the percentage of oxygen saturation in the blood).

During a review of Patient 2's "Vital Signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) Flowsheet (VS flowsheet)," dated 8/15/2025, the VS flowsheet indicated, on 8/15/2025 at 8 p.m. Patient 2's oxygen saturation level (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) was 93 % (normal range 95-100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) with 18 respiratory rate (RR) per minute (normal respiratory rate range 12 - 20 per minute) on oxygen 3 LPM via nasal cannula.

During a review of Patient 2's "Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration [worsening]) Note (RRT notes)," dated 8/16/2025, the RRT notes indicated, "(on 8/16/2025) RRT called at 0223hr (2:23 a.m.) due to worsening hypoxemia (low oxygen level). Upon arrival, patient on high dose of oxygen, 100 % NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patient with severe respiratory distress [difficulty breathing] or hypoxia) and HFNC (High-Flow nasal Cannula [a medical device delivers a mixture of heated and humidified air and oxygen at high flow rates to treat respiratory failure) 60 Liters [per minute] (L/min, unit of measure)/ 91 % [FiO2](Fraction of Inspired Oxygen [concentration of oxygen in the air) with O2 Sat of 71 % (critical low oxygen saturation)."

During further review of Patient 2's "Rapid Response Team Note (RRT notes)," dated 8/16/2025, the RRT notes indicated, "Per primary RN (RN 13), patient (Patient 2) had been desaturating (the blood oxygen saturation level was dropping) to 87 % since midnight. PMD [physician, MD 5] was informed with order of Lasix (medication to treat fluid overload [too much]) 40 mg (milligrams, unit of measure) IVP (Intravenous push, administered into a vein) given at 0027 (12:27 a.m.) and Bumex (medication to treat fluid retention, 40 times more potent than Lasix) 1 mg IVP & (and) Solu-Medrol (medication to treat inflammation [swelling] and breathing problem) 40 mg IVP given at 0207 (2:07 a.m.) which didn't show any improvement but instead patient (Patient 2) desaturated more to 69 %. Hence RRT was called ... RR 25, shallowing breathing ... patient (Patient 2) continued to desaturate as low as 55 %... intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) at 0248hr (2:48 a.m.)." The RRT notes also indicated Patient 2 was transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) on a ventilator (an appliance for artificial respiration)."

During an interview on 9/18/2025 at 10:58 a.m. with the Charge Nurse (CN) 10 of Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring), CN 10 stated the following: anyone could call rapid response team (RRT) when the patient had a change of condition including change in respiratory status, mentation (mental activity) changes and change in vital signs. Staff should call RRT also for extra help and to evaluate possible intubation when they were not able to maintain patient's oxygenation.

During a concurrent interview and record review on 9/18/2025 at 11:12 a.m. with the CN 10, the facility's "Daily Central Monitoring Log Sheet (tele log)," dated from 8/15/2025 to 8/16/2025, was reviewed. The tele log indicated "O2 Sat low" calls were made by the monitor tech (MT) 4 to Patient 2's primary nurse (RN 13) on 8/16/2025 at 12:13 a.m., 12:48 a.m., 1:14 a.m., and 2:07 a.m. The tele log also indicated RRT was called at 2:25 a.m. for Patient 2. CN 10 stated the following: as general rule, the monitor tech would notify the nurse when a patient's O2 Sat was below 90 %. The number of calls during the time span from 12:13 a.m. to 2:07 a.m. indicated Patient 2's O2 Sat was fluctuating (changing up and down) and not stable. CN 10 stated, "it is a long time (from onset time 12:13a.m. to RRT time 2:25 a.m.)." CN 10 further stated the following: the RRT was delayed. Even though there was communication with the physician and interventions provided, it should not take long to see an improvement. RN 13 took too long to call the RRT. Patient 2's condition could decompensate and result in respiratory distress.

During a concurrent interview and record review on 9/18/2025 at 11:25 a.m. with the Manager (RM 1) of Respiratory, Patient 2's "Respiratory Treatment Form (RT notes)," dated 8/16/2025 was reviewed. The RT notes indicated, on 8/16/2025 at 00:25 a.m. Patient 2 was noted to have shortness of breath light to moderate with or without activity, coarse crackles (loud, low-pitched, and longer-lasting "bubbling" or "rattling" discontinuous lung sounds) bilaterally (both) and using accessory muscle (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) to breath. Patient 2 was on HFNC with liter flow rate of 50 L/min. Breathing treatment of Albuterol (bronchodilators [relax and open the air passage to the lungs to make breathing easier]) and Mucomyst (medication to break apart mucus in the lungs) were given. The oxygen flow rate of HFNC was increased to 55 L/min and Patient 2's respiration rate was 26. RM 1 stated RRT should have been called because Patient 2 was not getting better and tachypneic (rapid breathing). There was a delay in calling the RRT. RM 1 further stated prolonged hypoxemia could cause damage to brain and heart.

During a review of the facility's "Quality & Patient Safety Committee," or "PI (Performance Improvement," minutes, dated 8/13/2025, the minutes indicated the following: There was a new protocol for respiratory services regarding the dislodgment of the tracheostomy, including education and ensuring supplies were always available. There was no documentation in the PI minutes addressing the delayed activation of an RRT for Patient 1, this was verified by IDQ.

During a review of the facility's "Performance Improvement (PI) Plan," dated 4/2022, the Performance Improvement Plan indicated the following:
Goals: The annual performance goals of the Hospital's PI Plan are: To continually and systematically plan, design, measure, assess, and improve performance of priority focus, improve healthcare outcomes, and reduce and prevent serious safety events.
Action: To achieve these goals the plan strives to: Incorporate performance improvement throughout the facility, provide systematic mechanisms for the Hospital staff, departments, and professions to function collaboratively in their efforts toward performance improvement, provide feedback and learning throughout the organization ...determining ongoing opportunities for improvement ...plan and incorporate processes for conducting thorough and credible root cause analysis, focusing on process and system factors in response to sentinel events and other serious safety events as defined by the hospital.
Approach and Purpose: In an effort to continually improve organizational and maintain high quality of patient care, the Hospital uses a systematic approach in the design of new processes or improvement of existing processes ...The following concepts, tools and techniques may be used, as applicable, to guide performance improvement activities ...D. Root Cause Analysis (RCA) is a structured facilitated team process to identify root causes of an event that resulted in an undesirable outcome and develop corrective actions. The purpose of the RCA is to find out what happened, why it happened and determine what changes are needed to prevent it from happening again.

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

1. Ensure one of 33 sampled patients (Patient 18) was provided peri-care (refers to cleaning and maintenance of the perineum, the area between the anus and the genitals) every shift, in accordance with the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice."

This deficient practice had the potential for putting Patient 18 at increased risk for infections (urinary tract [infection involving the urethra [tube where urine leaves the body] and the bladder, where urine is stored in the body]), skin break down (damage or injury to the skin, resulting in open wounds), and discomfort.

2. Ensure one of 33 sampled patient's (Patient 3) vital signs (includes temperature, heart rate, blood pressure) were assessed, every two hours, in the Emergency Department (ED, a hospital service providing immediate, unscheduled medical care for severe illnesses or injuries that require urgent attention, 24 hours a day), in accordance with the facility's policies and procedures regarding assessment and reassessment in the ED.

This deficient practice had the potential for changes of condition to go unnoticed by nursing staff, which may lead to patient harm and/or death.

3. Ensure one (1) of 33 sampled patients (Patient 24), received complete assessments after falls (unintentional coming to rest on the ground, floor, or other lower level), in accordance with the facility's policy and procedure, "Fall Prevention and Management." Patient 24 fell six (6) times during the hospital stay, but there was no documentation of post (after)-fall vital signs (basic measurements of body function: temperature [a measure of body heat], heart rate [the number of times the heart beats in one minute], breathing rate [the number of breaths taken in one minute], and blood pressure [the force of blood pushing against the walls of the blood vessels]) and no documentation of post-fall head-to-toe assessments (a full exam performed by a nurse after a fall to check for injury or change in condition).

This deficient practice had the potential to place Patient 24 at risk for harm; for delayed recognition of injuries or complications after a fall, such as bone fracture (a broken bone) or head injury (trauma of the skull or brain caused by impact), which may require urgent medical treatment.

Findings:

1. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/29/2025, the H&P indicated Patient 18 was admitted to the facility with chief complaint of leg wounds, presented to Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) with bilateral (both) foot wounds. The H&P also indicated Patient 18 had been wheelchair-bound (patient is restricted or confined to a wheelchair) for multiple months due to hip arthritis (pain and stiffness in hip joint).

During a concurrent interview and record review on 9/17/2025 at 11:25 a.m. with Registered Nurse (RN) 7, Patient 18's, "Braden Assessment flow sheet," dated 7/29/2025 and 8/3/2025, was reviewed. RN 7 stated patients with Braden score of 18 or below would be at risk for skin integrity (the state of the skin being intact, healthy, and free from damage or injury) issues. RN 7 said that Patient 18's Braden score was 17 on 8/3/2025, Patient 18 would be at risk for skin integrity problems and that it was important to keep Patient 18 clean and dry.

During the same interview and record review on 9/17/2025 at 11:25 a.m. with RN 7, Patient 18's, "Neurological vascular (refers to both nervous system and blood vessels) assessment flow sheet," dated 8/3/2025, was reviewed. The neurological assessment flow sheet indicated Patient 18 was unable to stand and continent in bladder control (ability to control and hold urine without leakage).

During the same interview on 9/17/2025 at 11:25 a.m. with RN 7, Patient 18's "Bedside Mobility Assessment Tool (BMAT, nursing tool that assess a patient's mobility [ability to move] to select appropriate equipment for safe transfer and mobilization, BMAT level from 1-4, mobility level 1 patients are those needing the most assistance. Mobility level 4 patients need the least assistance.)," dated 8/3/2025, was reviewed. RN 7 stated Patient 18's BMAT was level 1, meaning Patient 18 was dependent on staff for care.

During the same interview on 9/17/25 at 11:25 a.m. with RN 7, Patient 18's "ADL's (Activities of Daily Living such as feeding and grooming) -Peri-care (perineal care, refers to cleaning and maintenance of the perineum, the area between the anus and the genitals) flow sheet," dated 8/3/2025-9/4/2025, was reviewed. RN 7 stated Patient 18's peri care was last provided as follows:

-8/3/2025 - 6:00 a.m.-7:59 a.m., Peri Care with assist
-8/4/2025 - 8:00 a.m. -9:59 a.m., Peri Care with assist

During the same interview on 9/17/25 at 11:25 a.m. with RN 7, RN 7 stated that per documentation, Patient 18 was not provided peri-care for about 27 hours. RN 7 also stated Patient 18 had motor weakness (the loss of normal strength in one or more muscles, making it difficult or impossible for a patient to perform expected muscle movements), in bed for extended periods, and this could lead to moisture skin issues, and Patient 18 could have a skin breakdown (damage or injury to the skin, resulting in open wounds).

During the same interview on 9/17/2025 at 11:25 a.m. with RN 7, RN 7 stated peri-care should be performed by either a registered nurse (RN) or certified nursing assistant (CNA) and should be documented, at a minimum, once a shift.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," effective date 12/2021, the P&P indicated, "The Standards of Practice for adult core nursing (Medical Surgical, Orthopedic, Oncology, and Acute Rehab) serve as guidelines for the provision of nursing care and professional performance expectations ...Peri-care and urinary catheter care should be provided a minimum of every shift and PRN."

2. During an interview on 9/18/2025 at 1:09 p.m. with the Director of the Emergency Department (DED), the DED stated the following: Patient 3 presented to the Emergency Department on 1/29/2025 at 6:55 p.m., for an itchy rash to both legs due to an allergic reaction to medication. Patient 3's vital signs were initially checked at 7:53 p.m. during triage (a medical process used to prioritize and categorize patients based on the severity of their condition and their need for immediate medical attention), then checked again at 10:52 p.m., three (3) hours later. Vital signs should be checked every two hours to assess for changes in the patients' condition.

During a review of Patient 3's "ED Triage - Text," dated 1/29/2025 at 7:53 p.m., the Text indicated Patient 3 was triaged and assigned an ESI (Emergency Severity Index, ESI level from 1 [most urgent] to 5 [least urgent], with Level 1 patients requiring immediate care and Level 5 patients having minor, non-urgent issues) Level 4 (Stable conditions that require fewer resources, such as a single exam or consultation). Patient 3's chief complaint was allergic reaction, itchy rash to bilateral (both) legs, "started this morning ...denies shortness of breath (difficulty breathing) or airway swelling ..."

