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

1. The facility failed to ensure its staff provided a copy of a signed "An Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) prior to one of 30 sampled patient's (Patient 20) discharge, in accordance with the facility's policy regarding "An Important Message From Medicare."

This deficient practice had the potential for Patient 20 not knowing the rights to appeal a hospital's discharge decision. (Refer to A-0117)

2. The facility failed to ensure that one of 30 sampled patients (Patient 1), received a respectful, dignified and fair treatment, in accordance with the facility's policy on patient rights, when Patient 1's urine toxicology drug screen results (UDS, refers to a laboratory test that analyzes a urine sample to detect the presence of drugs or substance of abuse, used to screen for opioids [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin], amphetamines [stimulant drugs that speed up messages between the brain and body; are prescribed by doctors to treat certain medical conditions or others, like methamphetamine, produced and sold illegally], cocaine [an addictive drug derived from coca or prepared synthetically, used as an illegal stimulant], and other illicit or prescription medications) were positive for amphetamines and opioids. Patient 1 was diagnosed with methamphetamine use (methamphetamine use disorders involve the recreational use of these substances [other than for unapproved medical indication] and are defined by a pattern of substance use leading to clinically significant impairment or distress), solely based on testing positive for amphetamines in urine, without verifying the medication history (all currently and recently prescribed drugs) of Patient 1, who had a documented history of taking Adderall (a combination of amphetamine and dextroamphetamine, two central nervous stimulants that improve focus and reduce impulsivity by increasing dopamine and norepinephrine levels in the brain).

Patient 1 also received a diagnosis of opiate overdose, despite the lack of documentation demonstrating that Patient 1 responded to Narcan (naloxone, a medicine that rapidly reverses an opioid overdose) administration. In addition, the facility failed to ensure that Patient 1 was assessed for suicidal ideation (thoughts of harming or inflicting death on one's self) after presenting to the emergency department (ED) following a suspected overdose on prescription medications (on both consecutive separate visits to the facility's emergency department on 2/23/2025 and 2/24/2025).

This deficient practice had the potential to result in Patient 1 experiencing psychological distress and had the potential to result in worsening of Patient 1's condition, due to inappropriate treatment and increased risk for complications, which can compromise Patient 1's safety. (Refer to A-0129)

3. The facility failed to provide considerate and respectful care, in accordance with the facility's policy on Patient Rights, for one of 30 sampled patients (Patient 19), when Patient 19 was given a discharge instruction on getting car seat after a diagnosis of fetal demise (death of a fetus before it is born), instead of being provided a discharge instruction regarding miscarriage after care that addresses both the physical and emotional well-being of Patient 19.

This deficient practice had the potential to cause Patient 19 not to be aware of proper after care for miscarriage (the natural loss of a pregnancy before the 20th week of gestation) and also cause emotional distress (a highly unpleasant emotional reaction resulting from an experience or event). (Refer to A-0129)

4. The facility failed to ensure two of 30 sampled patients' (Patient 4 and Patient 5) call lights (a device that allows to alert staff when assistance is needed), were placed within reach to be able to summon help when needed without delay, in accordance with the facility's fall (an unintentional event that results in a person coming to rest on the ground, floor, or other lower surface) prevention policy. Both Patient 4 and Patient 5 were assessed to be a moderate, and a high fall risk, respectively.

This deficient practice had the potential for Patient 4 and Patient 5 to sustain harm, such as falls, injuries or had their care needs not being met, compromising their (Patient 4 and Patient 5) recovery and well-being. (Refer to A-0144)


5. The facility failed to ensure its nursing staff utilized rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) to assist with expediting the transfer for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedures regarding rapid response, when Patient 21 remained in the Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit waiting to be transferred to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for four (4) hours on 5/20/2024.

This deficient practice had the potential to result in Patient 21 not receiving appropriate level of care and monitoring while waiting to be transferred to PCU and may lead to delay in treatment and care, which may result in complications requiring intubation (a medical procedure where a tube is inserted into the windpipe [trachea] to maintain an open airway). (Refer to A-0144)

6. The facility failed to ensure its nursing staff assessed and performed pulse and skin checking every fifteen (15) minutes for one of 30 sampled patients (Patient 11), in accordance with the facility's policy and procedures regarding restraints use (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), when Patient 11 was restrained with 4-point (both wrists and both ankles) restraints on 4/14/2025.

This deficient practice had the potential to put Patient 11 at risk for skin injury or getting out from restraints. (Refer to A-0175)

7. The facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN), evaluated the medical condition and taken vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) for one of 30 sampled patients (Patient 11), when performing a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on 4/14/2025 and 4/28/2025, in accordance with the facility's 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) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) guidelines.

This deficient practice had the potential for the nursing staff not immediately recognizing Patient 11's abnormal vital signs and changes in respiratory (breathing) status resulting from the use of restraints and seclusion, which may cause delay in care or treatment. (Refer to A-0179)

8. The facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN), consulted the attending physician within an hour after performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 30 sampled patients (Patient 11), in accordance with the facility's policy regarding face to face assessment.

This deficient practice had the potential to result in Patient 11's physician not knowing Patient 11's response to the restraints use (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) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving), the need for continuation of restraint and/or seclusion, and the possible use of alternatives and, therefore, may lead to unnecessary or prolonged restraints use. (Refer to A-0182)

9. The facility failed to ensure one of two Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN 3), was trained and demonstrated competency in performing correct face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), when RN 3 did not complete the face-to-face assessment training upon hire and annually (every year), in accordance with the facility's policy and procedures regarding restraints use (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) and face-to-face assessment.

This deficient practice resulted in RN 3 not evaluating Patient 11's medical condition and not consulting the attending physician, when performing face-to-face assessments on 4/14/2025 and 4/28/2025, which may result in the delay of necessary medical care or treatment and/or prolonged use of restraints for Patient 11. (Refer to A-0205)

10. The facility failed to ensure three of five sampled registered nurses (RN 2, RN 3 and RN 4), completed their advance directive training (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) yearly, in accordance with the facility's Annual Competency (ability to demonstrate mastery of specific skills and knowledge) Education requirements.

This deficient practice had the potential for violations of patient rights, thus causing harm to patients, due to lack of staff training. This deficient practice may also result in the failure to honor patient's wishes or neglecting to provide necessary information to allow patients to have informed decision-making. (Refer to A-0208)

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

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

1. The facility failed to ensure one of 30 sampled patient's (Patient 3) enteral feeding set (the tubing and associated components used to deliver nutrition directly into the stomach through a feeding tube), was changed every 24 hours or once infused (not to exceed 24 hours), in accordance with the facility's standard practice regarding changing the enteral feeding administration set.

This deficient practice had the potential to compromise Patient 3's safety by increasing the risk of infection, such as bacterial contamination due to improper or inconsistent changing of feeding sets, which may contribute to the increased risk of hospital-acquired infections (HAIs, infections that patients develop while receiving care in a healthcare facility, such as a hospital) and complications for Patient 3. (Refer to A-0395)

2. The facility failed to ensure one of 30 sampled patient's (Patient 6), two sterile water containers, were signed with the date and time after opening, to ensure that the containers were not used beyond expiration date (the labeled date and time indicate when the container was opened, as sterile water may become contaminated with germs after opening).

This deficient practice had the potential for Patient 6 to receive sterile water that could have been contaminated, which might lead to a compromised health status and complications such as hospital-acquired infections (HAI) for Patient 6. (Refer to A-0395)

3. The facility failed to ensure Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurses (RNs), reassessed one of 30 sampled patients (Patient 11), after anti-psychotic (medication injected to a patient's muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) injections were given to Patient 11 on multiple occasions on 4/14/2025.

This deficient practice resulted in Patient 11 not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management. (Refer to A-0395)

4. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 3), to address Patient 3's high risk for aspiration (refers to the inhaling of food, liquid, or secretions into the lungs instead of the esophagus [a muscular tube that conveys food from the mouth to the stomach]), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for the lack implementation of aspiration precautions (aim to prevent food or liquid from entering the lungs while a person is receiving nutrients through a feeding tube) for Patient 3, which could result in aspiration and possible injury or harm such as aspiration pneumonia (a lung infection caused by inhaling food, or stomach contents into the lungs), which can lead to serious respiratory complications, prolonged hospitalization, and even death. (Refer to A-0396)

5. The facility failed to ensure one of 30 sampled patient's (Patient 3) total intake (refers to the amount of feeding formula consumed by a patient) of feeding formula per 24 hours, was documented, in accordance with the facility's policy and procedure regarding enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) administration documentation.

This deficient practice had the potential to compromise Patient 3's nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3's risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications. (Refer to A-0398)

6. The facility failed to ensure one of 30 sampled patients (Patient 21), received a complete neurological assessment (an exam that evaluates brain and nervous system function through test of mental status, reflexes [automatic body response], movements, and speech) following a fall (an unplanned change in position where a patient lands on the floor or a lower surface), in accordance with the facility's policy and procedures titled, "Fall Prevention and Reduction."

This deficient practice had the potential to delay recognition of serious medical problems such as a head injury or stroke (occurs when blood flow to the brain is interrupted). Signs and symptoms such as brain swelling, bleeding, or damage might not be noticed in time. (Refer to A-0398)

7. The facility failed to ensure staff removed from service a hospital bed with a malfunctioning alarm for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedure titled, "Medical Equipment Management Program." Specifically, the bed alarm was found to be non-functional, and staff failed to ensure the bed was taken out of commission, resulting in uncertainty whether the same bed continued to be used for patient care.

This deficient practice increased the potential for failure to prevent or respond to patient bed exit in a timely manner, placing patients at increased risk of injury due to falls. (Refer to A-0398)

8. The facility failed to ensure that one of 30 sampled patients (Patient 22), received prescribed pain medication, in accordance with the physician's orders and the facility's policy and procedure titled "Administration of Medications."

This deficient practice resulted in Patient 22 experiencing unrelieved pain, which had the potential to limit the patient's ability to walk and begin physical therapy (treatment to help restore movement and strength). (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare 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 for one patient of 30 sampled patients (Patient 1), the emergency department (ED, a hospital department that provides immediate medical care to patients experiencing sudden, serious health problems) visit medical record (MR) contained accurately completed documentation on suicidal (SI, plans or intentions to harm self) and homicidal (HI, thoughts or plans to harm others) ideation assessments (an evaluation conducted by healthcare professionals to determine the patient's risk to harm self or others, involving questions about thoughts, behaviors, and intent), in triage (the process of quickly assessing and prioritizing patients based on the severity of their condition to determine who needs immediate care), in accordance with the facility's policy and procedure regarding SI/HI screening, when Patient 1 was documented to have arrived at the facility after a possible overdose on medication -Baclofen (a muscle relaxant medications used to treat muscle spasms).

This deficient practice had the potential for Patient 1 not to be correctly assessed for risk of harm to self or others, which could lead to inadequate safety measures, failure to implement appropriate interventions, increased risk of self-harm or harm to others, and potentially serious adverse outcomes such as death. (Refer to A-0438)

2. The facility failed to ensure for one of 30 sampled patients (Patient 1), documentation of the response to Narcan (naloxone, an emergency medication used to reverse the effects of opioid overdose) was documented, after Narcan was administered to Patient 1 due to suspected opioid overdose (a medical condition where opioids cause significant respiratory depression [a breathing disorder characterized by slow or shallow breathing], sedation [a state of calmness, relaxation, or sleepiness induced by medications to help manage pain and anxiety], or coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment], potentially leading to death).

This deficient practice had the potential to compromise Patient 1's well-being and recovery and may lead to delayed recognition of treatment effectiveness or adverse reactions, potentially hindering the effective clinical evaluation in documenting patient progress after an intervention (response to medication administration) when planning patient's (Patient 1) care. (Refer to A-0449)

3. The facility failed to ensure that one of 30 sampled patient's (Patient 6), informed consent (a voluntary agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) form, was completed and indicated the date and time when Patient 6 or Patient 6's representative (Rep) signed the informed consent for a medically indicated procedure (an intervention that is performed based on clinical judgement to benefit the patient and is necessary for diagnosis, treatment, or management of a medical condition), in accordance with the facility's informed consent protocol.

This deficient practice had the potential to jeopardize Patient 6's rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 6's autonomy (person's right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (informed consent form). (Refer to A-0466)

4. The facility failed to ensure one of 30 sampled patient's (Patient 1) medical reconciliation (process of reviewing and comparing a patient's current medications, treatments, and medical history to ensure accuracy and continuity of care) was recorded on two consecutive Emergency Department (ED) visits (2/23/2025 and 2/24/2025), in accordance with the facility's policy and procedure regarding medication reconciliation and assessment.

This deficient practice had the potential to compromise Patient 1's continuity of care and increase the risk of harm to the patient (Patient 1). In addition, this deficient practice had resulted in a gap in Patient 1's medical record completeness violating Patient 1's right to transparency, accountability, and accurate and complete medical records. (Refer to A-0467)

5. The facility failed to ensure that one of 30 sampled patient's (Patient 22), medication reconciliation (involves creating the most complete and accurate list of a patient's medications-including prescriptions, over-the-counter drugs, vitamins, and supplements-and comparing this list to the medications ordered or prescribed during a transition of care), was reviewed during Emergency Department (ED) visits (from 3/9/2025 and 3/11/2025), in accordance with the facility's policy and procedure titled, "Medication Reconciliation."

This deficient practice had the potential to result in an incomplete or inaccurate list of Patient 22's medications. Without this information, doctors and nurses may not have had everything they needed to safely monitor Patient 22's condition or give the right care, and had the potential for missed doses, drug interactions, receiving the wrong medicine, or serious side effects. (Refer to A-0467)

6. The facility failed to ensure that one of 30 sampled patient's (Patient 3) total enteral feeding intake (refers to the amount of feeding formula consumed by a patient) of feeding formula, was consistently documented, in accordance with the facility's policy regarding documentation of enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) administration.

This deficient practice had the potential to compromise Patient 3's nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3's risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications, hindering interventions necessary to maintain optimal patient (Patient 3) health. (Refer to A-0467)

7. The facility failed to consistently perform and document neurological assessments (a systemic evaluation of a patient's nervous system function, including mental status, motor and sensory responses, and reflexes to detect abnormalities), every 4 hours as ordered by the physician, for one of 30 sampled patients (Patient 4), after Patient 4 was diagnosed with a stroke (sudden interruption of blood flow to the brain that can cause neurological deficits, impairments, or death), in accordance with the facility's policy regarding assessments and documentation.

