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



1.Based on interview and record review the facility failed to come to a resolution (decision) of a grievance (complaint that can not be resolved in a short period of time) initiated (started) by one of 30 sampled patients (Patient 30) in a timely manner.

This deficient practice has the potential for patients not receiving responses and resolutions to their requests to investigate problems encountered during their stays at the facility. (Refer to A-0118)



2. Based on interview and record review, the facility failed to provide condition of admission (COA, a documents that outline the terms and agreements between a hospital and a patient upon admission that include the patient's consent to treatment, acknowledgment of financial responsibilities, and understanding of various hospital policies) and consent (a document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) for surgery or special procedure in patient's preferred language for one of 30 sampled patients (Patient 9).

This deficient practice might lead to Patient 9 unable to understand the patient ' s right procedure ' s risk, benefits and alternatives (choice between two or more things) and not in the patient ' s best interest while the patient was hospitalized due to Patient ' s 9 preferred language was Russian, (Refer to A-0131).



3. Based on interview and record review, the facility failed to ensure background check was performed on two of nine sampled staff members (Registered Nurse (RN 1) and Charge Nurse (CN2) prior starting to work at the facility.

This deficient practice had the potential exposing patients to individuals with possible criminal records and inadequate credentials which could put patients ' safety at risk for abuse. (Refer to A-0144)

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

Based on interview and record review the facility failed to come to a resolution (decision)of a grievance (complaint that can not be resolved in a short period of time) initiated (started) by one of 30 sampled patients (Patient 30) in a timely manner.

This deficient practice has the potential for patients not receiving responses and resolutions to their requests to investigate problems encountered during their stays at the facility.



Findings:



During an interview on 6/25/2025 at 2:22 PM, the Risk Manager (RM 1) stated the facility acknowledged Patient 30 voiced a grievance regarding the quality of care during her stay from 7/7/2024 through 7/8/2024 and then again on 7/10/2024. The Risk Manager (RM 1) stated Patient 30 filed a grievance that alleged Patient 30 was sexually assaulted while sedated during a procedure. This occurred through a conversation with a risk management staff member (RM 2) who no longer works at this facility. The Risk Manager said details of the grievance from Patient 30 were forwarded to staff in a ' Leadership Meeting ' email sent September of 2024. The Risk Manager then confirmed that grievances are not initiated through a conversation but typically through a written document; the Risk Manager stated she considered this just a conversation about patient safety. The Risk Manager subsequently(next) stated, after reviewing risk management documentation, the response to Patient 30 ' s grievance took longer than 30 days as per the hospital ' s grievance policy.



During a review of an email from Risk Manager 2 (RM 2) to Risk Manager 1 dated 9/11/2024, RM 2 wrote a former patient had made vague (uncleared) allegations of sexual abuse and not being informed of the anesthesia (use of medicines to prevent pain during procedures) used during her planned cardioversion (medical procedure used to restore a normal heart rhythm). The email indicated, Patient 30 was concerned something may have happened during the time Patient 30 was sedated (drugged) during this procedure. This email indicated RM 2 stressed to RM 1 that ' Leadership ' needed to completely investigate Patient 30 ' s concerns.



During a review of an email between the Risk Management Department and Patient 30 dated 11/27/2024, this correspondence (messages between two people) indicated the Risk Management Department received the Grievance filed by Patient 30 on 11/25/2024. This email also specified Patient 30 would receive a written response to this grievance, regarding Patient 30 ' s stay on 7/10/2024, within 30 calendar days from 11/25/2024.



During a review of a grievance resolution letter addressed to Patient 30 on 1/16/2025 (52 days after initial receipt of the grievance letter from Patient 30), this letter indicated, after reviewing details of Patient 30 ' s stay from 7/7/2024 through 7/10/2024, there was no evidence of deficient practices or inappropriate behavior during investigation.