During a review of Patient 3's "MSE [Medical Screening Examination, purpose of an MSE is to determine, with "reasonable clinical confidence," whether or not a person who comes to the ED has an emergency medical condition (EMC)] Screening - Text," dated 1/29/2025 at 7:59 p.m., the Text indicated MSE Screening was initiated - Patient 3 "presents for C/C (chief complaint) of pruritic (itchy) rash only on legs since this morning (1/29/2025). Started taking Augmentin (an antibiotic used to treat bacterial infections) and Flagyl (an antibiotic used to treat infections caused by bacterial and parasites) yesterday (1/28/2025), Currently, breastfeeding. No acute distress (patient appears stable and is not exhibiting signs of severe or sudden suffering, discomfort, or difficulty), unlabored respirations (normal, effortless breathing). Orders placed, further evaluation by definitive provider."

During a review of Patient 3's Vital Signs (includes the temperature, heart rate, blood pressure) Record, dated 1/29/2025, the Record indicated the following:

-At 7:53 p.m., Patient 3's Temperature was 36.5 degrees Celsius (normal), Respiratory Rate (RR) was 18 (normal), Blood Pressure (BP) was 108/67, Heart Rate (HR) was 74 (normal) and Oxygen saturation (measurement of the amount of oxygen in the blood) was 99 % on room air (normal).
-At 10:52 p.m., Patient 3's Temperature was 36.5 Celsius, RR was 18, BP was 113/80 (normal), HR was 74 and oxygen saturation was 97 % (normal) on room air.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department Nursing Standards of Practice," dated 8/2024, the P&P indicated the following: Triage - All patients will be assessed by a Registered Nurse upon presentation to the Emergency Department. Results will be documented in the patient's healthcare records. The following data elements will always be included in the assessments of: Adults patients, including Vital Signs: temperature, blood pressure, heart rate, respiratory rate, oxygen saturation. Addendum D: Charting Requirement per ED Standard of Care. These are the minimum requirements. Follow physician's orders & nursing judgment for more frequent charting ...Physical Reassessments (physical, pain and vital signs), frequency: Every 2 hours and as needed change in condition ...

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Emergency Department Patient," dated 10/2022, the P&P indicated the following. All patients will be triaged by an RN (Registered Nurse) as soon as possible after their arrival ...Patients will be reassessed based on acuity as determined by the triage RN or assigned RN. Reassessment includes repeating vital signs or any change in patient status and documenting those updated in the EHR (electronic health record) ...Subsequent vital signs and reassessments will be documented per patient acuity and emergency care, physician treatment plan and at discharge from the department if not completed within the past 2 hours.

3. During a review of Patient 24's "History and Physical (H&P, History and Physical)," dated 3/23/2025, the "H&P" indicated, Patient 24 was admitted from a skilled nursing facility (a healthcare facility that provides 24-hour medical and rehabilitation services) after a fall (unintentional coming to rest on the ground, floor, or other lower level). The H&P further indicated Patient 24's medical history included alcoholic cirrhosis (a chronic liver disease caused by long-term alcohol use), hypertension (chronic high blood pressure, defined as a systolic blood pressure [top number] of 130 mmHg [a unit of measurement] or higher), diabetes (a chronic condition that affects how the body uses glucose [sugar] for energy), and blindness in the right eye (significant loss of vision not correctable by glasses or surgery).

During a concurrent interview and record review on 9/17/2025 at 10:20 a.m. with the Stroke Program Coordinator (SPC 1, a healthcare leader responsible for managing and improving hospital stroke programs-a service designed to care for patients who have had a stroke, which occurs when blood flow to the brain is interrupted), Patient 24's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" record, dated 4/21/2025 through 6/2/2025, was reviewed. The record indicated the following:

-On 4/21/2025 at 8:00 p.m., indicated, "Spoke to (name of provider, Patient 24's primary MD), made her (Primary MD) aware patient (Patient 24) fell, landed on her left side."
- On 4/25/2025 at 12:00 a.m., indicated, "MD notified that patient (Patient 24) fell in hallway while ambulating with safety sitter (is a staff member who provides continuous, undivided attention to a single patient to ensure their safety and prevent harm, falls, or harmful actions) beside her (Patient 24)."
-On 4/27/2025 at 3:32 p.m., indicated, "Patient (Patient 24) received on the floor in the shower while being helped to get up by staff. Patient assisted back to room."
-On 5/2/2025 at 11:55 p.m., indicated in Nursing Progress Note, "Patient ambulating with 1:1 sitter, missed a step, knees buckle, fell knees first."
-On 5/11/2025 at 9:20 a.m. indicated, "Patient fell ambulating to bathroom with sitter. Patient lost balance and fell to the ground and landed on her back and bottom."
-On 5/31/2025 at 8:50 p.m. indicated, "Patient (Patient 24) had unassisted fall to floor claiming to put out cigarette." SPC stated that Patient 24 did not have cigarettes. SPC 1 confirmed that according to documented evidence in Patient 24's medical record, Patient 24 fell six (6) times (during the entire hospitalization).

During the same interview and record review on 9/17/2025 at 10:20 a.m. with SPC 1, Patient 24's "Vital Signs" record, dated 4/21/2025 through 5/11/2025 (dates and time that Patient 24 sustained a fall), were reviewed. The record indicated the following:

- On 4/21/2025 at 8:00 p.m., there were no vital signs documented until 4/22/2025 at 8:00 a.m. (12 hours later).
-On 4/25/2025 at 12:00 a.m., there were no vital signs documented until 4/22/2025 at 8:00 a.m. (12 hours later).
- On 4/27/2025 at 3:32 p.m., there were no vital signs documented until 4/27/2025 at 8:pm a.m. (4 hours and 28 minutes later).
-On 5/2/2025 at 11:55 p.m., there were no vital signs documented until 4/27/2205 at 8:pm a.m. (4 hours and 28 minutes later).
-On 5/31/2025 at 8:50 p.m., there were no vital signs documented until 6/1/2025 at 5:00 a.m. (8 hours and 10 minutes later).
-SPC 1 stated vital signs should be taken immediately after a fall as part of the post-fall assessment.

During a concurrent interview and record review on 9/17/2025 at 3:00 p.m. with SPC 1, Patient 24' s "Nursing Assessment" record, dated 4/21/2025 and 4/25/2025, was reviewed. SPC 1 confirmed there were no head-to-toe assessments documented after these falls.

During an interview on 9/17/2025 at 10:55 a.m. with the Director of Clinical Education (DIR) 4, DIR 4 stated post-fall assessment must include vital signs and documentation of changes in condition (any significant deviation from a patient's normal heath status). DIR 4 stated if a patient refused vitals, nurses must educate the patient on the risk, document this education, and notify the provider (patient's primary MD).

During an interview on 9/19/2025 at 9:57 a.m. with the Nurse Manager of Medical Surgical Unit (NM) 5, NM 5 stated a head-to-to-toe assessment (a systemic exam of the body, including vital signs) which includes vital signs must be completed after every fall, and the provider (primary MD/Attending physician) must be notified. NM 5 stated vital signs were critical for identifying changes in patient condition.

During a review of the facility's policy and procedure (P&P) titled, "Plan Provision of Care," dated 4/2022, the P&P indicated, "Patient assessments are the foundation for all disciplines to determine the need for acute intervention, specialty screening, diagnostic workup and hospitalization when indicated. The patient is periodically reassessed during hospitalization as defined in discipline or subject specific policies including but not limited to screening for... fall risk... risk/self-injury, violent behavior, pain/comfort needs."

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "Assessment - The registered nurse performs and/or oversees the collection of pertinent data and information relative to the patient's health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record. Priority of data collection is determined by the patient's immediate health care needs. A focused assessment for chief complaint should be completed within 30 minutes of admission. Focused assessments/reassessments are completed PRN as indicated by patient condition and/or LP order. Vital signs should be obtained within 30 minutes of admission and monitored approximately every 8 hours thereafter unless patient condition and/or LP order require more frequent monitoring. Vital signs include temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry ..."

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Management," dated 6/2022, the P&P indicated the following: Post Fall Management: immediate post-fall head-to-toe assessments including vital signs, neurological checks, and documentation of provider notification and family contact.

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 33's) nursing care plans (part of the nursing process, and is a set of goals, assessments, and interventions for each identified problem) were accurate, actionable, and reflected ongoing nursing assessment, in accordance with the facility's policy regarding care plans, when:

1. Patient 33's documented care plan titled, "POC (Plan of Care) Impaired Verbal Communication," inaccurately reflected that Patient 33's goal of "Communicate needs effectively," was achieved.

2. Patient 33's documented care plan titled, "POC Agitation (feelings of irritability and severe restlessness)," included the intervention "Patient Specific Interventions" that was incomplete and did not include the very specific nursing interventions for implementation.

These deficient practices resulted in Patient 33 not having an individualized goal-oriented plans of care for the identified problems of impaired verbal communication and agitation, which could have compromised ongoing interdisciplinary communication and coordination towards Patient 33's care. These deficient practices also had the potential for not appropriately addressing Patient 33's vulnerabilities, care needs, and risks.

Findings:

1. During a review of Patient 33's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/20/2025, the "H&P" indicated the facility admitted Patient 33 on 8/20/2025, after Patient 33 presented to the facility's Emergency Department (ED) with shortness of breath (SOB, difficulty breathing). Patient 33 had a medical history of tobacco, methamphetamine (a powerful stimulant that can lead to muscle injury), and fentanyl (a powerful drug to relieve pain) use.

During a review of Patient 33's care plan titled, "POC Impaired Verbal Communication," dated 8/26/2025, the care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each identified problem) indicated nursing staff had been documenting that the care plan's goal titled, "Communicate needs effectively," was being documented as "Met" for Patient 33 on several dates between 8/31/2025 through 9/16/2025.

During a concurrent interview and record review on 9/17/2025 at 11:28 a.m. with the Director of the Medical Surgical Unit (DOM), Patient 33's care plan titled, "POC Impaired Verbal Communication," dated 8/26/2025, was reviewed. The DOM stated, per her (DOM) awareness of Patient 33's ongoing and current condition, Patient 33's care plan was not completed accurately, as Patient 33 was not able to communicate effectively. The DOM stated that there should be specific interventions documented to support that Patient 33's needs were met, and the DOM did not think that Patient 33's care plan goal titled, "Communicate needs effectively" should have been documented as "Met." The DOM reviewed the documentation and stated, the last nurse that documented "Met" on Patient 33's care plan goal titled, "Communicate needs effectively," was Registered Nurse 2 (RN 2).

During a concurrent interview and record review on 9/18/2025, between 10:30 a.m. and 10:55 a.m., with RN 2, Patient 33's care plan titled, "POC Impaired Verbal Communication," dated 8/26/2025, was reviewed. RN 2 stated the following:

-RN 2 stated that when considering a patient's care plan, the expectations were to complete the patient's care plans every shift and to determine the goal of the patient based on the evaluation and assessment of that patient. RN 2 stated that it was important for nurses to accurately assess the patients.
-RN 2 stated Patient 33 resorts to yelling, and Patient 33 does not have the ability to communicate effectively.
-RN 2 stated that on 9/16/2025, she (RN 2) documented that Patient 33's care plan goal of "Communicate needs effectively" was "Met."
-RN 2 stated Patient 33's care plan was not accurate as documented, and Patient 33's care plan goal of "Communicate needs effectively" should not have been documented as "Met," and should have been documented as "Not Met."
-RN 2 stated a patient's care plan should be accurate based on the accurate nursing assessment of the patient.
-RN 2 stated, for Patient 33's care plan goal of "Communicate needs effectively," she (RN 2) misunderstood and documented "Met" as a care plan intervention for Patient 33, rather than as the care plan goal.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 10/22/2024, the P&P indicated, "... STANDARD 1: NURSING PROCESS... 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: ... e. Uses evidenced-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or needs... 5. Implementation, a. Care Coordination - The registered nurse coordinates care delivery. The registered nurse: ... iii. Manages a patient's care in order to reach mutually agreed upon outcomes... 6. Evaluation - The registered nurse evaluates progress toward attainment of goals and outcomes. The registered nurse: ... c. Uses ongoing assessment data to revise the diagnoses, outcomes, plan, and implementation strategies..."