This deficient practice had the potential to result in delayed recognition of neurological deterioration of Patient 4's condition, increasing the risk for adverse outcomes for Patient 4 such as neurological deficits (permanent impairment or loss of function in the nervous system such as difficulty with coordination, paralysis, numbness, inability to speak or understand language) or death. (refer to A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare 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 ensure there was a standardized procedure developed to monitor and reassess patients in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after receiving anti-psychotic injections (medication injected to a patient's muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) to manage their behavior, when there was missing nursing re-assessment for one of 30 sampled patients (Patient 11) after receiving multiple anti-psychotic injections on 4/14/2025.

This deficient practice resulted in lack of consistency on re-assessment post anti-psychotic injections putting Patient 11 and other BHU patients at risk for not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management thus affecting quality of patient care.

Findings:

During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility's Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Progress notes (nursing narrative notes)," dated 4/14/2025, the progress notes indicated, "At 8:30 a.m., Patient 11 was pacing in the hallway frequently and dismissing staff instruction, Patient 11 also threatening and posturing towards staff ... MD 8 was notified and new orders received. Patient 11 tolerated injections and continued to pace ... At 11:30 a.m. Patient 11 came out of the shower ... upon exiting the shower room, Patient 11 grabbed staff on the buttocks ... MD 8 was notified and new orders received. Patient 11 tolerated injection."

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's and others' (other patients and staff) safety.

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m.
During a concurrent interview and record review on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), Patient 11's "Medication Administration Record (MAR, record of medications given to patients)," dated 4/14/2025, was reviewed. The MAR indicated Patient 11 received the following medications on 4/14/2025:

-At 8:40 a.m.: Zyprexa (medication injectable for rapid control of agitation [feeling of severe restlessness, and excessive motor activity such as pacing, rocking, gesturing] and disturbed behavior) 10 milligrams (mg, unit of measure) intramuscular (IM, delivering medication directly into the muscle tissue) injection one time, and Benadryl (medication helps to help calm agitation and anxiety in psychotic [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality] patient) 50 mg IM one time;

-At 11:56 a.m.: Thorazine (medication injectable to treat psychotic disorder) 50 mg IM one time; and

-At 5:34 p.m.: Thorazine 50 mg IM one time and Benadryl 50 mg IM one time.

During the same interview on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated these (referring to the Zyprexa, Thorazine and Benadryl medications) were one-time order anti-psychotic injections given to manage Patient 11's agitated behavior.

During an interview on 5/1/2025 at 11:35 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: BHU RN should reassess patients after any one-time order anti-psychotic injection was given. It should be done within thirty (30) minutes to an hour after the administration of the injection to check the patient's response and to evaluate the effectiveness of the medications then determine if patient would require additional interventions. DIR 5 also stated there was no re-assessment done after the anti-psychotic injections were given at 11:56 a.m. and at 5:34 p.m.

During an interview on 5/2/2025 at 3:12 p.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: the one-time order anti-psychotic injections were given when a patient was actively a danger to self or others. The purpose of these injections was to manage the patient's behavior. The BHU RN should perform a reassessment to evaluate patient's behavior and response to treatment. Currently, the re-assessment was done per nurses' discretion because there was no policy and procedures to speak to the process. DIR also stated they were trying to develop some standardized process for the BHU RNs to follow.

During an interview on 5/2/2025 at 4:24 p.m. with the Clinical Pharmacy Coordinator (CPC), CPC stated the following: nursing staff should perform a reassessment within thirty (30) minutes to an hour after any anti-psychotic injections were given to BHU patients. The reassessment would include evaluating the patient's response to the medication so the patient could be safely managed and cared for.

During an interview on 5/2/2025 at 6:20 p.m. with the Quality Management Patient Safety (QM), QM stated Quality Assessment and Performance Improvement (QAPI, a process by which 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 was not aware there was no policy and procedure developed to address reassessment and management of giving one-time order anti-psychotic injections in BHU.

During an interview on 5/2/2025 at 6:22 p.m. with the Director of Quality Management and Clinical Safety (ARLM), ARLM stated the governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was ultimately responsible for the facility and providing oversight to the facility's operation and quality of care.

During an interview on 5/2/2025 at 6:49 p.m. with the Director of Medical Staff Services (DMSS), DMSS stated the GB relied on QAPI to communicate with the departments and identify issues then report to GB.

During a review of the facility's policy and procedures (P&P) titled, "Assessments," dated 6/2023, the P&P indicated, "Purpose: to determine patient's care through assessment of each patient's needs; and to provide guidelines for patient assessment activities ... Ongoing assessments will be performed as the need arises to determine the patient's response to treatment ... Any significant change in a patient's condition or diagnosis will warrant ongoing assessment by a Registered Nurse ... Re-assessment shall be documented in the patient's medical record."

During a review of the facility's "Governing Body Bylaws (GB Bylaws)," dated 1/2023, the GB Bylaws indicated, "Section 3. Quality of Care: the Board of Directors (GB) is ultimately responsible for the quality of care provided by [the facility] ...To fulfill this responsibility, the Board of Directors assures ... (e) Mechanisms and policies designed to ensure the provision of quality patient care."

Based on interview and record review, the facility failed to ensure its staff provided a copy of a signed "An Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) prior to one of 30 sampled patient's (Patient 20) discharge, in accordance with the facility's policy regarding "An Important Message From Medicare."

This deficient practice had the potential for Patient 20 not knowing the rights to appeal a hospital's discharge decision.

Findings:

During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/25/2025, the "H&P" indicated, Patient 20 was admitted to the facility with diagnoses including but not limited to non-ST elevated myocardial infraction (NSTEMI, a type of heart attack), altered mental status (significant change in a person's cognitive function [the mental processes involved in thinking, learning, remembering, and problem-solving], level of consciousness [he degree of wakefulness and awareness a person has] and/or behavior) and hypertension (high blood pressure).

During a concurrent interview and record review on 5/1/2025 at 3:51 p.m. with the Quality Clinical Safety Coordinator (CQ 2), Patient 20's "An Important Message from Medicare About Your Rights (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights)," dated 4/26/2025, was reviewed. The IMM indicated it was signed on 4/26/2025. CQ 2 stated that IMM was signed by Patient 20's representative.

During an interview on 5/2/2025 at 11:52 a.m. with the Case Manager (CM 1), CM 1 stated the following: the IMM notified patients of their rights to appeal a discharge. There was information on the IMM to instruct what patient and/or family members would do to file an appeal. The IMM was given to patients once there was a discharge order so that the patient and/or family members would have enough time to file an appeal if they decide to do so.

During a review of Patient 20's "physician order," dated 4/30/2025, the physician order indicated, discharge Patient 20 home with home health.

During an interview on 5/2/2025 at 12:40 p.m. with the Case Management Assistant (CMA), CMA stated the following: there was no documentation that the signed IMM was given to Patient 20 prior to discharge (on 4/30/2025). The signed IMM should be given to Patient 20 so he (Patient 20) would know his (Patient 20's) rights to appeal the discharge if he (Patient 20) disagreed with the physician's decision.

During a review of the facility's policy and procedures (P&P) titled, "An Important Message From Medicare," dated 3/2022, the P&P indicated, "[the facility] will meet requirements of Medicare by issuing 'An Important Message from Medicare (IMM)' ... to all Medicare Beneficiaries who are admitted as inpatients to the hospital within two (2) days of admission, and must obtain the signature of the beneficiary or his or her representative. [the facility] case management shall also deliver a copy of the signed notice prior to discharge, but not more than two days before the discharge ... Documentation. Case Management must document timely delivery of the follow-up copy of the IMM in the patient records."

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

1. Ensure that one of 30 sampled patients (Patient 1) received a respectful, dignified and fair treatment, in accordance with the facility's policy on patient rights when Patient 1's urine toxicology drug screen results (UDS, refers to a laboratory test that analyzes a urine sample to detect the presence of drugs or substance of abuse, used to screen for opioids [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin]. , amphetamines [stimulant drugs that speed up messages between the brain and body; are prescribed by doctors to treat certain medical conditions or others, like methamphetamine, produced and sold illegally], cocaine [an addictive drug derived from coca or prepared synthetically, used as an illegal stimulant], and other illicit or prescription medications) were positive for amphetamines and opioids. Patient 1 was diagnosed with methamphetamine use (methamphetamine use disorders involve the recreational use of these substances [other than for unapproved medical indication] and are defined by a pattern of substance use leading to clinically significant impairment or distress), solely based on testing positive for amphetamines in urine, without verifying the medication history (all currently and recently prescribed drugs) of Patient 1, who had a documented history of taking Adderall (a combination of amphetamine and dextroamphetamine, two central nervous stimulants that improve focus and reduce impulsivity by increasing dopamine and norepinephrine levels in the brain).

Patient 1 also received a diagnosis of opiate overdose, despite the lack of documentation demonstrating that Patient 1 responded to Narcan (naloxone, a medicine that rapidly reverses an opioid overdose) administration. In addition, the facility failed to ensure that Patient 1 was assessed for suicidal ideation (thoughts of harming or inflicting death on one's self) after presenting to the emergency department (ED) following a suspected overdose on prescription medications (on both consecutive separate visits to the facility's emergency department [ED] on 2/23/2025 and 2/24/2025).

This deficient practice had the potential to result in Patient 1 experiencing psychological distress and had the potential to result in worsening of Patient 1's condition, due to inappropriate treatment and increased risk for complications, which can compromise Patient 1's safety.

2. Provide considerate and respectful care, in accordance with the facility's policy on Patient Rights, for one of 30 sampled patients (Patient 19), when Patient 19 was given discharge instruction on getting car seat after a diagnosis of fetal demise (death of a fetus before it is born), instead of being provided discharge instruction regarding miscarriage after care that addresses both the physical and emotional well-being of Patient 19.
This deficient practice had the potential to cause Patient 19 not to be aware of proper after care for miscarriage (the natural loss of a pregnancy before the 20th week of gestation) and also cause emotional distress (a highly unpleasant emotional reaction resulting from an experience or event).

Findings:

1. During a review of Patient 1's medical record (MR) titled, "Emergency Documentation-Physician Note," dated 2/23/2025, the MR indicated the following: "Patient (Patient 1) found ALOC ([Altered Level of Consciousness, refers to a state where a person's level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment]) in a hotel room by family ...was combative, and now lethargic per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug." The MR indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient's previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, "at the time of initial assessment ..." The MR further indicated that Patient 1 was described (by family) to be found with a "pile of prescription drugs," and had markings on abdomen that are "related to being in a hot tub."

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's "Triage (refers to the detailed record of an initial, rapid assessment of a patient's condition and the prioritization of care needed based on their presenting complaint and urgency)," record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented that Patient 1 had a history of being prescribed dextroamphetamine-amphetamine (Adderall, used to treat attention-deficit hyperactivity disorder [ADHD] and narcolepsy [a condition characterized by an extreme tendency to fall asleep]).

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's medical record (MR) titled, "Emergency Department Visit" summary, dated 2/23/2025, was reviewed. The QC stated that Patient 1 had a documented past medical history (PMH, a comprehensive record of a patient's past and present health conditions) of:
- ADHD, a neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity, and impulsivity which are excessive, pervasive, and developmentally inappropriate.
-Anxiety, a mental condition characterized by excessive apprehensiveness about real or perceived threats.
-Carpal tunnel syndrome, a condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist.
- Cholelithiasis, the formation of gallstones.
-Chronic pain, persistent pain that lasts for more than three months.
-Cognitive disorder, a mental disorder characterized by impaired cognitive [the mental processes involved in thinking, learning, remembering, and problem-solving] abilities and daily functioning, caused by factors that affect brain function.
-Fibromyalgia, a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia (difficulty falling asleep or staying asleep).
-Hypertension (HTN), a condition where the force of your blood against your artery walls is consistently too high (high blood pressure).
-Hypothyroidism, a condition where the thyroid gland doesn't produce enough thyroid hormones (regulates how the body uses energy) to meet the body's needs.
-Multiple sclerosis (MS), a chronic, inflammatory disease of the central nervous system (brain and spinal cord).
-Multilevel Degenerative Disk disease, the breakdown or deterioration of the discs between the vertebrae (bones that make up the spine) in the spine (long, bony structure from the base of the skull to the tailbone)
-Muscle spasms, an involuntary, sudden contraction of a muscle, often resulting in pain.
-Neuropathy, refers to any condition that affects the nerves outside your brain or spinal cord.
-Osteomyelitis- a bone infection, usually caused by bacteria, mycobacteria, or fungi, that can spread through the bloodstream or from a nearby infection.

During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), the QC 1 said that Patient 1's ED Visit medical record on 2/23/2025 had no documentation of patient's (Patient 1) medication reconciliation (the process of creating a list of all medications a patient is taking) being performed, including prescription medications that Patient 1 might have been possibly taking at home for the medical conditions identified.

During further review of Patient 1's "ED Documentation-Physician Note," dated 2/23/2025, the note indicated that Patient 1 told the ED physician that they (Patient 1) had PMH of Ehlers-Danlos syndrome (a group of inherited connective tissue disorders that affect the skin, joints, and other organs. It can be painful, particularly due to joint hypermobility and the resulting instability).

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's emergency department (ED) visits, dated 2/23/2025 and 2/24/2025, were reviewed. The ED visit record indicated that Patient 1's medication reconciliation was not recorded during both visits [on 2/23/2025 and 2/24/2025]. This was verified with the QC 1 during a concurrent interview. The QC 1 also said that nurses should do medication reconciliation in the emergency department (ED).

During an interview on 4/30/2025 at 12:29 p.m. with the Quality Management (QM), QM stated that the Chief Medical Officer (CMO) confirmed (on 4/20/2025) that medical providers should perform medication reconciliation on admission and discharge

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's "Triage (refers to the detailed record of an initial, rapid assessment of a patient's condition and the prioritization of care needed based on their presenting complaint and urgency)," record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented the following in Patient 1's "Triage" record (on 2/23/2025 at 11:28 a.m.):
-Thoughts of harming yourself: NO
-Thoughts of harming others: NO
-Level of consciousness: Drowsy [sleepy, lethargic]
-Orientation Assessment (refers to a person's level of awareness of their surroundings, time, and identity): Unable to assess

During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), The QC 1 verified the documentation indicating that Patient 1 was documented to be lethargic upon arrival to the emergency department (ED) and was unable to answer questions during the triage assessment regarding Suicidal (SI) and Homicidal ideation (HI, thoughts about or planning to kill another person).