During a review of the ' Patient Complaint/Grievance Management ' policy 5043036 last revised 7/2018, this policy indicated all written complaints received in paper form, email or fax are considered grievances. This policy stipulated (required) all complaints initiated by a patient or a patient ' s representative may be managed as a grievance if the patient wishes. Lasty, the ' Patient Complaint/Grievance Management ' policy specified a grievance response shall be issued within 30 calendar days of receipt of the grievance unless more time is required to gather pertinent information.

Based on interview and record review, the facility failed to provide condition of admission (COA, a documents that outline the terms and agreements between a hospital and a patient upon admission that include the patient's consent to treatment, acknowledgment of financial responsibilities, and understanding of various hospital policies) and consent (a document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) for surgery or special procedure in patient's preferred language for one of 30 sampled patients (Patient 9).

This deficient practice might lead to Patient 9 unable to understand the patient ' s right, procedure ' s risk, benefits and alternatives (choice between two or more things) and not in the patient ' s best interest while the patient was hospitalized.



Findings:

A review of Patient 9 ' s Obstetrical (medicine focused on pregnancy, childbirth, and the postpartum period) History and Physical (H&P) note dated 6/24/2025 indicated Patient 9 was 39 weeks of pregnant(the period of time during which a baby is developing inside the mother's womb) and was scheduled for Induction of Labor (IOL, process of artificially starting the giving of birth with tightening of the abdomen of the mother before they begin naturally) due to pregnancy complicated by Gestational Diabetes Mellitus (GDM, a condition where high blood sugar develops during pregnancy in women).



During a concurrent interview and record review on 6/26/2025, at 2:30 p.m., with Nurse Manager (NM1), Patient 9 ' s profile indicated patient ' s preferred language was Russian that required an interpreter. NM1 stated that if patient preferred language was Russian then an interpreter service should be used and documented on medical records with interpreter ID and the language interpreted.

A reviewed of patient 9 ' s condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), indicated patient 9 ' s preferred language was Russia. COA was signed by Patient 9 on 6/23/25 at 8:07 p.m. The COA was written in English. No interpreter was documented on the signed COA form.



A reviewed of patient 9 ' s Consent to Surgery/Special procedures/Anesthesia forms for possible vaginal delivery, possible episiotomy (a surgical incision made in the perineum, the area between the vaginal opening and the anus, during childbirth), and possible operative delivery using vacuum or forceps if necessary was signed by Patient 9 on 6/23/25 at 9:16 p.m.. The Consent to Surgery form was written in English. The translator section was blank. No interpreter was documented on the signed COA form.



During an interview on 6/27/2025 at 1:45 p.m. with Risk Management Director (RMD), there was no documentation for interpreter service that was use when patient 9 signed the COA and Consent to Surgery for the IOL.



During a review of the facility ' s policy and procedure (P&P) titled "Consent", date 7/2018, indicated "the consent form must either be in a language the patient can read and understand or be translated into the patient's preferred language for the patient by an approved translator. Refer to the policy on interpreter and translation services .....When an interpreter is used, the section of the English language consent form dedicated to documenting the translation must be completed. The operator/translator number is entered to the interpreter section of the consent form. The caregiver reads the consent form to be interpreted verbatim.

Based on interview and record review, the facility failed to ensure background check was performed on two of nine sampled staff members [Registered Nurse (RN 1) and Charge Nurse (CN2)] prior starting to work at the facility. This deficient practice had the potential exposing patients to individuals with possible criminal records and inadequate credentials which could put patients ' safety at risk for abuse.



Findings:

During a concurrent interview and record review on 6/27/2025 at 11:25 a.m. with the Human Resources Business Partner (HRBP), Charge Nurse (CN2) ' s personnel file was reviewed. The personnel file indicated there was no background check document found in CN2 ' s personnel file. HRBP stated background check was required for all employees prior working at the facility to make sure the employee was checked for employment, education and criminal record. CN2 was hired on 3/20/1995 as an acute care nurse and promoted to acute care charge nurse on 3/20/2016. HRBP stated that they could not find the background check for CN2 since she was hired before the hospital change of ownership.