2. During a review of Patient 33's "History and Physical (H&P)," dated 8/20/2025, the "H&P" indicated the facility admitted Patient 33 on 8/20/2025, after Patient 33 presented to the facility's Emergency Department (ED) with shortness of breath (SOB, difficulty breathing). Patient 33 had a medical history of tobacco, methamphetamine, and fentanyl use.

During a review of Patient 33's care plan titled, "POC Agitation (feeling of unease and severe restlessness)," dated 9/14/2025, the care plan indicated that there were no specific, actionable interventions listed under the intervention titled, "Patient Specific Intervention."

During a concurrent interview and record review on 9/17/2025 at 11:22 a.m. with the Director of the Medical Surgical Unit (DOM), the DOM reviewed Patient 33's care plan and verified that the patient specific interventions for agitation were not included. The DOM stated that there should be specific interventions for agitation included and documented in Patient 33's care plan.

During an interview on 9/18/2025 at 10:30 a.m. with Registered Nurse 2 (RN 2), RN 2 stated that when considering a patient's care plan, the expectations were to complete the patient's care plans every shift and to determine the goal of the patient based on the evaluation and assessment of that patient. RN 2 stated that it was important for nurses to accurately assess the patients.

During an interview on 9/18/2025 at 11:06 a.m. with the Director of Telemetry (DOT), the DOT stated that specific patient care plan interventions meant that the interventions should be individualized for each patient. The DOT stated that there should have been specific interventions listed for Patient 33's care plan for agitation.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 10/22/2024, the P&P indicated, "... STANDARD 1: NURSING PROCESS... 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: ... e. Uses evidenced-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or needs..."

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

1. Ensure one of seven sampled facility employees (RN 3), met the necessary qualification to provide safe nursing care in the Emergency Department (ED, a hospital service providing immediate, unscheduled medical care for severe illnesses or injuries that require urgent attention, 24 hours a day), when RN 3's assessment and competency validation checklist (a document used in healthcare to assess and formally verify a nurse's ability to perform essential job functions and meet specific standards) was not completed within 90 days of hire, in accordance with the facility's policy regarding competency assessment and validation plan.

This deficient practice had the potential for RN 3 not being competent to perform patient care which had the potential to put patient safety at risk.

2. Ensure that nursing care assignments were made and carried out in accordance with patient care and safety needs and the facility's policy and procedure titled, "Safety Attendant for Patient at Risk of Harm to Self or Others, for two (2) of 33 sampled patients (Patient 28 and Patient 32) located in the same room (Bed 1 and Bed 2). One sitter (a staff member assigned to observe patients who require close monitoring for safety)- Certified Nursing Assistance (CNA, a healthcare professional who provides basic patient care, such as assisting with daily living activities) 2, was assigned to observe both patients (Patient 28 and Patient 32) at the same time. Both patients were unable to use the call bell (a button patients press to call for staff assistance) and were incontinent (unable to control urination or bowel movements). Both patients (Patient 28 and Patient 32) also needed line-of-sight observation (continuous visual monitoring where the patients must remain in direct view).

This deficient practice had the potential to place Patient 28 and Patient 32 at risk for harm, including falls (unintentional coming to rest on the ground, floor, or other lower level), removal of medical equipment (such as IV lines [thin tubes inserted into a vein to deliver medication] or monitors), or self-injury (when patients harm themselves) due to periods without required observation (line of sight observation).

3. Ensure one of seven sampled facility employees (RN 13) met the necessary qualifications and competencies to provide nursing care in the facility's Telemetry Unit (a hospital unit dedicated to the continuous, remote monitoring of patients whose cardiac [heart] conditions or other illnesses require constant observation, using portable equipment to track vital signs like heart rate and rhythm), when RN 13's latest due annual competency trainings and specialized EKG (electrocardiogram, a medical test that records the electrical activity of the heart by placing electrodes on the skin) testing, were not completed, in accordance with the facility's policy regarding competency assessment and Telemetry RN job description.

This deficient practice had the potential to result in RN 13 being unable to provide safe and effective patient care in the facility's Telemetry Unit, potentially putting patients in the facility at risk of harm.

Findings:

1. During a concurrent interview and record review on 9/19/2025 at 11:15 a.m. with the Director of Human Resources (DHR), RN 3's "Offer of employment letter," dated 3/31/2025, was reviewed, the letter indicated RN 3 was hired to Emergency Department (ED) as a Registered Nurse to start on 5/5/2025. DHR stated RN 3's date of hire was 5/5/2025.

During a concurrent interview and record review on 9/19/2025 at 11:15 a.m. with the Director of Education (DOE), DOE stated RN 3's files did not include assessment and competency validation (a document used in healthcare to assess and formally verify a nurse's ability to perform essential job functions and meet specific standards) which should have been turned in by RN 3 as it was overdue (past 90 days of hire date 5/5/25).

During the same interview on 9/19/2025 at 11:15 a.m. with the DOE, the DOE stated it was a shared responsibility of Education department and the ED management to obtain and ensure completion of the staff's competency validation checklist. DOE stated it was important for the competency check list to be completed to ensure RN 3 was safe to practice and knew what to do. DOE stated that DOE had a conversation with the manager and the director of ED regarding RN 3's competency checklist not being completed.

During a concurrent interview and record review on 9/19/2025 at 1:30 p.m. with the Director of the Emergency Department (DED), a blank form from ED titled, "Assessment and competency validation," was reviewed. DED stated ED had their own orientation competency check list to be completed in 90 days to ensure an employee was comfortable in carrying out patient care related procedures. DED stated the ED competency check list covered the topics regarding GI (gastrointestinal, the stomach and intestines), blood transfusion, stroke (occurs when blood flow to the brain is disrupted) and everything needed to be able to provide safe care to patients.

During the same interview on 9/19/2025 at 1:30 p.m. with the DED, the DED stated DED was unable to find RN 3's competency validation check list from RN 3's personnel file. DED stated the assessment and competency validation checklist would indicate RN 3 was competent, safe to perform and provide patient care. DED stated RN 3 was practicing independently already and should not be practicing until signed off by preceptor. DED stated the preceptor had to validate RN 3's skills and knowledge for patient safety through the competency validation checklist and should not be handling patient on her (RN 3) own until the competency validation checklist was completed and signed off by an assigned preceptor.

During a review of facility's policy and procedure (P&P) titled, "Competency Assessment and Validation Plan," effective 11/1995, the P&P indicated, "Each employee shall participate in a continuous assessment of competency, which will begin at the point of hire and continue through the annual performance appraisal ...Copies of Competency documents i.e., self-assessment, orientation check lists, competency assessment tools, and annual performance appraisal documents will be maintained ...Self-assessment completed during the 90-day probationary period and annually ...Completion of orientation checklist and validation Key Competencies with signed acknowledgement by both employees and Department Leader or designated validator.

2.a. During a concurrent observation and interview on 9/16/2025 at 2:15 p.m. with Certified Nursing Assistant (CNA) 2, in the presence of the Director for Medical Surgical Unit (DOM, a healthcare leader responsible for oversight of nursing care on the unit), CNA 2 was observed seated in the back of the patient room (occupied by patients 28 and 32) while assigned to observe both Patient 28 and Patient 32. Patient 32 was sleeping, and Patient 28 did not respond when greeted.

During the same interview on 9/16/2025 at 2:15 p.m. with CNA 2, CNA 2 stated Patient 28 was not oriented (confused and unable to correctly identify person, places, or time) and confirmed both Patient 28 and Patient 32 were unable to use the call bell (a device that allows patients to alert staff when they need help) and both patients required total assistance with incontinence (a condition where there is involuntary loss of urine or stool) care. CNA 2 demonstrated that when cleaning one patient, the privacy curtain would be left slightly open to allow occasional glances at the other patient. CNA 2 confirmed that this process did not allow for immediate intervention if one patient's safety was at risk but stated they (the CNA assigned to both patients) will immediately call for assistance.

During a review of Patient 28's "History and Physical (H&P, comprehensive document that includes a patient's medical history and findings on admission)," dated 9/8/2025, the "H&P" indicated, Patient 28 was admitted to the facility for lethargy (severe drowsiness of lack of energy), confusion (inability to think clearly or understand surroundings), hypotension (low blood pressure), generalized weakness (overall loss of strength in the body).

During a review of Patient 28's "Nursing Progress Note," dated 9/8/2025, the note indicated, "Patient refuses telemetry monitoring (a system that continuously tracks heart activity using small sticky patches called electrodes, which are placed on the skin), patient self-removed IV (intravenous line, a thin tube inserted into a vein to deliver medication), patient is confused trying to get out of bed."

During a review of Patient 28's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" record, dated 9/8/2025, record indicated, Patient 28 was "Getting out of bed. Combative (aggressive and physically resisting care), swinging arms at nurse while report given. Pulling out IV line. Charge nurse notified for safety sitter."

During a review of Patient 28's "Observation/Intervention," record dated from 9/16/2025, the record indicated, the "Reason for Observation: 1:1 Observation (one competent observer to one patient within line of sight [(requires a designated staff member to maintain constant, unobstructed visual contact with a patient to prevent harm to themselves or others)], in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others) and Safety intervention by staff: Direct observation (a healthcare worker who provides continuous, direct observation and supervision of a single patient to ensure their safety)."

During a concurrent interview and record review on 9/16/2025 at 2:30 p.m. with the DOM, the "Nursing Assignment Schedule," dated 9/16/2025, was reviewed. The schedule indicated CNA 2 was assigned as a one-to-one sitter for both Patient 28 and Patient 32 simultaneously. The DOM stated both patients required line-of-sight observation (requires a designated staff member to maintain constant, unobstructed visual contact with a patient to prevent harm to themselves or others) for safety. The DOM confirmed that when CNA 2 was cleaning one patient, the CNA could not immediately intervene if the other patient was in danger, and other staff would need to be called for help. The DOM further stated one-to-one observation was based on nursing assessment and did not require a provider order.

During an interview on 9/19/2025 at 11:36 a.m. with the Nurse Manager (NM) 6, NM 6 stated it was not safe to assign one sitter to two patients on a line-of-sight observation, because line-of-sight required continuous, direct visual monitoring. NM 6 stated patients on a line-of-sight observation may be confused, at high risk for falls (an unintentional descent of a patient to the ground), or at risk for self-harm, and if the sitter was occupied with one patient, the staff would not be able to immediately intervene for the other patient.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. Integrates interprofessional team partners in implementation of the plan through collaboration and communication across the continuum of care... Delegates according to the health, safety, and welfare of the patient and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care... The registered nurse performs and/or oversees delivers care according to the patient's need, LP orders, and the plan of care to achieve identified outcomes."

During a review of the facility's policy and procedure (P&P) titled, "Safety Attendant for Patients at Risk of Harm to Self or Others on a Unit other than behavioral health unit," dated 10/2021, the P&P indicated, "The implementation of a Safety Attendant will be used to provide a safe environment with interventions to allow for close monitoring and observation of the environment and behaviors of the patient. One-to-one Observation - means one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others. This requires continuous visual observation of one designated patient."

2.b. During a concurrent observation and interview on 9/16/2025 at 2:15 p.m. with CNA 2, in the presence of the Director for Medical Surgical Unit (DOM, a healthcare leader responsible for oversight of nursing care on the unit), CNA 2 was observed seated in the back of the room (occupied by Patient 28 and Patient 32) while assigned to observe both Patient 28 and Patient 32. Patient 32 was sleeping, and Patient 28 did not respond when greeted.

During the same interview on 9/16/2025 at 2:15 p.m. with CNA 2, CNA 2 stated Patient 28 was not oriented (confused and unable to correctly identify person, places, or time) and confirmed both Patient 28 and Patient 32 were unable to use the call bell (a device that allows patients to alert staff when they need help) and required total assistance with incontinence care. CNA 2 demonstrated that when cleaning one patient, the privacy curtain would be left slightly open to allow occasional glances at the other patient. CNA 2 confirmed that this process did not allow for immediate intervention if one patient's safety was at risk but stated they 9the staff) will immediately call for assistance.