During a review of Patient 1's nursing shift assessments (a systematic and ongoing process where a nurse gathers, analyzes, and interprets data to evaluate a patient's health status and plan appropriate care) completed during Patient 1's stay in the Emergency Department on 2/23/2025 from 11:37 a.m. to 5:57 p.m., no record of an additional SI/HI screening was found to be documented in Patient 1's electronic medical record (EMR, a digital version of a patient's paper-based chart or medical record within a single healthcare practice). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025.

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation (ED)-Physician Note," dated 2/24/2025, the MR indicated the following: (On 2/24/2025 at 11:25 a.m.) "Patient [Patient 1] was brought to the facility by the ambulance (from hotel) for overdose. Patient (Patient 1) was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient was seen for the same (on 2/23/2025) a day ago."

During a concurrent interview and record review on 5/1/2025 at 10:01 a.m. with the emergency department provider (MD 3), Patient 1's ED visit medical record (MR), dated 2/24/2025, was reviewed. The "ED Documentation-Provider Note," dated 2/24/2025, indicated that Patient 1 was diagnosed with opiate overdose, toxic encephalopathy (a brain disorder resulting from exposure to toxic substance), and methamphetamine use (identifying and confirming the use of methamphetamines [a powerful stimulant, known as crystal meth]). The MD 3 stated the following regarding Patient 1's diagnoses and medication reconciliation: "(On 2/24/2025) Patient (Patient 1) was diagnosed with an opiate overdose because she (Patient 1) responded to an antidote (Narcan) administered during her treatment in the field, on the way to the emergency department, but this was not clearly documented in the patient's (Patient 1) medical chart. Regarding methamphetamine use, the patient's history from 2018 ED visit must have automatically generated methamphetamine use history into the (current 2025) record. The Patient's (Patient 1) visit on 2/23/2025 (prior to the second ED visit on 2/24/2025) demonstrated that she (Patient 1) tested positive for amphetamines and opiates. However, medication reconciliation was not completed for this patient, and it is possible that the positive results were due to prescription medications-such as prescribed opioids and Adderall (amphetamine-containing medication)-which patient (Patient 1) may have been using as a part of her (Patient 1) treatment plan." MD 3 also stated that urine toxicology cannot differentiate between amphetamine use and methamphetamine use.

During an interview on 5/1/2025 at 12:01 p.m. with the director of the Emergency Department (Dir 1), the Dir 1 stated the following regarding medication reconciliation process in the emergency department (ED): "When a patient arrives at the Emergency Department (ED), the expectation is for the nurses to conduct an initial assessment, which includes gathering the patients' past medical history and medication history. However, there is typically not enough time to review mediations during triage, and the medication reconciliation is typically done by the assigned nurse once the patient is stabilized. The physician also obtains additional medication history information during their assessment of the patient. Medication reconciliation is marked as complete after the physician reviews and verifies the medication list. Not all patients require nurses to complete the medication history, but Patient with ESI level of 3 and above (Patient 1 had an ESI level of 2) are expected to have the medication reconciliation performed during their ED visit." The Dir 1 also said that it's important to know what medications patient is currently taking, especially if patient is admitted on overdose."

During a concurrent interview and record review on 5/1/2025 at 10:50 a.m. with the Quality Coordinator (QC 1), Patient 1's Medication Administration Record (MAR), dated 2/24/2025, was reviewed. QC 1 confirmed that Patient 1's MAR contained no documentation of Patient 1 being re-assessed for the response to naloxone (Narcan) administration.

During an interview on 5/2/2025 at 11:00 a.m. with the Clinical Pharmacy Coordinator (CPC), the CPC stated the following regarding documentation expectations after administering Narcan for a suspected opioid overdose: "Narcan is an opioids reversal agent. I don't believe we (the facility) have a specific policy stating that the response to Narcan administration must be documented. However, if this medication is given for an actual opioid overdose in the emergency department, the expectation is for the nurses to document the patient's reaction and response to the medication, but we don't audit emergency department Narcan administration. We conduct audits for this documentation to monitor for suspected inpatient adverse reactions to opioids. We specifically look for the assessment documentation conducted after Narcan administration to evaluate its effectiveness."

During an interview on 5/1/2025 at 12:09 p.m. with the Director of the Emergency Department (Dir 1), Dir 1 stated the following regarding Suicidal/Homicidal (SI/HI) ideation screening in triage upon a patient's arrival to the hospital: "The patient must be alert and oriented (a patient who is awake, awake of their surroundings, and able to understand and respond appropriately) to be able to communicate effectively and to answer questions regarding suicidal ideation (SI) or HI."

During a concurrent interview and record review on 5/1/2025 at 12:15 p.m. with the Director of the Emergency Department (Dir 1), Patient 1's "Triage" record, dated 2/23/2025, was reviewed. The record indicated that Patient 1 presented drowsy and was not able to be assessed for orientation, but the patient (Patient 1) was documented to have answered "NO" to questions regarding thoughts of harming self or others. Dir 1 reviewed the documentation and stated that the most appropriate option in this documentation would be "unable to assess" rather than to record "no" for a patient who was recorded to be lethargic and unable to communicate. Dir 1 also stated that if a nurse was unable to assess SI/HI in triage, the next nurse (bedside nurse) should follow up with a re-assessment. Dir 1 said, "Even if the patient has answered "NO" to SI/HI questions in triage, nurses can still re-assess during the time patient is in the emergency department, especially if the patient was admitted with a possible overdose. We want to make sure that the patient remains safe."

During a review of Patient 1's nursing shift assessments completed during Patient 1's stay in the Emergency Department (ED) on 2/24/2025 from 11:25 a.m. through 2/25/2025 at 6:18 a.m. (second ED visit), no record of additional SI/HI screening was found to be documented in Patient 1's electronic medical record (EMR). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m.

During an interview on 5/2/2025 at 8:00 a.m. with the registered nurse (RN 6), the nurse who discharged Patient 1 on 2/25/2025, RN 6 stated that Patient 1 refused to sign discharge instructions (guidelines that patients have to follow after discharge to deal with any remaining illnesses that need to be taken care of personally by the patient) because of the diagnosis of methamphetamine use and opiate overdose, which Patient 1 disagreed with. RN 6 said this was communicated to the physician, but the physician said these diagnoses were based on the urine drug screen and being positive for opioids and amphetamines. RN 6 also said that when Patient 1 left the ED, she (Patient 1) was alert and oriented (meaning the patient was aware of person, place, and time), and able to walk independently. RN 6 said that, according to the facility's policy, medication reconciliation should have been done for Patient 1. RN 6 could not recall whether the medication reconciliation was done for Patient 1 prior to discharge but stated that she [RN 6] did not complete the medication history for Patient 1 prior to Patient 1's discharge from the ED (on 2/25/2025).

During an interview on 5/2/2025 at 3:04 p.m. with the emergency Department physician (MD 4), MD 4 reviewed Patient 1's ED visits, dated 2/23/2025 (first ED visit) and 2/24/2025 (second ED visit), and stated the following: "Based on the physician's documentation in the patient (Patient 1) record, it is not possible to determine whether Patient 1 was screened for suicidal ideation and if Patient 1 intentionally or unintentionally overdosed on medications. You would have to ask the physicians." MD 4 also said that "perhaps methamphetamine use diagnosis was based on 2021 admission records (Patient 1 was last admitted to the facility on 10/8/2021)." MD 4 also said, "Regarding 1 mg of Morphine (an opioid used for pain relief) that was documented to be given to the patient (patient 1) on 2/25/2025 at 4:49 p.m., (only an hour and 20 minutes prior to Patient 1's discharge from the ED on 2/25/2025), the reason for this medication is unclear; the physician who ordered it can only state the purpose. It's possible that Patient 1 was in pain after waking up, but the exact rationale is not documented or known."

During an interview on 5/2/2025 at 4:14 p.m. with the Director of Clinical Laboratory Services (Dir 1), the Dir 1 stated the following: "The urine drug screen test conducted in the facility do not differentiate between prescription amphetamines such as Adderall, and illegal drugs like methamphetamine. In fact, taking Adderall can sometimes lower the concentration of amphetamine in the urine, potentially resulting in a false-negative test when the amount taken or the drug has been partially metabolized, is below the test's detection threshold. To accurately determine if Adderall, specifically, is present in the urine, samples must be sent to an external reference laboratory, as the facility's current testing process does not include this measurement."

During a review of Patient 1's previous admission to the facility, dated 10/8/2021 through 10/10/2021, the History and Physical (H&P), dated 10/8/2021, indicated that Patient 1 presented to the facility's emergency department from a motel, with high fever and body chills and was admitted to the facility with a diagnosis of pyelonephritis (an inflammation of the kidneys caused by a bacterial infection) and urinary tract infection (UTI, an infection that affects any part of the urinary system, including the kidneys, bladder, and urethra).

During a review of Patient 1's "Discharge Documentation," dated 10/10/2021, the record indicated that Patient 1 was discharged with the following diagnoses: pyelonephritis, UTI, chronic pain, hypothyroid, tobacco use, weakness and fever. The record also indicated that Patient 1 had positive urine drug toxicology screen for amphetamines and opiates ... The record also indicated that Patient 1 was prescribed 5/325 mg oral tablet Percocet (the brand name of a combination medication used to treat moderate to severe pain. Its two main ingredients (5 milligrams [mg, measuring unit] oxycodone and 325 mg of acetaminophen) relieve pain) for pain and was instructed to continue taking Adderall (indication, dose, and frequency not documented). The record also indicated that no medication reconciliation was completed during Patient 1's visit from 10/8/2021 through 10/10/2021. This information was verified by the quality coordinator (QC 1) during a concurrent interview and record review on 4/30/2025.
During a review of the facility's policy and procedure (P&P) titled, "Patients' Rights and Responsibilities," dated 11/24/2024, the P&P indicated that: "A. Persons with mental or substance abuse disorders have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws of the State of California, unless specifically limited by federal or state law regulations.
During a review of the facility's policy and procedure (P&P) titled, "Patients' Rights and Responsibilities," dated 3/21/2022, the P&P indicated: "VIII.STATEMENT OF PATIENT RIGHTS: The patient has the right to:
A. Considerate and respectful care, to be made comfortable. To respect for the patient's cultural, psychosocial, spiritual and personal values, beliefs and preferences.
D. Receive information about the patient's health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms the patient can understand. The right to effective communication and to participate in the development and implementation of the patient's plan of care.
During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented ... All PRN (as needed) medication, the reason for administering and the effectiveness of same shall be documented in the medical record ..."

During a review of the facility's Policy and Procedure (P&P) titled, "Plan for Provision of Care, Treatment, and Services," dated 10/2024, the P&P indicated the following: "The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment," dated 9/2022, the P&P indicated that all patients admitted to the hospital or in the ED, shall be screened for the presence of suicide risk factors ... All patients who screen positive for suicide risk factors and/or present with a primary complaint of an emotional or behavioral disorder, shall be further assessed using a comprehensive suicide risk assessment tool for the risk of suicide by a mental health professional.
Procedure:
1.A licensed healthcare professional will screen every patient for suicide risk during the initial assessment and reassessment by identifying with special emphasis on those who are being evaluated and/or treated for:
a. Suicide attempt (overdosing, self-injury) or suspected suicide attempt ... 3. If any of the above screening indicators are present for a patient in ED, the Psychiatric Liaison Nurse or MHRN who has LPS certification will complete a Columbia Suicide Severity Rating Scale (C-SSRS) form..."

During a review of the facility's policy and procedure (P&P) titled, " Initial Patient Assessment and Re-assessment," dated 3/24/2025, the P&P indicated the following [The P&P applies to all nursing areas, including the Emergency Department (ED)]: " At the time of admission or as soon as possible thereafter, each patient shall have an initial physical/psychological assessment completed by a registered nurse (RN). IV. The assessment is structured to identify facilitating factors and possible barriers to the patient reaching his or her goals including presenting problems and needs such as:
I. Psychological, emotional, behavioral, suicidal and mental disorders"
During a review of the facility's policy and procedure (P&P), titled "Triage," dated 12/18/2023, the P&P indicated the following: "IX. Behavioral Health Patients
a. Patients who present to triage exhibiting behaviors such as aggressiveness, agitation, or suicidal ideation present a danger to him/herself, or others, including the ED staff, and are considered violent until proven otherwise.
b. The patient will be moved to a secured area away from the triage area. After the patient has had a medical screening exam and it is determined to be medically stable, a mental health evaluation may be requested on any person the provider deems appropriate, i.e., homicidal, suicidal, psychotic, etc."

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," dated 3/6/2024, the P&P indicated that: "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation," dated 9/2022, the P&P indicated the following: "Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists ... Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record ...Upon discharge, the ED physician and licensed staff will reconcile the medication list in electronic medical record and determine whether the medication list requires a change or not. This information is included in discharge teaching and the patient's written instructions."

2. During a review of Patient 19's "Emergency Documentation (ED notes, medical notes completed by Emergency Department [hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician)," dated12/9/2023, the ED notes indicated Patient 19 was diagnosed with fetal demise (death of a fetus before it is born) before twenty (20) weeks with retention of dead fetus (unborn baby).

During a concurrent interview and record review on 5/2/2025 at 12:50 p.m. with the Data Analyst (DA 1), Patient 19's "Discharge Instruction," dated 12/9/2023, was reviewed. The discharge instructions indicated patient education including (the state) law requirement of getting car seat for children. DA 1 stated car seat requirement was not related to what Patient 19 came in for, which was fetal demise. DA 1 stated the discharge instruction given to Patient 19 should have included teaching about miscarriage (the natural loss of a pregnancy before the 20th week of gestation) aftercare.

During an interview on 5/2/2025 at 3:28 p.m. with the Director of Emergency Department (Dir 1), Dir 1 stated the following: discharge instruction was prepared by the provider. The discharge instruction should provide education related to patient's diagnosis and what they came to ED for.
Discharge instruction for patients with fetal demise and miscarriage should include signs and symptoms to return to emergency department including but not limited to severe abdominal pain and vaginal bleeding.

During a concurrent interview and record review on 5/2/2025 at 3:50 p.m. with Dir 1, Patient 19's "Discharge Instruction," dated 12/9/2023, was reviewed. The discharge instructions indicated patient education including (the state) law requirement of getting car seat for children. Dir 1 stated the following: giving information about car seat for patient with fetal demise could make patient (Patient 19) feel bad and emotional. Dir 1 stated he (Dir 1) would communicate with the ED providers to be more sensitive in the future.

During a review of the facility's policy and procedure (P&P) titled, "Patient Discharge," dated 7/2023, the P&P indicated, "Patient shall be educated on their diagnosis and/or disease process."