During a concurrent interview and record review on 6/27/2025 at 11:58 a.m. with the HRBP, Registered Nurse (RN1) ' s personnel file was reviewed. There was no background check document found in RN1 ' s personnel file. HRBP stated background check was required for all employees prior working at the facility to make sure the employee was checked for employment, education and criminal record. RN1 was hired on 8/5/1996 as an acute care nurse. HRBP stated that they could not find the background check for RN1 since she was hired before the hospital change of ownership.



During an interview on 6/27/2025 at 12:15 p.m. with the Human Resources Business Partner (HRBP) stated background check was required for all employees prior starting at the facility. HRBP stated that all employee hired before change of ownership should be treated as re-hire and re-run the background checks with current employer.



During a review of the facility ' s policy and procedure (P&P) titled, "Background Check and Excluded Individual", dated 10/24/2024, the P&P indicated, "Background checks and monthly exclusion screening are conducted to help ensure caregiver and patient safety as well as to comply with federal and state laws ... All prospective caregivers will be subject to a Background Check. The type of Background Check may vary by the type of position for which the prospective caregiver is applying. The criminal history check and an Exclusion Screening will be required of all prospective caregivers regardless of the type of position for which they are applying. Other verifications of a caregiver's background or credentials may also be conducted based upon position, and consistent with federal, state and local legal requirements. Human resources is responsible for determining if a caregiver is to be excluded from working at the ministry in any capacity based on the results of a Background Check and Exclusion Screening.

Based on interview and record review, the facility failed to ensure nursing staffed followed the facility's "Peripherally Inserted Central Venous Catheter (PICC is a long thin, flexible tube inserted into a vein(blood vessel that carries blood to the heart), in the upper arm, and then pass through into a larger vein near the heart) Policy" for one of 30 sampled patients (Patient 12). Patient 12 had a PICC line inserted (placed) through a peripheral vein (vein near the surface of the body), often in the arm, into a larger vein in the body where the tip of the catheter is position in a location near the heart, and used for intravenous (with in the vein) treatment that is required over a long period) line placement done, the nursing staff did not verify PICC line placement by calling the Radiologist (use medical imaging to diagnose disease or injury)to verify (confirm) if the PICC line was placed correctly to use and did not document the total inserted length PICC line used.

This deficient practice had the potential for unsafe use of a PICC line that was not verified for proper placement or documentation which may result in complications such as intravenous infiltration (medication is absorbed in the tissues and not the blood), serious burns, scarring, nerve damage, etc.

Findings:

During a review of Patient 12's "Face Sheet (document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated 6/15/2025, indicated Patient 12 was admitted to the facility on 6/15/2025 at 10:06 a.m.

During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/15/2025, the "H&P" indicated the following: Patient 12 with a history of gastric bypass surgery (surgery to change how the stomach and small intestine handle food) and presented to Emergency Department for abdominal pain with nausea.

During a review of Patient 12 ' s "Central Venous Catheter Insertion Procedure Note," dated 6/16/2025, the Procedure Note indicated the following: Patient 12 ' s had a Peripherally Inserted Central Catheter (PICC) inserted to the right upper arm for administration of medications.

During a concurrent interview and record review on 6/25/2025 at 3:22 p.m. with the Manager of Medical Surgical Unit (MMSU) 1, Patient 12 ' s "Chest X-ray Report," dated 6/16/2025, was reviewed. The Chest X-ray Report indicated the following: "There is a right PICC line catheter with the tip in the proximal/mid (near) SVC (superior vena cava-a large vein that carries deoxygenated blood(low oxygen in the blood) from the upper body to the heart), consider advancement by 5 to 8 centimeter (cm-unit of length)." The MMSU 1 stated, there was no documentation that the PICC line was advance 5 to 8 cm or confirmed to use PICC by the Radiologist (a medical doctor specializing in diagnosing and treating diseases and injuries using medical imaging techniques). After PICC line insertion completed by the PICC nurse, a chest Xray should be ordered to confirmed location of the PICC and the Radiologist would give the "okay to use" the PICC line.