During a review of Patient 32's "History and Physical (H&P)," dated 7/28/2025, the "H&P" indicated Patient 32 was admitted to the facility after falling 10-15 feet from a tree. The H&P further indicated Patient 32 sustained a large laceration (deep cut or tear in the skin) to the left arm and left knee region.

During a review of Patient 32's "Clinical Event Result (a significant and documented outcome that occurs during a patient's care)" record, dated 9/15/2025, the record indicated, "Patient (Patient 32) crying in bed for his dad," and "Patient yelling in the room."

During a review of Patient 32's "Activity of Daily Living (ADL, basic self-care tasks such as bathing, dressing, eating, and walking)" record, dated 9/16/2025, the record indicated Patient 32 required total assistance with ADLs (a person is completely dependent on another person to perform all aspects of a basic personal care task, such as feeding, bathing, or dressing, because they are unable to participate in the activity at all).

During a review of Patient 32's "Observation/Intervention," record, dated 9/16/2025, the record indicated, "Reason for Observation: Safety. Safety Intervention by Safety Attendant: Direct Observation (one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others) and Safety intervention by staff: Direct observation (a healthcare worker who provides continuous, direct observation and supervision of a single patient to ensure their safety)."

During a concurrent interview and record review on 9/16/2025 at 2:30 p.m. with the DOM, the "Nursing Assignment Schedule," dated 9/16/2025, was reviewed. The schedule indicated CNA 2 was assigned as a one-to-one sitter for both Patient 28 and Patient 32 simultaneously. The DOM stated both patients required line-of-sight observation (requires a designated staff member to maintain constant, unobstructed visual contact with a patient to prevent harm to themselves or others) for safety. The DOM confirmed that when CNA 2 was cleaning one patient, they (the CNA) would not be able to immediately intervene if the other patient was in danger, and other staff would need to be called for help. The DOM further stated one-to-one observation was based on nursing assessment and did not require a provider order.

During an interview on 9/19/2025 at 11:36 a.m. with the Nurse Manager (NM) 6, NM 6 stated it was not safe to assign one sitter to two patients on a line-of-sight observation, because line-of-sight required continuous, direct visual monitoring. NM 6 stated patients on a line-of-sight observation may be confused, at high risk for falls, or at risk for self-harm, and if the sitter was occupied with one patient, they (the CNA) could not immediately intervene for the other patient.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. Integrates interprofessional team partners in implementation of the plan through collaboration and communication across the continuum of care... Delegates according to the health, safety, and welfare of the patient and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care... The registered nurse performs and/or oversees delivers care according to the patient's need, LP orders, and the plan of care to achieve identified outcomes."

During a review of the facility's policy and procedure (P&P) titled, "Safety Attendant for Patients at Risk of Harm to Self or Others on a Unit other than behavioral health unit," dated 10/2021, the P&P indicated, "The implementation of a Safety Attendant will be used to provide a safe environment with interventions to allow for close monitoring and observation of the environment and behaviors of the patient. One-to-one Observation - means one competent observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area to ensure the safety and well-being of an individual patient or others. This requires continuous visual observation of one designated patient."

3. During a concurrent interview and record review on 9/19/2025 at 11:15 a.m. with the Director of Human Recourses (DHR), Registered Nurse 13's (RN 13) "Offer of employment letter," was reviewed. The letter indicated that RN 13 was hired to the facility's Telemetry Unit as a Registered Nurse on 4/3/2023.

During a concurrent interview and record review on 9/19/2025 at 1:21 p.m. with the Director of Education (DOE), the DOE was unable to provide documentation to reflect that RN 13 completed their latest annual nursing competency training. The DOE stated the latest due annual competencies included the following subject matters:
-Restraints/SI (Suicidal Ideation [thoughts of taking one's own life]/Ligature (a cord, rope, or other material used for strangulation or hanging, often by patients with suicidal ideation) Assessment and Risk
-Safe Patient Handling
-Active Shooter
-Hourly Rounding (a structured nursing practice where a nurse or patient care technician proactively visits patients at regular intervals to assess their needs for comfort, safety, and assistance with the "4 Ps": Pain, Potty, Positioning, and Possessions)
-Tele sitter (a trained healthcare professional who uses live video monitoring and two-way audio to remotely observe hospital patients, preventing falls and ensuring safety, especially for those at high risk)
-Health Equity (the fair and just opportunity for all people to achieve their highest level of health, regardless of their race, ethnicity, socioeconomic status, gender, sexual orientation, or other social determinants of health)
-Patient Experience
-Infection Control Management
-HAPI (Hospital Acquired Pressure Injury)

During an interview on 9/19/2025 at 1:25 p.m. with the DOE, the DOE stated that RN 13's latest annual competency was due prior to December 31, 2024. The DOE stated that the expectation was that all nurses were to complete their global competencies that included both classroom instruction and psychomotor (the relationship and interaction between mental processes and physical motor activities) skills demonstration. The DOE stated that a message was sent to the direct management of RN 13, but a follow-up was not completed to capture RN 13's lapse in their latest due annual competencies.

During a concurrent interview and record review on 9/19/2025 at 1:45 p.m. with the DOE, the DOE stated that RN 13 completed their EKG testing when hired in 2023, but did not complete their EKG testing for 2024, which was due by 12/31/2024. The DOE stated that it was possible that RN 13 was missed by fellow facility educators when courses were assigned through the facility's testing program. The DOE stated that the expectations for Telemetry nurses were that EKG testing was to be completed annually.

During an interview on 9/19/2025 at 1:48 p.m. with the DOE, the DOE stated, by nurses not completing their due annual competencies, it could lead to a delay in identifying and diagnosing heart arrythmias (a problem with the rate or rhythm of the heartbeat, causing it to beat too quickly, too slowly, or irregularly), and pose a risk for ensuring the nurses were prepared for doing their jobs.

During a review of the facility's policy and procedure (P&P) titled, "Competency Assessment and Validation Plan," dated 6/2023, the P&P indicated, "... POLICY: A. Each employee shall participate in a continuous assessment of competency, which will begin at the point of hire and continue through the annual performance appraisal. B. Key department/job classification competencies including age-specific and all mandated requirements will be assessed annually at the time of performance appraisal... H. The components and process of competency assessment in the department are as follows: ... 4. Initial assessments of department and/or job classification key competencies completed during and/or at the end of Department Orientation Assessment will be accomplished by verbal and written post-testing, job-related simulations and direct observation of performance... 6. Documentation records of mandatory, in-service and continuing education classes completed..."

During a review of the facility's "Telemetry RN Job Description," dated 10/10/2024, the document indicated, "... 16. General Competencies: 16.1 Job Standards: Maintains compliance with all mandatory licensure, certification and regulations. Completes annual safety, health, education, compliance and HIPAA (Health Insurance Portability and Accountability ACT, federal law that sets a national standard to protect medical records and other personal health information) requirements on time... Training: Basic or Advanced Dysrhythmias Certification..."

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

1. Ensure its staff activated a Rapid Response Team (RRT, an interdisciplinary team, critical care nurse and a respiratory therapist, that responds to RR activations throughout the hospital; purpose is to provide immediate, specialized care to patients who show signs of deteriorating health), in a timely manner, for two (2) of 33 sampled patients (Patients 1 and 2), who displayed a change of condition in respiratory (the process of breathing) status, in accordance with the facility's policy regarding RRT activation, when:

1.a. On 4/23/2025, the facility called Rapid Response Team (RRT) 40 minutes after Patient 1 started displaying signs and symptoms of respiratory distress (when breathing becomes difficult), oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) of 78 % (Normal: 95-100%), increased heart rate (156; Normal: 60 to 100 beats per minute [bpm]), and blood pressure (172/108; Normal: 120/90 millimeters of mercury [mm HG- a unit of measurement]). Two minutes later (after the RRT being called 40 minutes late from when Patient 1 started declining), a code blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when the patient stops breathing]) was subsequently called. Patient 1 expired.

1.b. On 8/16/2025, the facility called rapid response team (RRT) at 2:25 a.m. after Patient 2 started displaying signs and symptoms of respiratory distress with oxygen desaturation (a decrease in the amount of oxygen in the blood), increased respiratory rate (26; Normal: 12-20 breaths per minute) and increased breathing effort including use of accessory muscles (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) despite Hi-Flow oxygen (delivers heated, humidified air and oxygen at flow rates up to 60 L/min [liters per minute, a unit of measurement]) that was given since midnight of 8/16/2025. Patient 2 was intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) at 2:48 a.m. and was sent to the Intensive Care Unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care) for further management.

These deficient practices resulted in a delay in activating an RRT for Patients 1 and 2 and resulted in both patients being intubated. Patient 1 expired while the Code Blue was in progress. Patient 2 was transferred to the ICU for further management and was made a DNR (Do not resuscitate, a medical directive that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR, to maintain blood circulation and oxygen flow to vital organs during cardiac or respiratory arrest] if the patient's heart stops or breathing ceases) on 9/14/2025.

2. Ensure nursing staff followed the facility's policy and procedure (P&P) titled, "Fall (an unintentional descent of a patient to the ground) Prevention and Management, for one of 33 sampled patients (Patient 20), when there was no assessment completed for possible injuries post (after) fall, when the physician was not notified regarding Patient 20's fall incident, and when a fall related event report was not completed.

This deficient practice had the potential for Patient 20 to suffer from delayed detection and treatment of potentially life threating injuries (such as fractures [broken bones]) and other conditions that may have contributed to the fall. Thus, potentially resulting in long-term disability or even death for Patient 20.

3. Ensure that one of 33 sampled patient's (Patient 6), assessment regarding rectal bleeding finding (the passage of blood from the rectum [the final section of the large intestine, located just before the anus, and serves as a temporary storage site for feces]), was documented in the nursing flowsheet under gastrointestinal (GI, the stomach and intestines) assessment (evaluation of the digestive system, including the stomach, intestines, liver, and related structures; involves checking for signs and symptoms such as bleeding, and other indicators of GI health dysfunction) record, in accordance with the facility's policy regarding standards of nursing practice pertaining to assessment and documentation.

This deficient practice had the potential to impact Patient 6's safety and compromise care and discharge needs by potentially delaying treatment of the rectal bleeding, thus impairing accurate assessment of Patient 6's health status prior discharge.

4. Ensure that three (3) of 33 sampled patients (Patient 29, Patient 30, and Patient 31), who had provider orders for continuous telemetry monitoring (a system that continuously tracks a patient's heart activity by using small sicky patches called electrodes that send signals to a central monitor, allowing staff to detect dangerous heart rhythms [the pattern and timing of your heartbeats] in real time), were placed on telemetry monitoring immediately and continuously. The facility also failed to ensure that Patients 29 and 31 received timely cardiovascular assessment (a nurse's evaluation of the patient's heart and circulation to establish a baseline [the patient normal rhythms] for comparison if changes occur), in accordance with the facility's policies regarding telemetry monitoring and nursing standards of practice pertaining to patient assessment.

This deficient practice had the potential to delay recognition and treatment of serious heart complications, such as such as arrhythmias (irregular heartbeats) or cardiac arrest (when the heart suddenly stops beating), which can lead to death if not treated promptly.

On 9/18/2025 at 4:26 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 Chief Nurse Executive Officer (CNEO), Interim Chief Medical Officer (ICMO), and the Interim Quality Director (IQD). The facility failed to ensure its staff activated the Rapid Response Team (RRT, an interdisciplinary team, critical care nurse and a respiratory therapist), that responds to RR activations throughout the hospital, in a timely manner, when two patients (Patients 1 and 2) were displaying a change of condition of respiratory (the process of breathing) status.

For Patient 1: On 4/23/2025, the facility called a RRT (at 12:50 a.m.) 40 minutes after Patient 1 started displaying signs and symptoms of respiratory distress (difficulty breathing), starting at 12:10 a.m., oxygen saturation (measurement of the amount of oxygen in the blood) of 78 % (low, normal is above 90 %), increased heart rate (156; Normal: 60-100 beats per minute), and elevated blood pressure (172/108; Normal: 120/90). The RRT was called at 12:50 a.m. on 4/23/2025 and a Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when a patient stops breathing]) was subsequently called at 12:52 a.m. on 4/23/2025. Patient 1 expired (died) at 1:26 a.m. during the code blue. RRT activation was 40 minutes delayed.