During a review of the facility's policy and procedures (P&P) titled, "Patient/Family Teaching Plan," dated 7/2022, the P&P indicated, "Discharge Instruction: Patient and/or family education and discharge planning are interrelated in that discharge planning involves teaching the patient about care after discharge, understanding treatment, making life-style changes, and managing continuing care ... Physicians are responsible for first diagnosis teaching, and other elements of the medical plan of care ... Licensed Nurses may also provide information on medication, self-care, and use of medical equipment, discharge information, and access to community resources ... the licensed nurse is responsible for coordinating the educational needs of the discharged patient."

During a review of the facility's policy and procedures (P&P) titled, "Patients' Rights and Responsibilities," dated 3/2022, the P&P indicated, "All hospital employees, medical staff, members and contracted agency staff performing patient care activities shall observe these patients' rights ... Statement of Patients' Rights: the patient has the right to ... A. Considerate and respectful care, to be made comfortable. To respect for the patient's cultural, psychosocial, spiritual and personal values, beliefs and preferences ... D. Receive information about the patient's health status, diagnosis, prognosis, course of treatment, prospects for recovering and outcomes of care (including unanticipated outcomes) in terms that patient can understand."

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

1. Ensure two of 30 sampled patients' (Patient 4 and Patient 5) call lights (a device that allows to alert staff when assistance is needed), were placed within reach to be able to summon help when needed without delay, in accordance with the facility's fall (an unintentional event that results in a person coming to rest on the ground, floor, or other lower surface) prevention policy. Both Patient 4 and Patient 5 were assessed to be a moderate, and a high fall risk, respectively.

This deficient practice had the potential for Patient 4 and Patient 5 to sustain harm, such as falls, injuries or had their care needs not being met, compromising their (Patient 4 and Patient 5) recovery and well-being.

2. Ensure its nursing staff utilized rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) to assist with expediting the transfer for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedures regarding rapid response, when Patient 21 remained in the Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit waiting to be transferred to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for four (4) hours on 5/20/2024.

This deficient practice had the potential to result in Patient 21 not receiving appropriate level of care and monitoring while waiting to be transferred to PCU and may lead to delay in treatment and care, which may result in complications requiring intubation (a medical procedure where a tube is inserted into the windpipe [trachea] to maintain an open airway).

Findings:

1.a. During a review of Patient 4's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/29/2025, the H&P indicated that Patient 4 was admitted to the facility with a diagnosis of paresthesia (an abnormal sensation, typically tingling or pricking ["pins and needles"], caused chiefly by pressure on or damage to peripheral nerves [other than spinal cord and the brain], right-sided weakness, acute cerebrovascular accident [CVA, a medical term for a stroke, a sudden interruption of blood flow to the brain]). The H&P also indicated that Patient 4 was admitted to neuro-telemetry unit (a specialized hospital unit that provides remote monitoring and care for patients with neurological conditions).

During an observation on 4/29/2025, at 11:06 a.m., with the Quality Management (QM), in the Emergency Department (ED, a hospital department dedicated to providing immediate medical care to patients whose conditions require urgent attention), Patient 4 was observed resting on a gurney in a room located away from the nurse's station, and the patient (Patient 4) was alone in the room. The QM asked Patient 4 if they (Patient 4) had a call light (a device that alerts staff when assistance is needed) within reach to call for assistance. Patient 4 said, "No." The call light was not within Patient 4's reach and was coiled on the wall, out of Patient 4's immediate access. The QM placed the call light next to Patient 4 and tested its functionality by pressing the call light, which lit up the light bulb on the wall, outside Patient 4's room, indicating that the call light was working.

During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 1), the CE 1 stated the following: "Call lights are provided to all patients in the patients' rooms. Patients need call lights to call for help and contact their nurse whenever they need assistance. Cal lights are also a fall prevention intervention (a strategy or action aimed at reducing the risk of falls and minimizing their impact) and can be documented as a fall prevention strategy intervention for patients identified as a fall risk."

During a concurrent interview and record review on 5/2/2025, at 11:45 a.m. with Clinical Educator (CE 1), Patient 4's "Fall Risk," assessment record, dated 4/29/2025, was reviewed. The record indicated that Patient 4 was identified as a moderate risk for fall (It suggests that individuals are at a greater risk than those with low risk but may not require the most stringent fall precautions). CE 1 stated that Patient 4 was assessed to be a moderate risk for fall and required general fall precaution interventions such as keeping belongings near patient's reach, keeping call light within reach, and educating the patient of fall risk level and prevention interventions.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Reduction," dated 8/2024, the P&P indicated the following: "Fall: A patient fall is a sudden change in body position in a downward direction, which may or may not result in a physical injury ... Evidence-based high fall risk interventions will be implemented and documented based on the identified fall risk assessment ... 2. An environmental risk assessment is performed repeatedly throughout each shift or patient stay ensuring universal fall safety precautions are in place including but not limited to: Call light within reach ...Patient education includes, but not limited to: Ensure call light is in easy reach and assess patient's ability to use it ...Instruct patient to call for help before getting out of bed by using call light ...

1.b. During an observation and interview on 4/29/2025 at 11:15 a.m., in the emergency department (ED), Patient 5 was observed in the room. Patient 5 did not have a call light within reach. Patient 5 stated that nurses keep coming in and out of the room every 10 minutes and said, "I can scream loud and someone will come."

During a review of Patient 5's "Fall Risk" assessment record (in the Emergency Department), the record indicated that Patient 5 was identified as a high fall risk. The record also indicated that safety planning interventions documented for Patient 5 included: bed in low position, non-slip footwear side rails up, and wheels locked ...

During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 1), CE 1 stated the following: "Call lights are provided to all patients in their rooms. Patients need call lights to call for help and contact their nurse whenever they need assistance. Cal lights are also a fall prevention intervention (a strategy or action aimed at reducing the risk of falls and minimizing their impact]) and can be documented as a fall prevention strategy intervention for patients identified as a fall risk."

During an interview on 5/2/2025 at 11:46 a.m. with the clinical educator (CE 1), CE 1 said that for high fall risk patients, nurses must document all fall prevention strategies implemented for the patient. CE 1 then reviewed the documentation of the "Fall Risk" assessment (in Patient 5's medical record, documented on 4/29/2025 in the ED), and stated, "Call light was not documented as one of the safety interventions for Patient 5 assessment under "ED Safety Planning for Fall Prevention" (during Patient 5's visit in the ED on 4/29/2025).

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Reduction," dated 8/2024, the P&P indicated the following: "Fall: A patient fall is a sudden change in body position in a downward direction, which may or may not result in a physical injury ... Evidence-based high fall risk interventions will be implemented and documented based on the identified fall risk assessment ... 2. An environmental risk assessment is performed repeatedly throughout each shift or patient stay ensuring universal fall safety precautions are in place including but not limited to: Call light within reach ...Patient education includes, but not limited to: Ensure call light is in easy reach and assess patient's ability to use it ...Instruct patient to call for help before getting out of bed by using call light ...

2. During a review of Patient 21's "Progress Notes, (physician narrative notes)," dated 5/20/2024, the "Progress Notes" indicated, Patient 21 was admitted to the facility on 5/17/2024 with diagnoses including but not limited to acute (new onset) on chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (deficiency in the amount of oxygen reaching the tissues), Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by long-term poor airflow) exacerbation (worsening) and hypertension (high blood pressure).

During a review of Patient 21's "Provider Notification (communication record between nurses and physicians)," dated 5/20/2024, the "Provider Notification" indicated, at 10:05 a.m., Registered Nurse (RN) 5 reported an abnormal arterial blood test (ABG, a blood test that measures the levels of oxygen and carbon dioxide in arterial blood, as well as the blood's acidity and bicarbonate concentration) result to Patient 21's physician and received order to place Patient 21 on BIPAP (Bi-level positive airway pressure device, a pressure support ventilation to treat sleep respiratory problems) and transfer Patient 21 to Progressive Care Unit (PCU, a hospital unit that provides level of care between general medical-surgical [Med-Surg, general patient population hospitalized for various causes such as illness and surgery] unit and the intensive care unit [ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill]) for higher level of care (involves greater supervision, frequency, and intensity of care).

During an interview on 4/30/2025 at 12:51 p.m. with the Quality Coordinator (CQ 2), CQ 2 stated when a patient had an order to transfer to PCU from Med-Surg Unit, the patient assignment should be adjusted to make sure there was a competent nurse to provide PCU level of care for the patient until the patient was physically transferred to PCU.

During a concurrent interview and record review on 4/20/2025 at 2:48 p.m. with CQ 2, Patient 21's "Location History," dated from 5/17/2024 to 6/8/2024, was reviewed. The location history indicated Patient 21 was transferred to PCU on 5/20/2024 at 2:25 p.m. CQ 2 stated Patient 21 remained in Med-Surg Unit for about four (4) hours before Patient 21 was transferred to PCU.

During an interview with the Director of Quality Management and Clinical Safety (ARLM), ARLM stated the following: nursing staff should have called rapid response team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) so that the rapid response team nurse could monitor and provide the right level of care for Patient 21 while waiting for PCU transfer. ARLM stated no RRT was called on 5/20/2024 for Patient 21.

During a review of the facility's policy and procedures (P&P) titled, "Rapid Response," dated 4/2024, the P&P indicated, "It is the policy of [the facility] to provide rapid assessment and intervention when appropriate, in an effort to provide the best possible patient care and optimize outcomes. [the facility] had Rapid Response Team personnel available to assist with condition deterioration and interventions to prevent or avert further deterioration ... the critical care nurse provides clinical expertise, advanced assessment skills and support for the patients' nurse, patient and patient's family, as well as facilitates a timelier transfer to a higher level of care when needed ... Procedure ... Critical care/rapid response nurse responsibilities ... assist/facilitate with transfer to higher level of care if indicated. Remain with the patient until she/he can be transferred to the appropriate level of care and during transport unless there are other competent personnel available at the time."

Based on interview and record review, the facility failed to ensure its nursing staff assessed and performed pulse and skin checking every fifteen (15) minutes, for one of 30 sampled patients (Patient 11), in accordance with the facility's policy and procedures regarding restraints use (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), when Patient 11 was restrained with 4-point (both wrists and both ankles) restraints on 4/14/2025.

This deficient practice had the potential to put Patient 11 at risk for skin injury or getting out from restraints.

Findings:

During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility's Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's and others' (other patients and staff) safety.

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m.

During an interview on 4/30/2025 at 4:32 p.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated the following: nursing staff should perform circulation (assessing blood flow in the body including checking skin color, temperature, and pulse [the heart rate]) and skin check every fifteen (15) minutes to make sure the restraints were not too tight or too loose. Patients could get hurt if restraints were too tight or patients could get out from the restraints if they were too loose.

During a concurrent interview and record review on 5/1/2025 at 11:38 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11's "Restraints Information (restraints flowsheet, nursing assessment while a patient is restrained)," dated 4/14/2025, was reviewed. The restraints flowsheet indicated, Patient 11 was restrained on 4/14/2025 from 5:11 p.m. to 8:30 p.m. the restraints flowsheet also indicated "pulse distal to restraint check" and "skin intact under restraints" were blank from 7:15 p.m. to 7:59 p.m. and from 8:15 p.m. to 8:30 p.m. During the same interview on 5/1/2025 at 11:38 a.m. with DIR 5, DIR 5 stated nursing staff should be performing pulse and skin check every 15 minutes. DIR 5 stated the document was missing four (4) checks from 7:15 p.m. to 8:30 p.m.

During a review of the facility's policy and procedures (P&P) titled, "Restraint and Seclusion Guidelines," dated 7/2022, the P&P indicated, "Assessment, monitoring and documentation of patients in violent/self-destructive restraints: 1. A staff member who is trained and competent monitors the patient continuously from the initiation of restraint until discontinuation and documents every fifteen (15) minutes regarding: i. signs of injury or distress ii. Circulation and color to the affected extremity iii. Level of emotional and behavioral distress or agitation."

Based on interview and record review, the facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN) evaluated the medical condition and taken vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level), for one of 30 sampled patients (Patient 11), when performing a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on 4/14/2025 and 4/28/2025, in accordance with the facility's 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) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) guidelines.

This deficient practice had the potential for the nursing staff not immediately recognizing Patient 11's abnormal vital signs and changes in respiratory (breathing) status resulting from the use of restraints and seclusion which may cause delay in care or treatment.

Findings:

During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's and other's (the other patients and the staff) safety.

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m.

During a review of Patient 11's "Behavioral Health Forms," dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m. Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11's safety and safety of others.

During a review of Patient 11's physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion ordered on 4/28/2025 at 11:00 a.m.

During a concurrent interview and record review on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11's "Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN])," dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated the following:
-"On 4/14/2025 at 5:56 p.m. completed by Registered Nurse (RN 3): Restraints Face to Face ... (C) The patient's medical and behavioral condition: Patient's (Patient 11's) respirations are even and unlabored (normal, effortless breathing), no injury noted to patient (Patient 11). Patient (Patient 11) appears agitated (feeling of uneasiness and severe restlessness) and fighting against the restraints;" and
-"On 4/28/2025 at 11:27 a.m. completed by Registered Nurse (RN 3): Restraints Face to Face ... (C) The patient's medical and behavioral condition: Patient (Patient 11) is agitated, yelling, and fighting the restraints."

During the same interview on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: both face-to-face assessments completed by RN 3 were incomplete. The expectation was for the RN to obtain a set of vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) when performing face-to-face assessment. There were no vital signs documented for both face-to-face assessments. Also, the face-to-face assessment on 4/28/2025 did not address Patient 11's medical condition at all. A complete face-to-face assessment was to make sure Patient 11 was safe while being restrained, identify and address any abnormality.

During a review of the facility's policy and procedures (P&P) titled, "Restraint and Seclusion Guidelines," dated 7/2022, the P&P indicated, "A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment is to evaluate: 1. The patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint."

Based on interview and record review, the facility failed to ensure its Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN) consulted the attending physician within an hour after performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 30 sampled patients (Patient 11), in accordance with the facility's policy regarding face to face assessment.

This deficient practice had the potential to result in Patient 11's physician not knowing Patient 11's response to the restraints use (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) and seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving), the need for continuation of restraint and/or seclusion, and the possible use of alternatives and, therefore, may lead to unnecessary or prolonged restraints use.

Findings:

During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psych H&P, a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility's Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's safety and safety of others (other patients and the staff).

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion was ordered on 4/14/2025 at 5:18 p.m.