During a concurrent interview and record review on 6/26/2025 at 10:06 a.m. with the Manager of Medical Surgical Unit (MMSU) 1, Patient 12 ' s "Central Venous Catheter Insertion Procedure Note," dated 6/16/2025 was reviewed. The Procedure Note indicated the following: Patient 12 had a Peripherally Inserted Central Catheter (PICC) inserted to the right upper arm for administration of medications. The PICC verification of tip location would be confirmed by X-Ray. No documentation of the total length of the PICC line inserted and PICC was well position and okay to use from the Radiologist indicated.

The MMSU 1 stated the following: PICC Procedure note was completed by the PICC nurse. No confirmation from the Radiologist "Okay to use PICC line." There should be documentation for okay to use PICC line from the Radiologist. There should be documentation with the total length of the PICC line inserted in Patient 12 ' s records. It is important to know the length of PICC line place inside patient and important make sure PICC line was in the right location and was okay to use from the Radiologist. The facility would provide education to staff.

During a review of Patients 12 ' s "Assessment Flowsheet," dated 6/17/2025 to 6/18/2025, the Assessment Flowsheet indicated that the PICC line was used on 6/17/2025 to 6/18/2025 for fluid medication infusion (administering fluids or medication in the bloodstream). No documentation by nurses notifying the primary medical doctor or radiologist verifying PICC line was "ok to use."

During an interview 6/27/2025 at 10:43 a.m. with the PICC Registered Nurse (PRN 1) 1, PRN 1 stated after the PICC line is placed, there would be a chest X-ray ordered to confirmed PICC line proper placement. Needed to be confirmed if "okay to use PICC" by talking with the Radiologist. There was no "okay to use PICC line" documented from the Radiologist because the staff, the PICC nurse had certification (official recognition person ' s skills, knowledge, abilities in a specific field) to interpret (explain the meaning of something) tip location of the PICC line. They could put "okay to use PICC line."

PRN 1 confirmed there was no documentation of the total length from the PICC line inserted in Patient 12. It was important to document the total length of the PICC line inserted so upon removal was could check if the whole catheter was removed from the patient. Education would be provided to all PICC nurse in the department.

During an interview 6/27/2025 at 12:16 p.m. with the Executive Director Performance Excellence (EDPE 1) 1, and PICC Registered Nurse (PRN 1) 1, EDPE 1stated and confirmed by the PRN 1 that the PICC nurse who placed the PICC line for Patient 12 did not have the certification to interpret PICC line tip location. The PICC nurse should have gone to the Radiologist for placement verification of the PICC Line and got ' Okay to use PICC line." EDPE 1 stated we would educate staff on it.

During a review of the facility's policy and procedure (P&P) titled, " Central Venous Catheter: PICC: Insertion of PIC and Midline Catheters," dated 10/2024, the "P&P" indicated, "Purpose: Peripherally Inserted Central Catheters (PICC) are the most commonly inserted through a vein in the antecubital fossa (front side of the elbow) or upper arm in order to provide reliable (trusted) venous (vein) access for infusion therapy. 39. Send patient to Radiology for a STAT CXR (immediately chest X-ray) or obtain a STAT(Immediately) portable chest X-ray to confirm tip placement. 40. Confirm correct tip placement, i.e., distal SVC (a large vein that carries deoxygenated blood(low oxygen in the blood) from the upper body to the heart) or caval-atrial juncture (the point at which the upper vena cava (SVC) meets and joins into the upper walls the right atrium (one of the four chambers of the heart) of the heart). 45. For facilities that need chest Xray, it is important to view the chest Xray image for malpositioning (abnormal position) and consult with the radiologist for tip placement if PICC nurse is not certified to view and interpret tip placement before releasing the line for use. Documentation: A. Complete Insertion Information on the PICC Documentation Record and place in the patient ' s medical record: 1. Nursing notes should include: B. Catheter brand, French Size (measurement of the external (outer) diameter (straight line passing through a center of body or figure)of the catheter tube), single or dual lumen (separate working tube opening), catheter lot number, total insertable length of catheter. E. Chest x-ray results, radiologist reading the results, any action taken based on initial reading, PICC tip location.