For Patient 2: On 8/16/2025, the facility called a RRT at 2:25 a.m. (over 2 hours delayed activation of RRT), after Patient 2 displayed signs and symptoms of respiratory distress with oxygen desaturation (a decrease in the amount of oxygen in the blood), starting at 12:13 a.m., increased respiratory rate (26; Normal: 12-20 breaths per minute) and increased breathing effort including the use of accessory muscles (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) despite High-Flow oxygen (delivers heated, humidified air and oxygen at flow rates up to 60 L/min [liters per minute, a unit of measurement]) given since 12 a.m. on 8/16/2025. Patient 2 was intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) at 2:48 a.m., and was sent to the Intensive Care Unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care) with tracheostomy (trach, a surgical procedure that creates an opening in the trachea [windpipe] to allow air to enter and exit the lungs) and Patient 2 was made a DNR (Do Not Resuscitate, a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR, to maintain blood circulation and oxygen flow to vital organs during cardiac or respiratory arrest] if the patient's heart stops beating or breathing stops) on 9/14/2025.

On 9/19/2025 at 5:03 p.m., the IJ was removed in the presence of the CNEO, ICMO and the President, 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 acceptable IJ Removal plan included creating job aids and providing re-education for all staff regarding the criteria for activation of and immediate steps to take for a RRT. The criteria included but not limited to, acute (sudden and severe in onset) changes in condition, with regards to airway , breathing (rate less than 8 or more than 28, SpO2 (oxygen saturation of peripheral blood, measurement of the amount of oxygen in the blood) of less then 90 % despite being on oxygen supplement), circulation (heart rate less than 40 or more then 130; systolic blood pressure [the pressure in the arteries when the heart contracts and pumps blood throughout the body] of less than 90 or more than 180) ... Steps to take included, assessing the patient, activating the RRT, and documentation of the RRT. In addition, monitor technicians were educated on their responsibilities, including the escalation process in the event that the primary nurse or charge nurse do not respond to the call, and to not delay in calling a RRT or Code Blue, if necessary.

Findings:

1.a. During a concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit (a hospital unit that provides constant electronic monitoring of a patient's vital signs, such as heart rate, rhythm, and blood pressure), Patient 1's medical record, dated 4/26/2025, was reviewed. The DOT stated the following: Patient 1 was admitted on 3/25/2025 for shortness of breath (difficulty breathing), intubated (procedure that involves inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and admitted to the intensive care unit (ICU, a specialized hospital ward where critically ill patients receive close monitoring and intensive medical care. Patient 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to allow air to enter the lungs) placement on 4/9/2025 and was transferred to the Telemetry unit on 4/20/2025. Patient 1 was receiving oxygen at 10 Liters, FiO2 (Fraction of inspired oxygen, used to determine if a patient is receiving adequate oxygen) at 50 %, via T-piece (a medical device used to provide oxygen and ventilation to patients with a tracheostomy).

During the same interview on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT said Patient 1 started displaying signs of respiratory distress (when breathing becomes difficult) on 4/23/2025 at 12:10 a.m., after receiving trach (tracheostomy) care. At 12:10 a.m., Patient 1's oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) was 78 % (normal is above 90%), Patient 1's heart rate increased to 156, and 146 (Normal: 60-100). Blood pressure increased to 172/108 (high). Patient 1's nurse (RN 1) called the respiratory therapist (RT 1) to assess Patient 1. The RT assessed and suctioned Patient 1. A Rapid Response Team (RRT) was called, per nurse's notes at 12:35 a.m., however, the documentation on the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log, indicated the RRT was called at 12:50 a.m. A Code Blue (an emergency announcement indicating a patient is experiencing cardiac [when the heart stops beating] or respiratory arrest [when the patient stops breathing]) was called at 12:52 a.m.

During the same interview on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT said that Patient 1 met the criteria for an RRT, which included oxygen saturation of less than 90 % despite treatment, change in vital signs (HR, BP, O2 Sat). There was no evidence that RN 1 notified the physician of these changes. The DOT stated the RRT was called 40 minutes (at 12:50 a.m.) after Patient 1 started displaying signs of respiratory distress and changes in baseline vital signs. The DOT stated there was a delay in calling the RRT, which would trigger for a critical care nurse and a respiratory therapist to respond. At 12:52, a code blue was called. Patient 1 expired at 1:26 a.m. The DOT also verified there were no RRT notes documented in the medical record.

During an interview on 9/18/2025 at 4:01 p.m. with the Respiratory Therapist (RT) 1, RT 1 stated the following: RT 1 performed trach (tracheostomy) care for Patient 1 on 4/23/2025 from 12:03 a.m. to 12:10 a.m. About 20 to 25 minutes later, RN 1 called RT 1 to return and assess Patient 1 because Patient 1 was having increased work of breathing. RT 1 was in the Respiratory Department in a different building at that time. RT 1 returned to Patient 1 and assessed and suctioned Patient 1. RT 1 removed the inner cannula (a removable tube that fits inside the main tracheostomy tube [outer cannula, acting as a liner to make it easier to clean and prevent blockages from mucus buildup) to check for any obstructions and placed it back in. No obstructions were visualized. Patient 1 was not getting any better so an RRT was called and RT 1 started bagging (to provide assisted breathing using a manual, self-inflating resuscitation bag) Patient 1. A few minutes later a Code Blue was called. Patient 1 was intubated by the Anesthesiologist. Patient 1 expired (died) during the Code Blue.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, the H&P indicated Patient 1 had a past medical history of "multi-substance use, asthma, hypertension (high blood pressure) ...presented to the hospital due to worsening of shortness of breath (difficulty breathing), nausea (the urge to throw up), vomiting, altered mental status (a change in a person's level of consciousness [a person's degree of wakefulness and awareness of their surroundings and self] ...patient is intubated ...in the Intensive Care Unit."

During a review of Patient 1's Vital Signs (VS, includes the blood pressure, heart rate, temperature) record, the VS indicated the following:

-On 4/22/2025 at 8 p.m., Heart Rate (HR, reference range 51 - 119) was 93, Blood Pressure (BP) was 155/83 (high, reference range 91-139/51-89), Respiratory Rate (RR) 20 (normal, reference range 15 - 20), Temperature was 37 (normal).
-On 4/23/2025 at 12 a.m., HR was 78, Temperature 36.6 (normal)
-At 12:03 a.m., RR was 20, oxygen saturation was 95 % on FiO2 at 50% via T-Piece.
-At 12:08 a.m., HR was 108
-At 12:14 a.m., HR was 156 (high) and RR was 22 (high)
-At 12:15 a.m., BP was 172/108 (high)
-At 12:16 a.m., HR was 146 (high)

During a review of Patient 1's "Nursing Progress Note," dated 4/23/2025 at 6:37 a.m., the nursing progress notes indicated the following:

-At 12 a.m., "vital signs stable ...RT (respiratory therapist) came to do treatment for patient (Patient 1).
-At 12:10 a.m., "went into patient's (Patient 1's) room ...found patient having trouble breathing, checking patient. RT was called to check trach tie. RT came and trach was examined, continues on showing very anxious (feeling of fear, dread, or uneasiness)."
-At 12:14 a.m., the heart rate went up to 156.
-At 12:16 a.m., Patient remained short of breath, blood pressure went up to 172/108.
-At 12:35 a.m., RRT (Rapid Response Team) called. (Per DOT on 9/17/2025 at 10:35 a.m., DOT reviewed the PBX Rapid Response Log and stated the RRT was called at 12:50 a.m.)
-At 12:50 a.m. Code Blue called. ICU team arrived at 12:52 a.m.
-At 1:26 a.m., Despite resuscitation (to restart a patient's heart and breathing), Patient 1 expired.
-Addendum note, at 8 a.m. indicated the following:
-At 12:10 a.m., "After seeing RT do trach care, went inside patient's (Patient 1's) room to check, noted in respiratory distress oxygen saturation 78 % (Low, normal above 93 %), called RT to check the patient, titrated oxygen, suctioned the patient, continued to have respiratory distress. Charge nurse came and called for RRT ... patient (Patient 1) remained in respiratory distress, no pulse noted. Code Blue team came and took over."

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:45 a.m., the Respiratory Note indicated the following: Nurse called for RT (respiratory therapist), stated Patient 1 had increased work of breathing. Arrived in room and patient suctioned with catheter. Catheter was passed though airway with no resistance. Inner cannula was checked with no obstruction noted. Patient 1's saturation was checked and was noted to be falling below 90 % ...Rapid Response called. Bag (Ventilation bag) was connected to flowmeter on 100 % FiO2 and was provided to patient via trach ...Rapid Response team arrived with attending physician ...it was determined that the trach was dislodged ... minutes later a Code Blue was called.

During a review of Patient 1's "Respiratory Note," dated 4/23/2025 at 12:55 a.m., the Respiratory Note indicated the following: "RRT called ...upon arrival, patient (Patient 1) was being bagged on 100 % FiO2 via trach ...patient (Patient 1) appeared in respiratory distress ...It was determined the trach was dislodged. A few minutes later, a code blue was called due to the difficult airway ...patient (Patient 1) was intubated by the Anesthesiologist ...After a long resuscitation effort, ROSC (return of spontaneous circulation) was not obtained, and patient (Patient 1) was pronounced (declared dead) by the Attending Physician.

During a review of a PBX log titled, "Rapid Response," the PBX log indicated that on 4/23/2025 at 12:50 a.m., a code Rapid Response was called for Patient 1.

During a review of a PBX log titled, "Code Blue/White," the PBX log indicated that on 4/23/2025 at 12:52 a.m., a code blue was called for Patient 1.

During a review of the facility's policy and procedure (P&P) titled, "Adult Rapid Response Team," dated 8/24/2025, the P&P indicated the following: This policy allows patients, visitors, or employees to communicate an urgent need for rapid and timely intervention for a deteriorating person and for a critical care registered nurses (RN) to implement Standardized Procedures for adult patients ...The RRT: A Rapid Response Team is activated throughout the inpatient hospital. The composition of the team includes a critical care nurse and a respiratory care practitioner (RCP) ...

1. When a hospital staff member feels a patient warrants immediate assessment and intervention, they can activate the RRT dialing the hospital's Code line 77777 an specify the room and bed ...
Rapid Response Team Actitation Criteria:
Some patient's condition that may warrant activation of the Rapid Response Team (RRT) include, but are not limited to;
-A general feeling or urgency that the patient is not doing well
-Oxygen saturation < 90% or acute changes despite oxygen supplementation ...
-Failure to respond to a treatment (i.e. fluid bolus, respiratory)
-Hemodynamic instability
-Acute change in vital signs or change from their baseline
Rapid Response Team Guidelines: include,
-Communication with the physician will begin immediately after the start of the RRT, throughout the RRT, as needed ...
Rapid Response Team Documentation:
-The assigned nurse or staff member who activated the rapid response and who was involved with the team's response will complete the RRT evaluation (debrief) tool and give it to the RRT lead nurse for review.
-The patient's assigned RN will document the time of code activation and the events leading to the activation.
-The Rapid Response Team lead nurse will document in the electronic health record and under Rapid Response Note ...

1.b. During a review of Patient 2's "Physician Note (physician progress notes)," dated 8/15/2025, the physician progress notes indicated, Patient 2 was admitted to the facility on 7/12/2025 with diagnoses including but not limited to acute hypoxic respiratory failure (a life-threatening condition where the lungs fail to adequately exchange oxygen from the air into the bloodstream, leading to low oxygen levels (hypoxemia) in the body), hepatic encephalopathy (a neuropsychiatric syndrome [These symptoms can affect a person's mood, behavior, cognition- the process of thinking and knowing, and physical health] that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (high blood sugar level) and acute kidney injury (a sudden decline in kidney function that leads to a buildup of waste products in the blood and an imbalance of fluids and electrolytes). The physician progress notes also indicated Patient 2 was receiving oxygen at three (3) liters per minute (LPM, how much oxygen delivered each minute) via nasal cannula (NC, a plastic flexible tube that provides oxygen through the nose).

During a review of Patient 2's physician order, dated 8/15/2025, the physician order indicated, Patient 2 was on continuous pulse oximetry monitoring (a noninvasive procedure that uses a small device to measure the percentage of oxygen saturation in the blood).