During a review of Patient 11's "Behavioral Health Forms," dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m., Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11's safety and safety of others.

During a review of Patient 11's physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion was ordered on 4/28/2025 at 11:00 a.m.

During a concurrent interview and record review on 4/30/2025 at 4:37 p.m. with the Risk Management Coordinator (CQ 3), Patient 11's "Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN])," dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated both face-to-face assessments were completed by Registered Nurse (RN) 3 and there was no documentation that RN 3 consulted the attending physician after the face-to-face assessment on both days (4/14/2025 and 4/28/2025). CQ 3 stated there was no communication with the physician after face-to-face assessment was completed by RN 3.

During an interview on 5/1/2025 at 11:05 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: there should be provider notification by RN after performing face-to-face assessment. The RN should document which provider was notified along with the date and time of notification. The provider could decide if restraints were needed or not, alternative consideration or give further orders as needed.

During a review of the facility's policy and procedures (P&P) titled, "Restraint and Seclusion Guidelines," dated 7/2022, the P&P indicated, "A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment is to evaluate: 1. The patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint. If a trained and competent RN (or NP or PA) conducts the face-to-face evaluation, the RN (or NP or PA) must consult with the attending physician who is responsible for the patient's care after completing the face-to-face evaluation. This consultation must be documented in the medical record along with the order to use or continue restraint."

Based on interview and record review, the facility failed to ensure one of two Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurse (RN 3), was trained and demonstrated competency in performing correct face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), when RN 3 did not complete the face-to-face assessment training upon hire and annually (every year), in accordance with the facility's policy and procedures regarding restraints use (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) and face-to-face assessment.

This deficient practice resulted in RN 3 not evaluating Patient 11's medical condition and not consulting the attending physician, when performing face-to-face assessments on 4/14/2025 and 4/28/2025, which may result in the delay of necessary medical care or treatment and/or prolonged use of restraints for Patient 11.

Findings:

During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Inpatient Provider Admission Note (psychiatric History and Physical [H&P], a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility's Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's safety and safety of others (other patients and the staff).

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion ordered on 4/14/2025 at 5:18 p.m.

During a review of Patient 11's "Behavioral Health Forms," dated 4/28/2025, the Behavioral Health forms indicated, at 10:40 a.m., Patient 11 attacked one of the staff members when Patient 11 was redirected. The Behavioral Health forms also indicated Patient 11 was placed in seclusion and restraints for Patient 11's safety and safety of others.

During a review of Patient 11's physician order, dated 4/28/2025, the physician order indicated violent 4-point restraints and seclusion ordered on 4/28/2025 at 11:00 a.m.

During a concurrent interview and record review on 4/30/2025 at 4:37 p.m. with the Risk Management Coordinator (CQ 3), Patient 11's "Restraint Face To Face (face-to-face assessment form, an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN])," dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated both face-to-face assessments were completed by BHU RN 3 and there was no documentation that RN 3 consulted the attending physician after completing the face-to-face assessment on both days. CQ 3 stated there was no communication with physician after face-to-face assessment was completed by RN 3.

During an interview on 5/1/2025 at 11:05 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: there should be provider notification by RN after performing face-to-face assessment. The RN should document which provider was notified along with date and time of notification. The provider could decide if restraints were needed or not, alternative considerations or give further orders as needed.

During a concurrent interview and record review on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), Patient 11's "Restraint Face To Face (face-to-face assessment form)," dated 4/14/2025 and 4/28/2025, were reviewed. The face-to-face assessment forms indicated the following:
-"On 4/14/2025 at 5:56 p.m. completed by BHU Registered Nurse (RN 3): "Restraints Face to Face ... (C) The patient's medical and behavioral condition: Patient's (Patient 11's) respirations are even and unlabored (normal, effortless breathing), no injury noted to patient (Patient 11). Patient (Patient 11) appears agitated (a feeling of irritability and severe restlessness) and fighting against the restraints;" and
-"On 4/28/2025 at 11:27 a.m. completed by Registered Nurse (RN 3): "Restraints Face to Face ... (C) The patient's medical and behavioral condition: Patient (Patient 11) is agitated, yelling, and fighting the restraints."

During the same interview on 5/1/2025 at 11:27 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: both face-to-face assessments completed by RN 3 were incomplete. The expectation was for the RN to obtain a set of vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) when performing face-to-face assessment. There were no vital signs documented for both face-to-face assessments (on 4/14/2025 and 4/28/2025). Also, the face-to-face assessment on 4/28/2025 did not address Patient 11's medical condition at all. A complete face-to-face assessment was to make sure Patient 11 was safe while being restrained and identify and address any abnormality.

During a concurrent interview and record review on 05/02/2025 at 10:50 a.m. with the Business Manager of Education (M1), RN 3's personnel records, specifically, RN 3's training records titled, "Student and Group Transcript Report," with date range from 05/1/2023 - 04/30/2025, was reviewed. The records indicated that RN 3 had no records of completing training on face-to-face assessment. This was confirmed by M1. M1 stated that RN 3 should have been trained and educated to perform face-to-face assessment every year.

During an interview on 5/2/2025 at 3:19 p.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated all BHU RNs should be trained to perform face-to-face assessment upon hire and every year.

During a review of the facility's policy and procedures (P&P) titled, "Restraint and Seclusion Guidelines," dated 7/2022, the P&P indicated, "A face-to-face evaluation shall occur within one (1) hour of each initiation of seclusion/restraint for violent/self-destructive reason ... and be documented in the medical record by the physician, RN, Physician Assistant (PA), or Nurse Practitioner (NP) that performed the evaluation. The purpose of the assessment if to evaluate: 1. The patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the seclusion or restraint. If a trained and competent RN (or NP or PA) conducts the face-to-face evaluation, the RN (or NP or PA) must consult with the attending physician who is responsible for the patient's care after completing the face-to-face evaluation. This consultation must be documented in the medical record along with the order to use or continue restraint ... Staff Training Requirements: A. Staff must be trained and demonstrate competency prior to application of restraints, and the implementation of, monitoring, and providing care for the patient in restraint before performing any of these actions, as part of orientation, and subsequently on an annual basis by either skills demonstration and/or electronic educational module ... B. In addition, the hospital must require appropriate staff to have education, training, and demonstrate knowledge based on the specific needs of the patient population in at least the following ... 6. Monitoring the physical and psychosocial well-being of the patient who is restrained or secluded, including but not limited to: i. respiratory and circulatory status ii. Skin integrity iii. Vital signs iv. Behavior observed."

Based on interview, and record review, the facility failed to ensure three of five sampled registered nurses (RN 2, RN 3 and RN 4) completed their advance directive training (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) yearly, in accordance with the facility's Annual Competency (ability to demonstrate mastery of specific skills and knowledge) Education requirements.

This deficient practice had the potential for violations of patient rights, thus causing harm to patients, due to lack of staff training. This deficient practice may also result in the failure to honor patient's wishes or neglecting to provide necessary information to allow patients to have informed decision-making.

Findings:

During a concurrent interview and record review on 05/02/2025 at 12 p.m. with the Business Manager of Education (M1), the personnel records, specifically, the training records titled, "Student and Group Transcript Report," with date range from 05/1/2023 - 04/30/2025, for registered nurses (RN 2, RN 3, and RN 4), were reviewed. The record indicated that RN 2, RN 3 and RN 4, failed to complete yearly training on advance directive (training module that focuses on educating facility staff about patient rights and responsibilities, end-of-life care and decision-making) titled "SQ: Patient Rights, Advance Directive." The records indicated that RN 2's last completion of training was 06/24/2023, RN 3's last completion date was 10/03/2023, and RN 4's last completion date was 06/14/2023.

During the same interview on 5/02/2025 at 12 p.m. with the Business Manager of Education (M1), M1 stated that the training for advance directive was mandatory for all direct patient care registered nurses and must be completed yearly. RN 2, RN 3 and RN 4 were current active employees and should have completed their training on advance directive yearly. This training was important because it helped staff understand the importance of advance directives, and how to ensure that patient wishes were respected and documented.

During a review of personnel's job description titled, "Registered Nurse," with last revised date 01/14/2022, the record indicated that registered nurses were to complete all mandatory initial and annual training within assigned time frames per established guidelines.

During a review of an education list titled, "Annual Competency Education," undated, the record listed patient rights/advance directive as an annual regulatory education for staff.

Based on interviews and record review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a hospital-wide approach used to continuously assess, monitor, and improve processes that impact patient care outcomes) failed to ensure that an adverse event (an unexpected and undesirable medical incident) involving one of 30 sampled patients (Patient 21), related to malfunctioning medical equipment, specifically, a critical monitoring device (bed alarm) was analyzed to determine the cause of the event and that preventive actions were developed and implemented. QAPI failed to analyze the event, track contributing factors, or implement timely corrective actions. This is not in accordance with the hospital's QAPI requirements or the facility's "Medical Equipment Management Program" policy.

This deficient practice compromised the facility's ability to reduce medical errors, undermined the safety of patients, and increased the risk of repeated adverse events.

Findings:

During a review of Patient 21's medical record (MR) document titled, "Internal Medicine Progress Note," dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days.

During a review of Patient 21's medical record (MR) document titled, "Nursing Note," dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, "No injuries found upon assessment post (after) fall (a sudden change in body position in a downward direction, which may or may not result in a physical injury). Patient (Patient 21) did have blood present on the right forearm from IV (intravenous- through the vein) removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient (Patient 21) assisted back into bed and cleaned up."

During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM), the facility's event report (a formal document used to record and document any deviation from standard care, including errors, near misses, or other events that could potentially cause harm to patients, staff, or visitors) regarding Patient 21's fall, dated 5/20/2025, was reviewed. The report indicated the bed alarm was not working and that the nurse was counseled on the need to remove the non-working bed immediately. QM stated she (QM) could not confirm how long Patient 21 remained on the bed and the incident was not reported to the Quality Department.

During an interview on 5/2/2025 at 4:16 p.m. with The Director of Medical Surgical and Telemetry (DIR) 6, DIR 6 stated verbal coaching was issued because staff failed to call the Transport Department to remove the bed immediately. DIR 6 stated staff were expected to call Transport, which will then retrieve the bed and place a work order for repair or replacement. DIR 6 confirmed that there was no practice in place to tag malfunctioning bed with signage, which could result in continued use of unsafe equipment and compromise patient safety.

During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM), the facility's "Performance Improvement" minutes, dated from 4/17/2024 through 3/19/2025, was reviewed. The minutes did not indicate the incident involving a malfunctioning bed alarm occurring in May 2024. QM Confirmed the bed alarm was not working at the time of Patient 21's fall and that no Root Cause Analysis (RCA, a structured method used to identify the underlying causes of adverse events) was conducted. The incident was also not reported to the Quality Department.

During an Interview on 5/2/2025 at 6:05 p.m. with the Quality Management Patient Safety (QM), QM stated QAPI had no formal system in place at that time to track or audit bed alarm functionality. She (QM) further confirmed that the gap between the policy and actual practice on Medical Surgical and Telemetry (T3) was not identified until later audits (QM was unable provide dates).

During an interview on 5/2/2025 at 6:20 p.m. with the Director of Medical Staff Services and Board (DMSS), DMSS stated that the incident was not reviewed by the Medical Quality or Executive Board Committees and acknowledged it should have triggered an RCA due to patient safety implications.

During a review of the facility policy and procedure (P&P) titled, "Medical Equipment Management Program," dated 10/10/2023, the P&P indicated: " The Risk Manager and Designated Biomedical Department Head are responsible for monitoring and reporting incidents in which a medical device is suspected of being involved with any death or serious illness or injury ...Events should be documented through the Electronic Event Reporting process... to support any requirements for Root Cause Analysis and/or reporting... The results of the evaluation are utilized to... identify opportunities for improvement through the replacement of equipment, changes in management procedures... or healthcare worker training."

During a review of the facility's policy and procedure (P&P) titled, "Quality Management/Clinical Safety Policy and Procedure Manual: Patient Safety Plan," dated 12/18/2024, the P&P indicated, "In order to reduce the likelihood of patient incidents and negative outcomes, (name of the facility) shall track the frequency and type of medical errors and compile them in order to learn from and prevent future negative occurrences. The Quality Assurance Performance Improvement (QAPI) Program will incorporate data including patient care data and other relevant data such as to identify opportunities for improvement and changes that will lead to improvement of the (QAPI) program ... a. Risk Occurrence reports with database compilation ... proactive risk assessment -An assessment that examines a process in detail including sequencing of events; accesses actual potential risk, failure, points of vulnerability; and through a logical process, priorities areas for improvement based on the actual or potential patient care impact (criticality).
...4. Data Analysis -Analysis of collected data will be undertaken to monitor and identify levels of performance, trends or patterns that vary significantly from expected outcomes and the need for possible change/ improvement in systems or processes.
5. Process Improvement -When undesirable outcomes are identified, the hospital shall involve the personnel, resources, disciplines, and department/services most directly involved with the process to reduce future risk."

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

1. Ensure one of 30 sampled patient's (Patient 3) enteral feeding set (the tubing and associated components used to deliver nutrition directly into the stomach through a feeding tube), was changed every 24 hours or once infused (not to exceed 24 hours), in accordance with the facility's standard practice regarding changing the enteral feeding administration set.

This deficient practice had the potential to compromise Patient 3's safety by increasing the risk of infection, such as bacterial contamination due to improper or inconsistent changing of feeding sets, which may contribute to the increased risk of hospital-acquired infections (HAIs, infections that patients develop while receiving care in a healthcare facility, such as a hospital) and complications for Patient 3.

2. Ensure one of 30 sampled patient's (Patient 6) two sterile water containers, were signed with the date and time after opening to ensure that the containers were not used beyond expiration date (the labeled date and time indicate when the container was opened, as sterile water may become contaminated with germs after opening).

This deficient practice had the potential for Patient 6 to receive sterile water that could have been contaminated, which might lead to a compromised health status and complications such as hospital-acquired infections (HAI) for Patient 6.

3. Ensure Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) Registered Nurses (RNs), reassessed one of 30 sampled patients (Patient 11), after anti-psychotic (medication injected to a patient's muscle to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality]) injections were given to Patient 11 on multiple occasions on 4/14/2025.

This deficient practice resulted in Patient 11 not receiving proper assessment and monitoring to evaluate the effectiveness of the medications received and the potential need for further management.

Findings:

1. During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body's organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach).