During a review of Patient 2's "Vital Signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) Flowsheet (VS flowsheet)," dated 8/15/2025, the VS flowsheet indicated, on 8/15/2025 at 8 p.m., Patient 2's oxygen saturation level (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) was 93 % (normal range 95-100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) with 18 respiratory rate (RR) per minute (normal respiratory rate range 12 - 20 per minute) and on oxygen at 3 LPM via nasal cannula.

During a review of Patient 2's "Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration [worsening]) Note (RRT notes)," dated 8/16/2025, the RRT notes indicated, "(on 8/16/2025) RRT called at 0223hr (2:23 a.m.) due to worsening hypoxemia (low oxygen level). Upon arrival, patient (Patient 2) on high dose of oxygen, 100 % NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patients with severe respiratory distress [difficulty breathing] or hypoxia) and HFNC (High-Flow nasal Cannula [a medical device delivers a mixture of heated and humidified air and oxygen at high flow rates to treat respiratory failure) 60 Liters [per minute] (L/min, unit of measure)/ 91 % [FiO2](Fraction of Inspired Oxygen [concentration of oxygen in the air) with O2 Sat of 71 % (critical low oxygen saturation). Per primary RN (RN 13), patient (Patient 2) had been desaturating (the blood oxygen saturation level was dropping) to 87 % since midnight. PMD [physician, MD 5] was informed with order of Lasix (medication to treat fluid overload [too much]) 40 mg (milligrams, unit of measure) IVP (Intravenous push, administered into a vein) given at 0027 (12:27 a.m.) and Bumex (medication to treat fluid retention, 40 times more potent than Lasix) 1 mg IVP & (and) Solu-Medrol (medication to treat inflammation [swelling] and breathing problem) 40 mg IVP given at 0207 (2:07 a.m.) which didn't show any improvement but instead patient (Patient 2) desaturated (decrease) more to 69 %. Hence RRT was called ... RR 25, shallowing breathing ... patient (Patient 2) continued to desaturate as low as 55 % ... intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) at 0248hr (2:48 a.m.)." The RRT notes also indicated Patient 2 was transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) on a ventilator (an appliance for artificial respiration).

During an interview on 9/18/2025 at 10:58 a.m. with the Charge Nurse (CN) 10 of Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring), CN 10 stated the following: anyone could call rapid response team (RRT) when the patient had a change of condition including change in respiratory status, mentation (mental activity) changes and change in vital signs. Staff should call RRT also for extra help and to evaluate possible intubation when they were not able to maintain a patient's oxygenation.

During a concurrent interview and record review on 9/18/2025 at 11:12 a.m. with the CN 10, the facility's "Daily Central Monitoring Log Sheet (tele log)," dated from 8/15/2025 to 8/16/2025, was reviewed. The tele log indicated "O2 Sat low" calls were made by the monitor tech (MT) 4 to Patient 2's primary nurse (RN 13) on 8/16/2025 at 12:13 a.m., 12:48 a.m., 1:14 a.m., and 2:07 a.m. The tele log also indicated RRT was called at 2:25 a.m. for Patient 2. CN 10 stated the following: as a general rule, the monitor tech would notify the nurse when a patient's O2 Sat was below 90 %. The number of calls during the time span from 12:13 a.m. to 2:07 a.m. indicated Patient 2's O2 Sat was fluctuating (changing up and down) and not stable. CN 10 stated, "it is a long time (from onset time 12:13a.m. to RRT time 2:25 a.m.)." CN 10 further stated the following: the RRT was delayed. Even though there was communication with the physician and interventions provided, it should not take long to see an improvement. RN 13 took too long to call the RRT. Patient 2's condition could decompensate (to worsen) and result in respiratory distress.

During a concurrent interview and record review on 9/18/2025 at 11:25 a.m. with the Manager (RM 1) of Respiratory, Patient 2's "Respiratory Treatment Form (RT notes)," dated 8/16/2025, was reviewed. The RT notes indicated, on 8/16/2025 at 00:25 a.m. (12:25 a.m.), Patient 2 was noted to have shortness of breath, light to moderate, with or without activity, coarse crackles (loud, low-pitched, and longer-lasting "bubbling" or "rattling" discontinuous lung sounds) bilaterally (both) and using accessory muscle (additional muscles that assist the primary respiratory muscles in expanding and contracting the chest cavity, facilitating breathing) to breath. Patient 2 was on HFNC with liter flow rate of 50 L/min. Breathing treatment of Albuterol (bronchodilators [relax and open the air passage to the lungs to make breathing easier]) and Mucomyst (medication to break apart mucus in the lungs) were given. The oxygen flow rate of HFNC was increased to 55 L/min and Patient 2's respiration rate was 26. RM 1 stated RRT should have been called because Patient 2 was not getting better and tachypneic (rapid breathing). There was a delay in calling the RRT. RM 1 further stated prolonged hypoxemia could cause damage to brain and heart.

During a review of the facility's policy and procedure (P&P) titled, "Adult Rapid Response Team," dated 8/24/2025, the P&P indicated the following: This policy allows patients, visitors, or employees to communicate an urgent need for rapid and timely intervention for a deteriorating person and for a critical care registered nurses (RN) to implement Standardized Procedures for adult patients ...The RRT: A Rapid Response Team is activations throughout the inpatient hospital. The composition of the team includes a critical care nurse and a respiratory care practitioner (RCP) ...

1. When a hospital staff member feels a patient warrants immediate assessment and intervention, they can activate the RRT dialing the hospital's Code line 77777 an specify the room and bed ...
Rapid Response Team Actitation Criteria:
Some patient's condition that may warrant activation of the Rapid Response Team (RRT) include, but are not limited to;
-A general feeling or urgency that the patient is not doing well
-Oxygen saturation < 90% or acute changes despite oxygen supplementation ...
-Failure to respond to a treatment (i.e. fluid bolus, respiratory)
-Hemodynamic instability
-Acute change in vital signs or change from their baseline
Rapid Response Team Guidelines: include,
-Communication with the physician will begin immediately after the start of the RRT, throughout the RRT, as needed ...
Rapid Response Team Documentation:
-The assigned nurse or staff member who activated the rapid response and who was involved with the team's response will complete the RRT evaluation (debrief) tool and give it to the RRT lead nurse for review.
-The patient's assigned RN will document the time of code activation and the events leading to the activation.
-The Rapid Response Team lead nurse will document in the electronic health record and under Rapid Response Note ...

2. During a review of Patient 20's, "ED (Emergency Department, a hospital service that provides immediate medical care for acute [sudden and severe onset] and life-threatening conditions) Triage (process used to prioritize and categorize patients based on the severity of their condition and their need for immediate medical attention)" notes, dated 7/29/2025, the ED triage note indicated Patient 20 presented to the facility's ED at 8:23 p.m. with chief complaint of dizziness and triage assessment also indicated Patient 20 was unsteady on feet and unsure if Patient 20 had a seizure (sudden burst of electrical activity in the brain causing jerking movements in the body).

During a concurrent observation and interview on 9/18/2025 at 2:46 p.m. with the Emergency Department Manager (NM 2) and the Manager of Security (MOS), the facility's ED security footage dated 7/30/2025 at 12:58 a.m., was reviewed. Patient 20 was observed sitting in the chair in the ED lobby waiting area and tried to get up. Patient 20 was observed leaning toward the left side, lost balance, and fell to the ground. Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 20 (RN 20) was the only staff present at the time of fall and approached Patient 20 after the fall. RN 20 and Patient 20's family representative was observed helping Patient 20 get back in the chair. MOS stated Patient 20 left the ED lobby about 1:42 a.m.

During a concurrent interview and record review on 9/18/2025 at 3:10 p.m. with NM 2, Patient 20's, "Event flow sheet," dated 7/30/2025, was reviewed. NM 2 stated Patient 20 left AMA (against medical advice, choosing to leave the hospital before the treating physician recommends discharge) and left the signed AMA paper at 1:45 a.m. NM 2 stated Patient 20 should have been assessed for possible injury after the fall. NM 2 also stated a provider should have been informed after the fall.

During the same interview on 9/18/2025 at 3:10 p.m. with NM 2, NM 2 stated the nurse (RN 20) seen in the security footage (on 7/30/2025) could have been assessing Patient 20 since it appeared that the RN (RN 20) was talking to Patient 20. However, this cannot be confirmed since there was no documentation made by the RN (RN 20) regarding post fall nursing assessment or physician notification after the fall incident.

During an interview 9/18/2025 at 3:29 p.m. with the Director of Education (DOE), DOE stated there was a potential risk for undiagnosed injury for Patient 20 when Patient 20 did not get evaluated after the fall. The DOE further said "patient safety was what we want."

During a concurrent interview and record review on 9/19/2025 at 9:36 a.m. with NM 2 and Clinic Educator (CE 2), Patient 20's "ED Triage" note, dated 7/29/2025, was reviewed. NM 2 stated Patient 20 was a risk for fall based on presenting symptoms of dizziness and unsteady gait upon arrival to the ED.

During

Based on interview and record review, the facility failed to ensure that one of 33 sampled patients (Patient 3), was treated immediately with prescribed medications (Pepcid [famotidine, treats heartburn and other conditions caused by excess stomach acid] and Benadryl [diphenhydramine, treats allergy symptoms]), when Patient 3 presented to the Emergency Department (ED) with an allergic reaction of an itchy rash to both legs, in accordance with the physician's orders and the facility's policy and procedures regarding medication administration.

This deficient practice resulted in a delay in treatment for Patient 3 and resulted in Patient 3's symptoms being unrelieved for three (3) hours.

Findings:

During an interview on 9/18/2025 at 1:09 p.m. with the Director of the Emergency Department (DED), the DED stated the following: Patient 3 presented to the Emergency Department (ED) on 1/29/2025 at 6:55 p.m., for a rash to both legs. Both Pepcid (famotidine, treats heartburn and other conditions caused by excess stomach acid) and Benadryl (diphenhydramine, treats allergy symptoms) were ordered in combination, to treat Patient 1's itchy rash to the legs. Benadryl and Pepcid were ordered on 1/29/2025 at 8:02 p.m., and were supposed to be given within 30 minutes, as ordered. The DED verified that the Benadryl and Pepcid were given at 11:11 p.m., three hours later. Patient 3 had to wait 3 hours for her (Patient 3) symptoms to be relieved.

During a review of Patient 3's "ED Triage (to sort or prioritize something, most commonly patients in an emergency setting, based on the severity of their condition to determine who needs immediate care) - Text," dated 1/29/2025 at 7:53 p.m., the Text indicated Patient 3 was triaged and assigned an ESI Level 4 (semi-urgent condition, that is not immediately life-threatening). Patient 3's chief complaint was "allergic reaction, itchy rash to bilateral (both) legs, started this morning ...denies shortness of breath or airway swelling ..."

During a review of Patient 3's "MSE (Medical Screening Examination, purpose of an MSE is to determine, with "reasonable clinical confidence," whether or not a person who comes to the ED has an emergency medical condition (EMC) Screening - Text," dated 1/29/2025 at 7:59 p.m., the Text indicated MSE Screening was initiated - Patient 3 "presents for C/C (chief complaint) of pruritic (itchy) rash only on legs since this morning (1/29/2025). Started taking Augmentin (an antibiotic used to treat bacterial infections) and Flagyl (an antibiotic used to treat infections caused by bacterial and parasites) yesterday (1/28/2025). Currently, breastfeeding. No acute distress (patient appears stable and is not exhibiting signs of severe or sudden suffering, discomfort, or difficulty), unlabored respirations (normal, effortless breathing). Orders placed, further evaluation by definitive provider."

During a review of Patient 3's "Medication Orders," dated 1/29/2025 at 8:02 p.m., the medication orders indicated the following:

-diphenhydramine (Benadryl, relieves allergy symptoms) 25 mg (milligrams, a unit of measurement) capsule x 1 (once) PO (by mouth) STAT (immediately).
-famotidine (Pepcid, aids in treating allergy symptoms) 20 mg PO STAT x1 (once).

During a review of Patient 3's nurse's notes, dated 1/29/2025 at 10:52 p.m., the nurse's note indicated Patient 3 called in to "recheck VS (vital signs). C/O (complained of) itching to both legs but denied SOB (shortness of breath)."

During a review of Patient 3's "Medication Administration Record," dated 1/29/2025 at 11:11 p.m., the record indicated Benadryl and Pepcid were administered (approximately 3 hours after being ordered STAT) to Patient 3.
During a review of Patient 3's nurse's notes, dated 1/30/2025 at 12:36 a.m., the nursing note indicated Patient 3 stated "feels no itching now."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 2/2025, the P&P indicated the following: All drugs and biologicals shall be prepared and administered according to the physician orders ...Medications not eligible for scheduled dosing times may include, but are not limited to: A. Stat doses (immediate)...

Based on interview and record review, the facility failed to ensure that discharge instruction form was promptly signed by patient and properly filed and retained, for one of 33 sampled patients (Patient 4), in accordance with the facility's policy regarding documentation, when there was no copy of a signed Discharge instructions (personalized instructions given to a patient and/or their caregiver to guide them in continuing their care at home after leaving a hospital or other healthcare facility) form filed and retained by the facility to indicate that Patient 4 was provided the post (after) discharge care educational material and instructions and understood them.

This deficient practice had the potential for Patient 4 not to receive and/or understand the discharge instructions thus increasing the risk of compromised continuity of care, misunderstanding about the patient's (Patient 4) condition and recovery plan, and delayed follow-up and treatment after discharge.

Findings:

During a review of Patient 4's History and Physical (H&P, a formal assessment by a healthcare provider that includes the patient's medical history, symptoms, physical examination findings, and a provider's assessment and treatment plan), dated 3/21/2025, the H&P indicated that Patient 4 was transferred to the facility on 3/20/2025 with altered mental status (AMS, a change in a person's level of consciousness, awareness, and cognitive function) and was diagnosed with low blood sugar levels (blood sugar levels drop below a healthy range). The H&P also indicated that Patient 4 had past medical history of pancreatic cancer (a malignant [cancerous] disease that arises in the pancreas, an organ located in the abdomen behind the stomach), and diabetes (a chronic condition in which the body does not produce or use insulin effectively, leading to high blood sugar levels).

During a review of Patient 4's physician's orders, dated 3/21/2025, the order indicated that the "Discharge" order for Patient 4 was recorded on 3/21/2025 at 2:12 p.m.

During a concurrent interview and record review on 9/18/2025 at 3:00 p.m. with the Clinical Educator (CE 1), Patient 4's electronic health record was reviewed to determine the time Patient 4 left the facility. CE 1 stated that Patient 4 left the facility on 3/21/2025 at 5:15 p.m.

During an interview on 9/17/2025 at 3:15 p.m. with the Clinical Educator (CE 1), CE 1 verified that Patient 4's digital healthcare record (electronic health record [EHR], is a computerized, comprehensive collection of a patient's health information that is shared across different healthcare providers and settings), did not contain a copy of a signed (by Patient 4) discharge instructions indicating that Patient 4 "received educational materials/instructions and medication list and have verbalized understanding."

During an interview on 9/18/2025 at 2:00 p.m. with Charge Nurse (CN 10), CN 10 said that discharge instructions and its documentation in the patient's medical record, summarize why the patient was in the hospital and what prescriptions (a formal written instruction, primarily a doctor's order, for a medication or a specific intervention, such as prescription glasses or an exercise program) were given to the patient, and that these prescriptions were reviewed with the patient prior to their departure. CN 10 also said, "Discharge instructions should be signed by the patient, and a copy should be retained."

During an interview on 9/18/2025 at 3:15 p.m. with Interim Quality Director (IQD), the IQD verified that there was no copy of Patient 4's signed discharge instructions retained in the medical records (the official documentation that contains a patient's complete health history, treatment records, and related documents) for Patient 4's admission from 3/20/2025 to 3/21/2025.

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," last revised 10/2024, the P&P indicated that, "Documentation is considered a communication tool ... 4. Documentation should be done as close to time of assessment, treatment, and response as possible to keep the record current and ensure availability of the most recent information for all caregivers using the record.

During a review of the facility's policy and procedure (P&P) titled, "Care Coordination Discharge Planning," last revised 4/2025, the P&P indicated that "...that all necessary patient or caregiver/representative teaching has occurred, completing discharge instructions, providing written discharge instructions (including post-acute follow up) and reconciled medication list, and documenting discharge in the medical record."

Based on interview and record review, the facility failed to ensure its nursing staff documented the reassessment and evaluation for one (1) of 33 sampled patient's (Patient 2) response to treatment and medications, given on 8/16/2025, , when there was a change of condition (a sudden change from the baseline condition requiring medical attention), in accordance with the facility's policy and procedure regarding standards of care pertaining to reassessment and documentation.

This deficient practice had the potential to result in other healthcare team members not being able to evaluate the cause of Patient 2's change of condition, response to treatment, which may potentially lead to delay of treatment and care.

Findings:

During a review of Patient 2's "Physician Note (physician progress notes)," dated 8/15/2025, the physician progress notes indicated, Patient 2 was admitted to the facility on 7/12/2025 with diagnoses including but not limited to acute hypoxic respiratory failure (a life-threatening condition where the lungs fail to adequately exchange oxygen from the air into the bloodstream, leading to low oxygen levels (hypoxemia) in the body), hepatic encephalopathy (a neuropsychiatric [These symptoms can affect a person's mood, behavior, cognition- the process of thinking and knowing, and physical health] syndrome that occurs when the liver is unable to properly metabolize toxins, leading to their accumulation in the brain), diabetes (high blood sugar level) and acute kidney injury (a sudden decline in kidney function that leads to a buildup of waste products in the blood and an imbalance of fluids and electrolytes). The physician progress notes also indicated Patient 2 was receiving oxygen at three (3) liters per minute (LPM, how much oxygen delivered each minute) via nasal cannula (NC, a plastic flexible tube that provides oxygen through the nose).

During a review of Patient 2's physician order, dated 8/15/2025, the physician order indicated, Patient 2 was on continuous pulse oximetry monitoring (a noninvasive procedure that uses a small device to measure the percentage of oxygen saturation in the blood).

During a review of Patient 2's "Vital Signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) Flowsheet (VS flowsheet)," dated 8/15/2025, the VS flowsheet indicated, on 8/15/2025 at 8 p.m., Patient 2's oxygen saturation level (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) was 93 % (normal range 95-100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) with 18 respiratory rate (RR) per minute (normal respiratory rate range 12 - 20 per minute) on oxygen 3 LPM via nasal cannula.

During a review of Patient 2's "Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration [worsening]) Note (RRT notes)," dated 8/16/2025, the RRT notes indicated, "(on 8/16/2025) RRT called at 0223hr (2:23 a.m.) due to worsening hypoxemia (low oxygen level). Upon arrival, patient on high dose of oxygen, 100 % NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patient with severe respiratory distress [difficulty breathing] or hypoxia) and HFNC (High-Flow nasal Cannula [a medical device delivers a mixture of heated and humidified air and oxygen at high flow rates to treat respiratory failure) 60 Liters [per minute] (L/min, unit of measure)/ 91 % [FiO2](Fraction of Inspired Oxygen [concentration of oxygen in the air) with O2 Sat of 71 % (critical low oxygen saturation)."

During further record review of Patient 2's "Rapid Response Team Note (RRT notes)," dated 8/16/2025, the notes indicated "patient (Patient 2) had been desaturating (the blood oxygen saturation level was dropping) to 87 % since midnight. PMD [physician, MD 5] was informed with order of Lasix (medication to treat fluid overload [too much]) 40 mg (milligrams, unit of measure) IVP (Intravenous push, administered into a vein) given at 0027 (12:27 a.m.) and Bumex (medication to treat fluid retention, 40 times more potent than Lasix) 1 mg IVP & (and) Solu-Medrol (medication to treat inflammation [swelling] and breathing problem) 40 mg IVP given at 0207 (2:07 a.m.) which didn't show any improvement but instead patient (Patient 2) desaturated more to 69 %. Hence RRT was called... RR 25, shallowing breathing ... patient (Patient 2) continued to desaturate as low as 55 %... intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) at 0248hr (2:48 a.m.)." The RRT notes also indicated Patient 2 was transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) on a ventilator (an appliance for artificial respiration).

During an interview on 9/19/2025 at 10:53 a.m. with the Director (DOT) of Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring), DOT stated the following: when there was intervention, there should be reassessment and documentation. The purpose of reassessment was to determine the response to treatment and need for further intervention. Patient 2 had a huge change in the respiratory status from baseline. RN 13 did not document any reassessment when Patient 2 had a change of condition. RN 13 also did not document Patient 2's response after medications (Lasix, Bumex and Solu-Medrol) were given. DOT stated it was unknown what caused Patient 2's change of condition and Patient 2's response to interventions before RRT was called due to lack of documentation by RN 13. DOT stated, "Documentation is important, so we know what happened (to Patient 2)."

During a review of the facility's policy and procedure (P&P) titled, "Telemetry and Stepdown Standards of Care," dated 2/2023, the P&P indicated, "Standard I (Roman numeral system meaning number one [1]): The Telemetry/ Stepdown nurse executes use of the nursing process. Criteria ... C. Implementation ... 5. Recording of action and response of action ... D. Evaluation ... 2. Ongoing comparisons of patient status with baseline data ... 4. Recording effective nursing measures ... Standard III (Roman numeral system meaning number three [3]): The Telemetry/Stepdown nurse will assess and maintain homeostasis and circulation of each patient ... D. Reassess the patient at the beginning of each shift and with any change in patient status; documentation on I view flowsheets/ events (part of patient's electronic health record)."

Based on interview and record review, the facility failed to ensure medical records were complete and accurate, in accordance with the facility's policy regarding rapid response team (RRT, a team that responds to Rapid Response activation, team consist of a critical care nurse and a respiratory therapist) documentation, for one of 33 sampled patients (Patient 1) when a Rapid Response Team was called for Patient 1. The RRT incident was not documented in the medical record. The time of the RRT documented in the nurse's notes was also inaccurate, when compared to the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) Log.

This deficient practice had the potential for wrong or misleading information, in the event that the RRT was under investigation and may also negatively impact the facility's ability to identify issues related to care, understand underlying causes, and implement improvement measures for patient safety.

Findings:

During a concurrent interview and record review on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit (a hospital unit dedicated to the continuous, remote monitoring of patients whose cardiac [heart] conditions or other illnesses require constant observation), Patient 1's medical record, was reviewed. The DOT stated the following: Patient 1 was admitted on 3/25/2025 for shortness of breath (difficulty breathing), intubated (inserting a tube into the trachea [windpipe] to maintain an open airway and facilitate breathing) and was admitted in the intensive care unit (ICU, a hospital department providing specialized, round-the-clock care for critically ill or injured patients, or those recovering from major surgery or serious illness). Patient 1 had a tracheostomy placement (a surgical procedure that creates an opening in the front of the neck [trachea or windpipe] to allow a person to breathe when their natural airway is blocked or compromised) on 4/9/2025 and was transferred to the Telemetry unit on 4/20/2025. Patient 1 was receiving oxygen at 10 L (liters), FiO2 (Fraction of Inspired Oxygen [concentration of oxygen in the air) at 50 %, via T-piece (a medical device used to provide oxygen and ventilation to patients who are either breathing on their own or require assisted ventilation). Patient 1 started displaying signs of respiratory distress (a condition where breathing becomes difficult) on 4/23/2025 at 12:10 a.m., after receiving trach (tracheostomy) care.

During the same interview on 9/17/2025 at 10:35 a.m. with the Director of the Telemetry (DOT) unit, the DOT stated the following: On 4/23/2025 at 12:10 a.m., Patient 1's oxygen saturation (the amount of oxygen in the blood) was 78 % (normal is above 90%), Patient 1's heart rate increased to 156, and 146 (Normal is 60-100). Blood pressure increased to 172/108 (high; Normal is 120/90). Patient 1's nurse (RN 1) called the respiratory therapist (RT 1) to assess Patient 1. A Rapid Response Team (RRT) was called, per nurse's notes at 12:35 a.m., however, the documentation on the PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log, indicated the RRT was called at 12:50 a.m. The DOT verified that the RRT was called 40 minutes (at 12:50 a.m.) after Patient 1 started displaying signs of respiratory distress and changes in baseline vital signs. The RRT turned into a Code Blue at 12:52 a.m., Patient 1 expired at 1:26 a.m. The DOT also verified there were no RRT notes regarding the incident that was documented in the medical record which should have been documented by the critical care nurse who responded to the RRT.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2025, the H&P indicated Patient 1 had a "past medical history of multi-substance use, asthma (a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breathe), hypertension (high blood pressure) ...presented to the hospital due to worsening of shortness of breath (difficulty breathing), nausea (the urge to throw up), vomiting, altered mental status (a significant change in a person's level of consciousness [a person's degree of wakefulness and awareness of their surroundings and self, existing on a spectrum from fully alert to completely unresponsive], cognitive function [memory, attention, learning, perception, and decision-making], or behavior ) ...patient (Patient 1) is intubated ...in the Intensive Care Unit."