During an observation on 4/29/2025 at 12:08 p.m. with the Quality Management (QM), in Patient 3's room, Patient 3 was observed resting in bed, connected to the enteral feeding device (a medical device that provides necessary nutrients directly into the stomach). The feeding set was connected to a tube feeding bottle or container [Brand] formula attached to the set (Kangaroo pump- a portable infusion device used to administer fluids, medications, or nutrition through enteral lines) had a label showing the date of 4/26/2025, the start time of 6:30 p.m., and a flow rate of 20 milliliters (ml, measuring unit) [to be infused in 1 hour]. The QM verified that the label observed was dated 4/26/2025.

During a concurrent interview on 4/29/2025 at 12:17 p.m. with registered nurse (RN 9), RN 9 stated that the night shift nurse hung the feeding for Patient 3. RN 9 also said that the feeding administration set (components such as the tubing and connectors) must be changed every 24 hours or after the entire container had been infused, whichever occurred first. RN 9 explained that enteral feeding cannot go over 24 hours due to a risk of infection for the patient [Patient 3] (prolonged use of the same feeding set increases the likelihood of bacterial growth or contamination, which can lead to infections such pneumonia [PNA, an infection that inflames the air sacs in one or both lungs] or gastrointestinal infections [infections of the stomach and intestines caused by bacteria, viruses, or parasites]).

During a concurrent interview and record review on 5/1/2025 at 2:00 p.m. with the Quality Coordinator (QC 1), the QC 1 verified that Patient 3 had no documentation of how and when the enteral tubing was changed from 4/26/2025 through 4/29/2025.

During an interview on 5/2/2025 at 11:24 a.m. with the clinical educator (CE 2), CE 2 stated that the current practice at the facility included changing the enteral tubing administration set every 24 hours or when the feeding container had been fully infused. CE 2 said, "The entire administration set should be replaced to prevent cross-contamination (the transfer of bacteria (germs) between products or patient sites) and to reduce the risk of infection. The date and time should be documented on the label attached to the feeding container when it is opened. The feeding container has labels where patient's name, date, and time and flow rate and the schedule for water flushes can be documented."

During an interview on 5/2/2025 at 11:15 a.m. with the quality management (QM), QM stated that the facility did not have a written policy or protocol addressing the recommended frequency for changing the enteral feeding administration set. QM presented the current enteral feeding policy, which contained no information regarding the recommended schedule or guidelines for changing enteral feeding administration set. QM also provided the educational material titled, "Feeding Tube-Education," [no date], which the facility used during new hire orientation to rate the employees on performance of the insertion, assessment, and maintenance of adult feeding tubes, which similarly lacked any information about the facility's expected practices regarding administration set changes for tube feedings. QM stated that since this was a nursing practice related issue, nursing leadership was ultimately responsible for ensuring that the facility had relevant policies and or protocols in place to guide staff on this matter.

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented."

During a review of published guidelines from Professional organizations like the American Society for Parenteral (administration of nutrients through routes other than gastrointestinal tract, such as through a vein, or muscle) and Enteral Nutrition (ASPEN) titled, " Guidelines for the Use of Enteral Nutrition in Adult Patients," dated 2020, the document provided evidence-based nutrition practice guidelines which recommended changing the entire feeding set every 24 hours unless otherwise specified by institutional policies or patient-specific needs to minimize infection risk.

2. During a review of Patient 6's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/26/2025, the H&P indicated that Patient 6 was found unresponsive (unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves) next to a scooter; was intubated (a tube, typically an endotracheal tube, has been inserted into a patient's trachea [windpipe] to assist with breathing) in the field and brought to the facility as a trauma patient (someone who has suffered a traumatic injury).

During a concurrent observation and interview on 4/29/2025 at 11:56 a.m. with the Quality Management (QM) and the Registered Nurse (RN 8), in Patient 6's room, four sterile water bottles were observed standing on the bedside table near Patient 6's bed. Two sterile water containers were still sealed, while the other two had been opened, and sterile water had been used from them. The open containers still contained about half their volume left in them, but there was no date and time marked on them when they were opened. RN 8 stated that sterile water for Patient 6 was used when medications were given through the G-Tube (surgically inserted feeding tube used to deliver nutritionist and medications directly into the stomach, bypassing the mouth). RN 8 also said that the sterile water containers must be signed with a date and time after opening because the solution must be used within 24 hours after opening, to minimize the risk of contamination (growth of harmful germs).

During an interview on 5/2/2025 at 11:25 a.m. with the Quality Management (QM), QM stated that the facility did not have a policy or protocol in place regarding the handling and use of sterile water containers once they have been opened. QM also said that nursing practices and protocols within the facility fell under the oversight of nursing leadership, and they were ultimately responsible for ensuring that policies, procedures, and protocols related to nursing practices were in place and followed by nurses' hospital-wide to ensure consistent and safe implementation of care.

3. During a review of Patient 11's "Behavioral Health (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)Inpatient Provider Admission Note (psych H&P, a formal and complete assessment of the patient and the problem completed by a psychiatrist [physician specializes in mental health])," dated 4/13/2025, the psych H&P indicated, Patient 11 was admitted to the facility's Behavioral Health Unit on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and cannabis use disorder (a complex condition that involves problematic pattern of cannabis [marijuana] use).

During a review of Patient 11's "Progress notes (nursing narrative notes)," dated 4/14/2025, the progress notes indicated, "At 8:30 a.m., Patient 11 was pacing in the hallway frequently and dismissing staff instruction, Patient 11 also threatening and posturing towards staff ... MD 8 was notified and new orders received. Patient 11 tolerated injections and continued to pace ... At 11:30 a.m. Patient 11 came out of the shower ... upon exiting the shower room, Patient 11 grabbed staff on the buttocks ... MD 8 was notified and new orders received. Patient 11 tolerated injection."

During a review of Patient 11's "Behavioral Health Forms," dated 4/14/2025, the Behavioral Health forms indicated, at 5:11 p.m., Patient 11 attempted to forcefully snatch a staff's badge to exit the unit and lunged at staff member aggressively. The Behavioral Health forms also indicated Patient 11 was placed in seclusion (involuntary confinement of a person in an area in a room or area where the person if physically prevented from leaving) and 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) for Patient 11's safety and safety of others.

During a review of Patient 11's physician order, dated 4/14/2025, the physician order indicated violent 4-point (both wrists and both ankles) restraints and seclusion was ordered on 4/14/2025 at 5:18 p.m.

During a concurrent interview and record review on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), Patient 11's "Medication Administration Record (MAR, record of medications given to patients)," dated 4/14/2025, was reviewed. The MAR indicated Patient 11 received the following medications on 4/14/2025:

-At 8:40 a.m.: Zyprexa (medication injectable for rapid control of agitation [feeling of severe restlessness, and excessive motor activity such as pacing, rocking, gesturing] and disturbed behavior) 10 milligrams (mg, unit of measure) intramuscular (IM, delivering medication directly into the muscle tissue) injection one time and Benadryl (medication helps to calm agitation and anxiety in psychotic [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality] patient) 50 mg IM one time;
-At 11:56 a.m.: Thorazine (medication injectable to treat psychotic disorder) 50 mg IM one time; and
-At 5:34 p.m.: Thorazine 50 mg IM on time and Benadryl 50 mg IM one time.

During the same interview on 5/1/2025 at 10:08 a.m. with the Risk Management Coordinator (CQ 3), CQ 3 stated these (referring to the Thorazine, Zyprexa and Benadryl medications) were one-time order anti-psychotic injections given to manage Patient 11's agitated behavior.

During an interview on 5/1/2025 at 11:35 a.m. with the Director of Behavioral Health Unit (DIR 5), DIR 5 stated the following: BHU RN should re-assess patients after any one-time order anti-psychotic injection was given. It should be done within thirty (30) minutes to an hour after the administration of the injection to check the patient's response and to evaluate the effectiveness of the medications then determine if patient would require additional interventions. DIR 5 also stated there was no re-assessment done after the anti-psychotic injections were given at 11:56 a.m. and at 5:34 p.m.

During an interview on 5/2/2025 at 3:12 p.m. with DIR 5, DIR 5 stated the following: the one-time order anti-psychotic injections were given when a patient was actively a danger to self or others. The purpose of these injections was to manage the patient's behavior. The BHU RN should perform a reassessment to evaluate patient's behavior and response to treatment. Currently, the re-assessment was done per nurses' discretion because there was no policy and procedures to speak the process. DIR also stated they were trying to develop some standardized process for the BHU RNs to follow.

During an interview on 5/2/2025 at 4:24 p.m. with the Clinical Pharmacy Coordinator (CPC), CPC stated the following: nursing staff should perform a reassessment within thirty (30) minutes to an hour after any anti-psychotic injections were given to BHU patients. The reassessment would include evaluating the patient's response to the medication so the patient could be safely managed and cared for.

During a review of the facility's policy and procedures (P&P) titled, "Assessments," dated 6/2023, the P&P indicated, "Purpose: to determine patient's care through assessment of each patient's needs; and to provide guidelines for patient assessment activities ... Ongoing assessments will be performed as the need arises to determine the patient's response to treatment ... Any significant change in a patient's condition or diagnosis will warrant ongoing assessment by a Registered Nurse ... Re-assessment shall be documented in the patient's medical record."

Based on interview and record review, the facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 3), to address Patient 3's high risk for aspiration (refers to the inhaling of food, liquid, or secretions into the lungs instead of the esophagus [a muscular tube that conveys food from the mouth to the stomach]), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for the lack implementation of aspiration precautions (aim to prevent food or liquid from entering the lungs while a person is receiving nutrients through a feeding tube) for Patient 3, which could result in aspiration and possible injury or harm such as aspiration pneumonia (a lung infection caused by inhaling food, or stomach contents into the lungs), which can lead to serious respiratory complications, prolonged hospitalization, and even death.

Findings:

During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body's organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach).

During a review of Patient 3's medical record (MR) titled, "Order Sheet," dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding (the delivery of nutrition directly into the gastrointestinal (GI) tract using a tube, instead of through normal oral consumption).

During a concurrent interview and record review on 5/1/2025 at 2:07 p.m. with the Quality Coordinator (QC 1), Patient 3's "Care Plans," dated 5/1/2025, and initiated on 4/26/2025, the Care Plans indicated that there was no initiated care plan to address aspiration risk for Patient 3 related to enteral feeding (the delivery of nutrition directly into the gastrointestinal (GI) tract using a tube, instead of through normal oral consumption). The QC 1 verified, that Patient 3 had no developed care plan for "Risk for Aspiration," and stated would need to refer to policy regarding this care plan.

During an interview on 5/2/2025 at 11:24 a.m. with the Clinical Educator (CE 2), the CE 2 stated that: "Some care plans that can be initiated for patients with G-tubes include "nutritional" care plans and "at risk for aspiration" care plans (that address the potential for stomach contents to enter the lungs), as all patients with G-Tubes have a risk of aspiration."

During further interview on 5/2/2024 at 12:06 p.m. with the Clinical Educator (CE 2), the CE 2 stated that nurses need to develop care plans because care plans serve as structured, individualized guides to delivering patients' care based on identified patients' needs. The CE 2 then also said that care plans establish specific goals for the patient to achieve, which were aligned with desired outcomes, such as improved health status, symptoms management, or safety.

During a review of the facility's policy and procedure (P&P) titled, "Adult Feeding Tubes," dated 3/2022, the P&P indicated that: "Patients with feeding tubes shall be assessed, monitored for risk of aspiration ...Aspiration precautions must be documented .... Care Plan must be developed, as appropriate ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Planning," dated 4/2024, the P&P indicated the following: "In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient ... The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response ... The Care Plan will be started by the Registered Nurse (RN) responsible for the admission of the patient ... Staff shall evaluate the patient's progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient's need for further care, treatment, and services; or the patient's achievement of goals and shall be closed at time of discharge."

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated that: "An admission assessment will be initiated as soon as possible after admission and must be completed within 24 hours of admission. For electronic documentation, Interdisciplinary Plans of Care (IPOC) shall be initiated to include goals & interventions."

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

1. Ensure one of 30 sampled patient's (Patient 3) total intake (refers to the amount of feeding formula consumed by a patient) of feeding formula per 24 hours, was documented, in accordance with the facility's policy and procedure regarding enteral feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) administration documentation.

This deficient practice had the potential to compromise Patient 3's nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3's risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications.

2. Ensure one of 30 sampled patients (Patient 21) received a complete neurological assessment (an exam that evaluates brain and nervous system function through test of mental status, reflexes [automatic body response], movements, and speech) following a fall (an unplanned change in position where a patient lands on the floor or a lower surface), in accordance with the facility's policy and procedures titled, "Fall Prevention and Reduction."

This deficient practice had the potential to delay recognition of serious medical problems such as a head injury or stroke (occurs when blood flow to the brain is interrupted). Signs and symptoms such as brain swelling, bleeding, or damage might not be noticed in time.

3. Ensure staff removed from service a hospital bed with a malfunctioning alarm for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedure titled, "Medical Equipment Management Program." Specifically, the bed alarm was found to be non-functional, and staff failed to ensure the bed was taken out of commission, resulting in uncertainty whether the same bed continued to be used for patient care.

This deficient practice increased the potential for failure to prevent or respond to patient bed exit in a timely manner, placing patients at increased risk of injury due to falls.

Findings:

1. During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body's organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach).

During a concurrent interview and record review on 4/29/2025 at 12:12 p.m. with registered nurse (RN 9), Patient 3's record of total enteral feeding intake, was reviewed. RN 9 stated that Patient 3 had a G-tube (gastrostomy tube, a surgically placed feeding tube directly into the stomach) and was on continuous enteral (feeding administered into the gastrointestinal tract ( GI Tract, a series of organs that process food from ingestion to excretion), typically through a feeding tube)], that was infused at 50 milliliters (ml, a unit of volume measurement) per hour through the G-Tube. RN 9 said that documentation of total enteral feeding intake (refer to the sum of all) per shift was not required and typically not documented, unless there was a specific order to do so. RN 9 then checked the documentation in Patient 3's chart and confirmed that no total intake for enteral feeding had been documented for Patient 3 in the past 24 hours.

During a review of Patient 3's medical record (MR) titled, "Order Sheet," dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding.

During a concurrent interview and record review on 5/1/2025, at 2:07 p.m. with the Quality Coordinator (QC 1), Patient 3's record titled, "GI-Tube," dated 4/26/2025 through 4/28/2025, was reviewed. The record indicated the following: (documentation of total intake [the overall amount of] of enteral feeding):

-On 4/26/2025 from 7:00 a.m. to 7 p.m. -Total intake of tube feeding was not documented.
-On 4/26/2025 from 7:00 p.m. through 4/27/2025 at 7:00 a.m.-Total intake of tube feeding infused was not documented.
-On 4/27/2025 from 7:00 p.m. through 4/28/2025 at 7 a.m.-Total Intake of tube feeding was not documented.