During a review of Patient 1's "Nursing Progress Note," dated 4/23/2025 at 6:37 a.m., the nursing progress notes indicated the following:

-At 12:35 a.m., RRT (Rapid Response Team) called. (Per DOT on 9/17/2025 at 10:35 a.m., DOT reviewed the PBX Rapid Response Log and stated the RRT was called at 12:50 a.m.)

During a review of a PBX (Public Broadcasting Exchange, overhead paging and emergency announcements for staff and visitors) log titled, "Rapid Response," the PBX log indicated that on 4/23/2025 at 12:50 a.m., a code Rapid Response was called for Patient 1.

During a review of the facility's policy and procedure (P&P) titled, "Adult Rapid Response Team," dated 8/24/2025, the P&P indicated the following: This policy allows patients, visitors, or employees to communicate an urgent need for rapid and timely intervention for a deteriorating person and for a critical care registered nurses (RN) to implement Standardized Procedures for adult patients ...The RRT: A Rapid Response Team is activated throughout the inpatient hospital. The composition of the team includes a critical care nurse and a respiratory care practitioner (RCP) ...
Rapid Response Team Documentation:
-The assigned nurse or staff member who activated the rapid response and who was involved with the team's response will complete the RRT evaluation (debrief) tool and give it to the RRT lead nurse for review.
-The patient's assigned RN will document the time of code activation and the events leading to the activation.
-The Rapid Response Team lead nurse will document in the electronic health record and under Rapid Response Note ...

Based on interview and record review, the facility failed to ensure that for two of 33 sampled patients (Patient 4 and Patient 8), pertinent information necessary to monitor Patient 4's and Patient 8's condition, was documented in their (Patient 4 and Patient 8) medical records, in accordance with the facility' policy regarding core nursing standards of practice pertaining to documentation, when:

1. Vital signs (VS, measurements of key bodily functions such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation [an important indicator of oxygenation status]) were not obtained and promptly recorded for Patient 4 prior to Patient 4's discharge from the facility.

This deficient practice had the potential for Patient 4's key vital signs (VS) to be unmonitored prior to discharge, which could lead to undetected physiological instability, delayed recognition of worsening of Patient 4's condition, and increased risk of adverse events such as post-discharge complications.

2. Patient 8's daily weight was not obtained and recorded every day as ordered by the provider.

This deficient practice had the potential to negatively impact clinical-decision making and continuity of care, compromise Patient 8's quality of care, leading to inadequate monitoring of fluid status (the balance between how much fluid a person takes in and how much they lose, indicating if they are adequately hydrated or experiencing fluid overload [hypervolemia] or dehydration [hypovolemia]), including missed signs of worsening in Patient 8's condition, which may delay treatment.

Findings:

1. During a review of Patient 4's History and Physical (H&P, the comprehensive documentation of a patient's medical history and the findings from their physical examination), dated 3/3/2025, the H&P indicated that Patient 4 presented to the facility on 3/2/2025 with a complaint of "chemo-port being pulled out (a small, surgically implanted device under the skin, usually in the chest, that provides long-term access to the bloodstream)." The H&P also indicated that Patient 4 was admitted to the facility on 3/3/2025 with a diagnosis of acute kidney injury (AKI, a condition where the kidneys suddenly lose their ability to function properly) with metabolic acidosis (a condition in which the body accumulates too much acid in the blood).

During a review of Patient 4's Discharge Summary, dated 3/72025, the record indicated that Patient 4 was discharged on 3/6/2025 at 4:31 p.m.

During a concurrent interview and record review on 9/17/2025 at 2:03 p.m. with Clinical Educator (CE 1), Patient 4's Vital Signs Flowsheet (VS a document, often electronic, used in healthcare to systematically record and display a patient's vital signs [temperature, pulse, respiration, blood pressure, and oxygen saturation [a percentage, %] indicating how "full" the red blood cells are with oxygen] over time), dated 3/6/2025, was reviewed. The flowsheet indicated that the last set of VS on the day of discharge was documented at 12:00 p.m. (on 3/6/2025, 4 hours before Patient 4 was physically discharged from the facility). CE 1 verified that the last set of VS was documented at 12:00 p.m. and said that VS should be obtained and recorded within 1 hour of discharge in accordance with the facility's policy.

During an interview on 9/18/2025 at 1:48 p.m. with Registered Nurse (RN) 15, RN 15 said the following, "I typically obtain Vital Signs (VS) within 30 minutes prior to discharge ...I want to make sure that my patient is stable and has safe vital signs before they leave the facility. VS help us to confirm that patient's condition is stable enough for discharge and reduces the risk of potential complications after discharge ...it is also important to document the vital signs because, if it is not documented, it is not done."

During an interview on 9/18/2025 at 2:00 p.m. with Charge Nurse (CN) 10, CN 10 said that Vital Signs (VS) should be obtained and documented 1 hour prior to the patient being discharged.

During a review of the facility's policy and procedure (P&P) titled, " Core Nursing Standards of Practice," dated 10/2024, the P&P indicated that "Documentation should be done as close to time of assessment, treatment, and response as possible to keep the record current and ensure availability of the most recent information for all caregivers using the record. Vital Signs should be obtained 1 hour prior to discharge..."

2. During a review of Patient 8's History and Physical (H&P, the comprehensive documentation of a patient's medical history and the findings from their physical examination), dated 9/15/2025, the H&P indicated that Patient 8 was admitted to the facility on 9/15/2025 with a diagnosis of acute respiratory failure (a life-threatening emergency that occurs when the lungs fail to adequately oxygenate the blood or remove carbon dioxide [a waste product of breathing process]) and fluid overload (occurs when there is an excessive amount of fluid in the body) due to noncompliance with hemodialysis, (HD, a medical treatment that replaces the function of the kidneys when they are no longer able to do so). The H&P also indicated that Patient 8 had past medical history (record of a patient's previous medical conditions, surgeries, hospitalizations, medications, and other relevant health information) of end-stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood).

During a concurrent interview and record review on 9/18/2025 at 11:23 a.m. with the Clinical Educator (CE) 1, the daily Weight Flowsheet (a detailed record used to document the patient's weight each day), for Patient 8, dated 9/15/2025 through 9/18/2025, was reviewed. The flowsheet review indicated that no daily weight was recorded for Patient 8 on 9/16/2025. CE 1 verified the lack of documentation for daily weight on 9/16/2025 and said: "This is a dialysis patient (an individual who requires a medical procedure called dialysis to remove waste products and excess fluid from their blood when their kidneys are no longer functioning properly); this patient requires daily weights checks regardless of whether or not there was a physician's order for daily weight checks. Nurses should obtain and record daily weight to monitor the patient's fluid status and to determine whether the therapies are effective or need to be adjusted based on the patient's conditions."

During an interview on 9/18/2025 at 11:36 a.m. with the Clinical Educator (CE) 1, CE 1 said that a physician had placed an order for "daily weights," on 9/15/2025 at 1:23 p.m.

During an interview on 9/18/2025 at 1:18 p.m. with the Director of Medical Surgical Unit (DOM), the DOM said the following regarding daily weight checks and documentation: "Daily weights should typically be obtained by the night shift staff. If not obtained, then the day shift should follow up, obtain, and record the daily weight. Patients who require daily weights checks need to be closely monitored for weight gain or loss, as these can indicate changes in their fluid status or overall conditions ...Fluid balance monitoring is another method used to assess patient's condition, as fluctuations in weight can reflect either a negative or positive fluid balance, which helps in managing edema (fluid overload) or dehydration (fluid loss) and guides ongoing treatment decisions for all healthcare providers..."

During a review of the facility's policy and procedure (P&P) titled, " Core Nursing Standards of Practice," dated 10/2024, the P&P indicated that "Documentation should be done as close to time of assessment, treatment, and response as possible to keep the record current and ensure availability of the most recent information for all caregivers using the record .... Actual patient weight should be obtained and documented on admission, PRN (as needed) and each day per physicians 'order or if patient condition warrants.'

Based on interview and record review, the facility failed to ensure that for one of 33 sampled patients (Patient 4), a discharge summary (a medical document summarizing the patient's hospital's stay, including discharging diagnoses, treatments, outcomes, and follow-up plans), was recorded indicating a discussion of the outcome of Patient 4's hospitalization and arrangements for follow-up care, in accordance with the facility's medical rules and regulations pertaining to discharge summary documentation.

This deficient practice had the potential to increase risk of poor continuity of care for Patient 4, create misunderstandings about the patient's (Patient 4} condition and recovery plan, delay follow-up and treatment, and incomplete medical records, which could impact Patient 4's safety and the hospital's record keeping accuracy.

Findings:

During a review of Patient 4's History and Physical (H&P, a formal assessment by a healthcare provider that includes the patient's medical history, symptoms, physical examination findings, and a provider's assessment and treatment plan), dated 3/21/2025, the H&P indicated that Patient 4 was transferred to the facility on 3/20/2025 with altered mental status (AMS, a change in a person's level of consciousness [a person's degree of wakefulness and awareness of their surroundings and self, existing on a spectrum from fully alert to completely unresponsive], awareness, and cognitive function [memory, attention, learning, perception, and decision-making]) and was diagnosed with low blood sugar levels (blood sugar levels drop below a healthy range). The H&P also indicated that Patient 4 had past medical history (PMH, define) of pancreatic cancer (a malignant [cancerous] disease that arises in the pancreas, an organ located in the abdomen behind the stomach), and diabetes (a chronic condition in which the body does not produce or use insulin effectively, leading to high blood sugar levels).

During a review of Patient 4's physician's orders, dated 3/21/2025, the physician's order indicated that the "Discharge" order for Patient 4 was recorded on 3/21/2025 at 2:12 p.m.

During a concurrent interview and record review on 9/18/2025 at 3:00 p. with the Clinical Educator (CE) 1, Patient 4's electronic health record, was reviewed, to determine the time Patient 4 left the facility. CE 1 stated that Patient 4 left the facility on 3/21/2025 at 5:15 p.m.

During an interview on 9/17/2025 at 3:15 p.m. with the Clinical Educator (CE) 1, CE 1 verified that Patient 4's digital healthcare record (electronic health record [EHR], is a computerized, comprehensive collection of a patient's health information that is shared across different healthcare providers and settings), did not contain a recorded discharge summary for Patient 4's inpatient stay from 3/20/2025 through 3/21/2025.

During an interview on 9/18/2025 at 3:23 p.m. with the medical director of the hospitalist group (MD) 1, MD 1 said that a discharge summary provided information about what happened during the patient's stay in the hospital. MD 1 said that ideally, the discharge summary should be available for both physicians and patients. MD 1 said that discharge summary was most often reviewed by physicians when patients were readmitted to the hospital. MD 1 said that the discharge summary represented an important part of the medical record and, therefore, must be completed and filed in the patient's medical record.

During a review of the facility's Medical Rules and Regulations (R&R), dated 6/2024, the R&R indicated the following:
"The attending practitioner or his physician designate shall make adequate admitting notes, progress notes, and discharge summary on each record of a patient under his care. The discharge summary must contain:
a. All relevant diagnoses and operative procedures performed;
b. Reason for hospitalization;
c. Significant findings;
d. Procedures performed and treatment rendered;
e. Condition of patient on discharge;
f. Specific instructions given to the patient and/or family, particularly in relation to physical activity, medication diet and follow-up care;
g. Final diagnosis (should be all inclusive, including pathology report, and should not be written in abbreviation· or symbols). The condition on di charge of the patient should be stated in terms that permit a specific measurable comparison with the condition on admission, avoiding the use of-' vague, relative terminology such as "improved. Patients should be discharged only on written order of the attending physician, or his physician designate. At the time of his discharge, the attending physician or his physician designate should ascertain that the record is complete, he must record the principal diagnosis, secondary diagnoses and operative procedures on the discharge summary form, verify and sign the record ... All medical records are to be completed within 14 days from patient discharge ..."