During the same interview on 5/1/2025 at 2:07 p.m. with the Quality Coordinator (QC 1), QC 1 confirmed that Patient 3's record titled, "GI-Tube," (dated 4-26/2025 through 4/28/2025) contained only the documented total infused enteral feeding intake on 4/27/2025 (7 a.m. to 7 p.m.), totaling 500 ml for that shift.

During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 2), the CE 2 stated the following: " ... The amount of enteral feeding infused, should be documented by the nurses, regardless of if there is a physician's order or not. We want to know if the patient is tolerating the feeding well and to monitor the nutritional status (encompasses the balance between nutrient intake and the body's needs for optimal health, growth, and function)."

During a review of the facility's policy and procedure (P&P) titled, "Adult Feeding Tubes," dated 3/2022, the P&P indicated that: "The policy is developed to ensure that patients with feeding tubes shall be assessed, monitored, and maintenance provided. D. Documentation for patients with Enteral Nutrition: 5. Intake and Output (I&O, "intake" refers to the fluids a patient consumes, while "output" refers to the fluids a patient eliminates from the body), including rate and volume of feeding, number of flushes (free water), discarded residuals (refers to the amount of fluid that remains in the stomach after a feeding, must be documented for patients with enteral nutrition, fluid is aspirated from the stomach via the feeding tube to monitor gastric emptying and assess a patient's tolerance to enteral nutrition )."
During a review of the facility's policy and procedure (P&P) titled, "Intake and Output (I&O, "intake" refers to the fluids a patient consumes, while "output" refers to the fluids a patient eliminates from the body)," dated 8/2021, the P&P indicated that: "II. When indicated for the patient based upon condition or orders: A. l&O should be routinely recorded every 12 hours with a 24-hour total computed, or more frequently as patient's status dictates. IV. It is the Registered Nurse's responsibility to be aware of a positive or negative fluid balance and ensure that l&Os ...are documented when ordered or as appropriate for patient's condition. Any medically significant positive or negative fluid balances shall be reported to the physician."

2. During a review of Patient 21's medical record (MR) document titled, "Internal Medicine Progress Note," dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days.

During a review of Patient 21's MR document titled, "Nursing Note," dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, "No injuries found upon assessment post (after) fall (an unplanned change in position where a patient lands on the floor or a lower surface). Patient did have blood present on the right forearm from IV (intravenous-into the vein) removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient assisted back into bed and cleaned up."

During a review of Patient 21's MR document titled, "Provider Notification," dated 5/20/2024 at 12:29 p.m., the Provider Notification indicated, "Small bleeding from left side of patient's (Patient 21) head post fall, no cut noted when examined and cleaned but blood noted on the pillow and gauze." The document further indicated, "Provider requested intervention: MD said place order for CT (computed tomography, a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) brain."

During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22's MR document titled, "Neurological" assessment dated from 5/20/2024 through 5/21/2025, was reviewed. The assessment indicated the following:

-On 5/20/2024 at 8:38 a.m., Patient 21 was oriented to person (being aware of who you are interacting with, including recognizing and remembering people and understanding their roles and relationships), and oriented to place (having a mental awareness of one's current location within a known environment, including the ability to understand the spatial relationships between objects and one's surroundings).
-On 5/20/2025 at 11:00 a.m. (following the fall) Patient 21 was oriented to person, and place.
-On 5/20/2025 at 2:45 p.m. (3 hours and 45 minutes later after the fall) Patient 21 was disoriented x 4 (a person is confused and unable to accurately identify four aspects of their surroundings: who they are [person], where they are [place], what time it is [time], and what is happening around them [situation]). CQ 2 stated after a fall, the patient neurologic assessment must follow the facility's protocol, and more frequent assessment should be done if there was a change in neurological (the nervous system, including the brain, spinal cord [a long, tubular structure made of nerve tissue that extends from the brainstem down the center of the back to the tail bone], and nerves throughout the body) status.

During an interview on 5/2/2025 at 10:52 a.m. with the Director of Telemetry 3 (DIR) 6, DIR 6 stated the process staff should follow after a patient fall was to notify the physician, Supervisor, and the patient's family, document the fall, and assess the patient including completing a neurological assessment. DIR 6 confirmed that following a fall, neurological assessment should be completed every two hours 2 times and following every 4 hours for 24 hours. However, if there were signs in mentation decline (gradual loss of thinking abilities), then the nurse should complete neurological assessments more frequently such as every hour.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Reduction," dated 10/12/2020, the P&P indicated, "In the event of a patient fall, staff shall take the following actions ...Immediately perform and document a complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries ...Attachment E: Record neuro observations if head involved (every 2 hours X2 and every 4 hours X 24 hours)."

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," dated 3/28/2024, the P&P indicated, "Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care and SBAR (Situation, Background, Assessment, and Recommendation- a structured communication tool used in healthcare to facilitate quick and efficient information exchange, particularly between healthcare professionals) tool reflecting the change in condition."

3. During a review of Patient 21's medical record (MR) document titled, "Internal Medicine Progress Note," dated 5/20/2025, the progress note indicated, Patient 21 had past medical history of chronic (a condition that lasts for a long period) hypoxic respiratory failure (occurs when the lungs struggle to deliver sufficient oxygen to the blood, leading to low oxygen levels in the blood), on 2.5 L (liters, a unit of measurement) nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at home, COPD (Chronic obstructive pulmonary, a disease that restrict breathing), hypertension (condition where the force of blood against the walls of the vessels is too high; the blood pressure [top number] of 130 mmHg or higher), who presented with shortness of breath (the feeling of not being able to get enough air into your lungs), cough, congestion (an abnormal or excessive accumulation of fluid, particularly blood or mucus, in a body part or organ), and wheezing (a high-pitched, whistling sound during breathing caused by airflow through narrowed or obstructed airways) for 2 days.

During a review of Patient 21's medical record (MR) document titled, "Nursing Note," dated 5/20/2025 at 11:00 a.m., documented by Registered Nurse (RN) 5, the note indicated, "No injuries found upon assessment post fall. Patient (Patient 21) did have blood present on the right forearm from IV removal. Appears to be no injury to head, arms, hands, legs, feet, or body. Patient (Patient 21) assisted back into bed and cleaned up."

During a review of Patient 21's MR document titled "Provider Notification," dated 5/20/2024 at 12:29 p.m., the Provider Notification indicated, "Small bleeding from left side of patient's (Patient 21) head post fall, no cut noted when examined and cleaned but blood noted on the pillow and gauze." The document further indicated, "Provider requested intervention: MD said place order for CT (computed tomography, a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) brain."

During a concurrent interview and record review on 5/2/2025 at 4:12 p.m. with the Quality Management Patient Safety (QM) the facility's event report (a formal document used to record and document any deviation from standard care, including errors, near misses, or other events that could potentially cause harm to patients, staff, or visitors) regarding Patient 21's fall, dated 5/20/2025, was reviewed. The report indicated the bed alarm was not working and that the nurse was counseled on the need to remove the non-working bed immediately. QM stated she (QM) could not confirm how long Patient 21 remained on the bed (with the bed alarm not working), and the incident was not reported to the Quality Department.

During an interview on 5/2/2025 at 4:16 p.m. with the Director of Medical Surgical and Telemetry (DIR) 6, DIR 6 stated verbal coaching was issued because staff failed to call the Transport Department to remove the bed immediately. DIR 6 stated staff were expected to call Transport, which will then retrieve the bed, and place a work order for repair or replacement. DIR 6 confirmed that there was no practice in place to tag malfunctioning bed with signage, which could result in continued use of unsafe equipment and compromise patient safety.

During a concurrent interview and record review with the Manager of Transportation Department (MT)1 on 5/2/2025 at 4:32 p.m., the facility's work orders placed in May 2024, were reviewed. The documents titled, "Corrective Work Order" and "Work Requested details" indicated that no work order had been placed for a bed alarm malfunction on the Medical Surgical and Telemetry unit (Tower 3-T3) or Documentation of order placed for T3 unit regarding a bed alarm malfunction or the status of a bed with malfunctioning alarm. MT 1 confirmed that, due to lack of detail or documentation, the facility could not determine the status of the bed with the malfunctioning alarm. MT 1 added that the staff member who discovered broken equipment was responsible for initiating the work order.

During a review of the facility's policy and procedure (P&P) titled, "Medical Equipment Management Program," dated 10/10/2023, the P&P indicated, "High-Risk Equipment (Life Support & Critical Equipment) - equipment this is critical to patient health and safety. At a minimum such critical equipment includes, but is not limited to, life-support devices, key resuscitation devices, critical monitoring devices, and other devices whose failure may result in serious injury to or death of patients or associates ... B. The healthcare worker who identifies that a medical device is in need of repair shall
1. Dial the Biomedical extension 4444 (option 2)
2. The Biomedical extension is automatically forwarded to the Engineering Department after hours where an Engineer will assess the request. C. The healthcare worker making the service call shall complete the Defective Equipment (Do Not Use) sticker, ...documenting the time of the service call and attach it to the defective device ... If a piece of equipment is directly involved, or is thought to have been directly involved, the equipment must be removed from service and quarantined with as little disturbance as possible to the settings and other evidence that might aid the investigation."

Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 22), received prescribed pain medication, in accordance with the physician's orders and the facility's policy and procedure titled "Administration of Medications."

This deficient practice resulted in Patient 22 experiencing unrelieved pain, which had the potential to limit the patient's ability to walk and begin physical therapy (treatment to help restore movement and strength).

Findings:

During a review of Patient 22's "Emergency Documentation: ED Note Physician," dated 3/9/2025, the note indicated Patient 22 had a history of congestive heart failure (CHF, a condition where the heart cannot pump blood effectively enough to meet the body's need), Crohn's disease (CD, a chronic inflammatory bowel disease that affects the digestive tract), and diabetes (a condition where your body can't regulate the amount of sugar in your blood). The patient (Patient 22) was admitted with ongoing generalized weakness (reduced muscle strength) and fatigue (lack of energy). The patient (Patient 22) reported being unable to care for himself and requested placement in a care facility. He (Patient 22) had recently suffered a femur (thigh bone) fracture and had not started physical therapy (treatment to help restore movement and strength).

During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22's medical record (MR) document titled, "Order Summary," dated 3/9/2025 through 3/11/2025, was reviewed. The order summary indicated the following:

-Acetaminophen-Hydrocodone (prescribed pain medication used to relieve moderate to severe pain) 325 mg (milligrams, a unit of measurement)-5 mg, 2 tablets every 6 hours, PRN (as needed) for pain, for 10 days.

During a concurrent interview and record review with CQ 2 on 4/30/2025 at 2:15 p.m., Patient 22's "Medication Administration Record (MAR, a patient's record that tracks the medications prescribed and administered to them)," from 3/9/2025 through 3/11/2025, was reviewed. The MAR indicated:

-3/9/2025 at 9:41 p.m. - Acetaminophen-Hydrocodone 2 tablets given
-3/10/2025 at 7:33 a.m. - Acetaminophen-Hydrocodone 2 tablets (10 hours, 32 minutes after prior dose)
-3/10/2025 at 3:06 p.m. - Acetaminophen-Hydrocodone 2 tablets (7 hours, 33 minutes later)
- 3/11/2025 at 12:39 a.m. - Acetaminophen-Hydrocodone 2 tablets (9 hours, 33 minutes later)
-3/11/2025 at 7:45 a.m. - Acetaminophen-Hydrocodone 2 tablets (7 hours, 6 minutes later)
- 3/11/2025 at 5:18 p.m. - Acetaminophen-Hydrocodone 2 tablets (9 hours, 33 minutes later)

During the same interview on 4/30/2025 at 2:15 p.m. with the Sepsis and Quality Coordinator (CQ) 2, CQ2 confirmed the medication (Acetaminophen-Hydrocodone), was not administered within the prescribed 6-hour interval and stated nurses should have notified the physician if pain was not relieved.

During a concurrent interview and record review with CQ 2 on 4/30/2025 at 2:20 p.m., Patient 22's "Vital Flowsheet (a structured chart within a patient's record used to track observations, trends, and data over time)," dated 3/9/2025 through 3/11/2025, was reviewed. The flowsheet indicated the following:

-3/9/2025 at 5:31 p.m. - Pain rated 7/10 in the knee; no pain medication administered or reassessment until 9:40 p.m. (4 hours later)
-3/10/2025 at 6:30 a.m. - Pain rated 7/10; medication given an hour later
-3/10/2025 at 8:08 p.m. - Pain continued to be rated at 7/10
-3/10/2025 at 9:50 a.m. - Pain increased to 10/10; medication not given until 3:06 p.m. (over 5 hours later)
-3/11/2025 at 7:35 a.m. - Pain rated 10/10; medication given at 7:45 a.m.
-3/11/2025 at 7:44 a.m. - Pain continued to be rated 10/10
-3/11/2025 at 8:15 a.m. - Pain rated 7-8/10
-3/11/2025 at 5:15 p.m. - Pain rated 8/10

During the same interview on 4/30/2025 at 2:20 p.m. with CQ 2, CQ 2 confirmed that Patient 22's tolerable pain goal was below 3. CQ 2 stated if pain continued more than 9 hours after medication was given, the physician should be notified. This was not done in the case of Patient 22.

During a concurrent interview and record review on 4/30/2025 at 2:40 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22's medical record document titled, "Communication Flowsheet," dated from 3/9/2025 through 3/11/2025, was reviewed. The flowsheet indicated there was no documentation that staff notified the physician about Patient 22's ongoing pain. CQ2 stated that the nurse should have informed the physician when the pain persisted.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medication," dated 7/8/2024, the P&P indicated: "Electronic medication records are reviewed at the beginning of each shift for order, dose, and timing...PRN medications... shall be administered within 30 minutes from the time assessment confirms the need ...Medications must be administered in a timely manner so as not to compromise safety or effectiveness."

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 6/28/2022, the P&P indicated, "Appropriate use of analgesic medications shall be encouraged ... Interventions shall be made to relieve pain when reported with evidence¿-based multi modal treatment modalities; these may be selected as indicated by physician order and patient preference ... Pain medication administration should be preceded by assessment of pain, patient rating of pain. The nurse shall consider subjective and objective factors prior to administration ... Reassessment of pain shall take place within a clinically appropriate time frame based upon the intervention used ... The registered nurse (RN) shall communicate with the physician to coordinate an alternative treatment plan when pain is above the identified comfort goal ..."

Based on interview and record review, the facility failed to ensure that for one patient of 30 sampled patients (Patient 1), the emergency department (ED, a hospital department that provides immediate medical care to patients experiencing sudden, serious health problems) visit medical record (MR) contained accurately completed documentation of suicidal (SI, plans or intentions to harm self) and homicidal (HI, thoughts or plans to harm others) ideation assessments (an evaluation conducted by healthcare professionals to determine the patient's risk to harm self or others, involving questions about thoughts, behaviors, and intent) in triage (the process of quickly assessing and prioritizing patients based on the severity of their condition to determine who needs immediate care), in accordance with the facility's policy and procedure regarding SI/HI screening when Patient 1 was documented to have arrived at the facility after a possible overdose on medication -Baclofen (a muscle relaxant medications used to treat muscle spasms).

This deficient practice had the potential for Patient 1 not to be correctly assessed for risk of harm to self or others, which could lead to inadequate safety measures, failure to implement appropriate interventions, increased risk of self-harm or harm to others, and potentially serious adverse outcomes such as death.

Findings:

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation-Physician Note," dated 2/23/2025, the MR indicated the following was documented in Patient 1's emergency visit medical record on 2/23/2025: "Patient [Patient 1] found ALOC (Altered Level of Consciousness, refers to a state where a person's level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment]) in hotel room by family ...was combative, and now lethargic (a state of drowsiness, sluggishness, and a lack of energy or alertness) per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug."

During a review of Patient 1's Medical Record titled, "Emergency Documentation-Physician Note," dated 2/23/2025 [time seen 11:44 a.m.], the record indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient's previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, "at the time of initial assessment, patient (Patient 1) is only arousable to painful stimuli (a painful stimulus is used to elicit a response, such as movement, vocalization, or other signs of awareness, when a person is not responding to normal interactions). The MR further indicated that Patient 1 was described (by family) to be found with a "pile of prescription drugs," and had markings on abdomen that were "related to being in a hot tub."

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's "Triage(refers to the detailed record of an initial, rapid assessment of a patient's condition and the prioritization of care needed based on their presenting complaint and urgency)" record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented the following in Patient 1's "Triage" record [on 2/23/2025 at 11:28 a.m.]:

-Thoughts of harming yourself: NO
-Thoughts of harming others: NO
-Level of consciousness: Drowsy [sleepy, lethargic]
-Orientation Assessment [refers to a person's level of awareness of their surroundings, time, and identity]: Unable to assess

During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), the QC 1 verified documentation indicating that Patient 1 was lethargic upon arrival to the emergency department (ED), Patient 1 was lethargic and unable to answer questions during the triage assessment regarding Suicidal (SI) and Homicidal ideation (HI).

During an interview on 5/1/2025 at 12:09 p.m., with the Director of the Emergency Department (ED) (Dir 1), Dir 1 stated the following regarding Suicidal/Homicidal (SI/HI) ideation screening in triage upon a patient's arrival to the hospital: "The patient must be alert and oriented (a patient who is awake, awake of their surroundings, and able to understand and respond appropriately) to be able to communicate effectively and to answer questions regarding suicidal ideation (SI, thoughts of harming or inflicting death on one's self) or HI (Homicidal ideation, thoughts about or planning to kill another person)."

During a concurrent interview and record review on 5/1/2025 at 12:15 p.m. with the Director of the Emergency Department (Dir 1), Patient 1's "Triage" record, dated 2/23/2025, was reviewed. The record indicated that Patient 1 presented drowsy and was not able to be assessed for orientation, but the patient (Patient 1) was documented to have answered "NO" to questions regarding thoughts of harming self or others. Dir 1 reviewed the documentation and stated that the most appropriate option in this documentation would be "unable to assess" rather than to record "no" for a patient who was recorded to be lethargic and unable to communicate. Dir 1 also stated that if a nurse was unable to assess SI/HI in triage, the next nurse (bedside nurse) should follow up with a re-assessment. Dir 1 said, "Even if the patient has answered "NO" to SI/HI questions in triage, nurses can still re-assess during the time patient is in the emergency department, especially if the patient was admitted with a possible overdose. We want to make sure that the patient remains safe."

During a review of Patient 1's nursing shift assessments (a systematic and ongoing process where a nurse gathers, analyzes, and interprets data to evaluate a patient's health status and plan appropriate care) completed during Patient 1's stay in the Emergency Department on 2/23/2025, from 11:37 a.m. to 5:57 p.m., no record of an additional SI/HI screening was found to be documented in Patient 1's electronic medical record (EMR, a digital version of a patient's paper-based chart or medical record within a single healthcare practice). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m.

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation (ED)-Physician Note," dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] "Patient [Patient 1] was brought to the facility by the ambulance [from hotel] for overdose. Patient [Patient 1] was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient 1 was seen for the same (on 2/23/2025, first ED visit) a day ago.

During a review of Patient 1's nursing assessments completed during Patient 1's stay in the Emergency Department (ED) on 2/24/2025 from 11:25 a.m. through 2/25/2025 at 6:18 a.m., no record of additional SI/HI screening was found to be documented in Patient 1's electronic medical record (EMR). This was verified by the Quality Coordinator (QC 1) during a concurrent interview and record review on 5/1/2025 at 12:20 p.m.

During an interview on 5/2/2025 at 3:04 p.m. with the emergency Department (ED) physician (MD 4), MD 4 reviewed Patient 1's ED visit (2 consecutive ED visits), dated 2/23/2025 and 2/24/2025, and stated the following: "Based on the physician's documentation in the patient's (Patient 1) record, it is not possible to determine whether Patient 1 was screened for suicidal ideation and if Patient 1 intentionally or unintentionally overdosed on medications. You would have to ask the physicians."

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented ..."

During a review of the facility's Policy and Procedure (P&P) titled, "Plan for Provision of Care, Treatment, and Services," dated 10/2024, the P&P indicated the following: "The Emergency Department (ED) will provide an assessment, and any treatment indicated to all patients presenting with any illness or injury.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment," dated 9/2022, the P&P indicated that all patients admitted to the hospital or in the ED, shall be screened for the presence of suicide risk factors ... All patients who screen positive for suicide risk factors and/or present with a primary complaint of an emotional or behavioral disorder, shall be further assessed using a comprehensive suicide risk assessment tool for the risk of suicide by a mental health professional.
Procedure:
1.A licensed healthcare professional will screen every patient for suicide risk during the initial assessment and reassessment by identifying with special emphasis on those who are being evaluated and/or treated for:
a. Suicide attempt (overdosing, self-injury) or suspected suicide attempt ... 3. If any of the above screening indicators are present for a patient in ED, the Psychiatric Liaison Nurse or MHRN who has LPS certification will complete a Columbia Suicide Severity Rating Scale (C-SSRS) form..."
During a review of the facility's policy and procedure (P&P) titled, " Initial Patient Assessment and Re-assessment," dated 3/24/2025, the P&P indicated the following [The P&P applies to all nursing areas, including the Emergency Department (ED)]: " At the time of admission or as soon as possible thereafter, each patient shall have an initial physical/psychological assessment completed by a registered nurse (RN). IV. The assessment is structured to identify facilitating factors and possible barriers to the patient reaching his or her goals including presenting problems and needs such as:
I. Psychological, emotional, behavioral, suicidal and mental disorders"
During a review of the facility's policy and procedure (P&P) titled, "Triage," dated 12/18/2023, the P&P indicated the following: "IX. Behavioral Health Patients
a. Patients who present to triage exhibiting behaviors such as aggressiveness, agitation, or suicidal ideation present a danger to him/herself, or others, including the ED staff, and are considered violent until proven otherwise.
b. The patient will be moved to a secured area away from the triage area. After the patient has had a medical screening exam and it is determined to be medically stable, a mental health evaluation may be requested on any person the provider deems appropriate, i.e., homicidal, suicidal, psychotic, etc."

Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 1), documentation of the response to Narcan (naloxone, an emergency medication used to reverse the effects of opioid overdose) was documented, after Narcan was administered to Patient 1 due to suspected opioid overdose (a medical condition where opioids cause significant respiratory depression [a breathing disorder characterized by slow or shallow breathing], sedation [a state of calmness, relaxation, or sleepiness induced by medications to help manage pain and anxiety], or coma [a state of prolonged unconsciousness where a person is unresponsive to their surroundings and environment], potentially leading to death).

This deficient practice had the potential to compromise Patient 1's well-being and recovery and may lead to delayed recognition of treatment effectiveness or adverse reactions, potentially hindering the effective clinical evaluation in documenting patient progress after an intervention (response to medication administration) when planning patient's (Patient 1) care.

Findings:

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation (ED)-Physician Note," dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] "Patient (Patient 1) was brought to the facility by the ambulance (from hotel) for overdose. Patient (Patient 1) was given 4 milligrams (mg, measuring unit) of Narcan (a medicine that rapidly reverses an opioid [a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs like heroin] overdose) intranasally (within or into the nose) on the way to the hospital. Patient (Patient 1) was seen for the same (on 2/23/2025, first of two consecutive ED visits) a day ago.

During a review of Patient 1's Medication Administration Record (MAR), dated 2/24/2025, the MAR indicated that on 2/24/2025, Patient 1 received 0.04 mg of naloxone (Narcan) (intravenously, [IV] given through a vein into the blood), ordered as needed (PRN) at 11:45 a.m.

During a concurrent interview and record review on 5/1/2025 at 10:50 a.m. with the Quality Coordinator (QC 1), Patient 1's Medication Administration Record (MAR), dated 2/24/2025, was reviewed. QC 1 confirmed that Patient 1's MAR contained no documentation of Patient 1 being re-assessed for the response to naloxone administration.

During an interview on 5/1/2025 at 11:00 a.m. with the Clinical Pharmacy Coordinator (CPC), the CPC stated the following regarding documentation expectations after administering Narcan for a suspected opioid overdose: "Narcan is an opioids reversal agent. I don't believe we (the facility) have a specific policy stating that the response to Narcan administration must be documented. However, if this medication is given for an actual opioid overdose in the emergency department, the expectation is for the nurses to document the patient's reaction and response to the medication, but we don't audit emergency department Narcan administration. We conduct audits for this documentation to monitor for suspected inpatient adverse reactions to opioids. We specifically look for the assessment documentation conducted after Narcan administration to evaluate its effectiveness."

During an interview on 5/2/2025 at 11:42 a.m. with the Emergency Department Clinical Educator (CE 1), the CE 1 stated that while some medications, such as pain medication, have prompts to document a patient's response to medication to evaluate their effectiveness, Narcan does not have any prompts for documentation after its administration. The CE 1 also said that, however, when a medication such as Narcan was administered for a suspected opioid overdose, documenting the patient response to Narcan administration was considered a standard nursing practice. The CE 1 then stated, "If I were the nurse administering Narcan for a possible opioid overdose, I would document the patient's response to the medication in the patient's medical record."

During an interview on 5/2/2025 at 12:05 p.m. with the Accreditation, Regulatory and Licensing Manager (ARLM), the ARLM stated that the facility did not have a policy or procedure regarding documentation post (after) Narcan administration to evaluate its effectiveness because this medication (Narcan) was available over the counter (by ordinary retail purchase, with no need for a prescription or license).

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented ... All PRN medication, the reason for administering and the effectiveness of same shall be documented in the medical record ... "

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications," dated 8/2024, the P&P indicated that: "Naloxone is an opioid antagonist ...indicated for the reversal of an opioid overdose ... is intended to ensure naloxone is readily available for patients at risk of experiencing an opioid overdose. The recommended medication regimen is naloxone 0.1 mg IV Push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] once PRN [as needed] for drowsiness and notify physician ..."

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," dated 3/2024, the P&P indicated that: "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status. All data collected shall be recorded in the nursing assessment record and shall be available to all those disciplines involved in the care of the patient. Based on the outcome of screening data, other disciplines may be contacted to perform a more comprehensive assessment of the patient as needed. This data shall be used by the multidisciplinary team to establish the information necessary to provide the most comprehensive plan of care for the patient."

Based on interview and record review, the facility failed to ensure that one of 30 sampled patient's (Patient 6), informed consent (a voluntary agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) form, was completed and indicated the date and time when Patient 6 or Patient 6's representative (Rep) signed the informed consent for a medically indicated procedure (an intervention that is performed based on clinical judgement to benefit the patient and is necessary for diagnosis, treatment, or management of a medical condition), in accordance with the facility's informed consent protocol.

This deficient practice had the potential to jeopardize Patient 6's rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 6's autonomy (person's right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (informed consent form).

Findings:

During a review of Patient 6's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/26/2025, the H&P indicated that Patient 6 was found unresponsive (unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves), next to a scooter; was intubated (a tube, typically an endotracheal tube, has been inserted into a patient's trachea [windpipe] to assist with breathing) in the field and brought to the facility as a trauma patient (someone who has suffered a traumatic injury).

During a concurrent interview and record review on 4/29/2025 at 12:25 p.m., at the nurses station on a medical-surgical telemetry unit (a hospital floor that provides general medical care with continuous electronic monitoring of heart rate and rhythm), with the Quality Management (QM), Patient 6's informed consent (a voluntary agreement given by the patient or their legal representative prior to a medical procedure, confirming they understand the risks, benefits, and alternatives) form titled, "Authorization of and Consent to Surgery or Special Diagnostic or Therapeutic Procedures," [no date], was retrieved from Patient 6's paper chart. The informed consent form indicated the following minimum elements:

-Name of the hospital where the procedure or other type of medical treatment is to take place;
-Name of the specific procedure, or other type of medical treatment for which consent is being given;
-Name of the responsible practitioner who is performing the procedure or administering the medical treatment;
-Statement that the procedure or treatment, including the anticipated benefits, material risks, and alternative therapies, was explained to the patient or the patient's legal representative ...
- Signature of the patient or the patient's legal representative;
- Date and time the informed consent form is signed by the patient or the patient's legal representative] of informed consent were documented:
-Patient [Patient 6] name
-The name of the procedure [Right Frontal Burr Hole-a surgical procedure involving drilling a small hole into the frontal lobe of the skull to access the brain]
-The name and signature of Patient 6's legal representative.

During the same interview on 4/29/2025 at 12:25 p.m. with the Quality Management (QM), the QM confirmed that the Informed Consent Form lacked the documentation of the following elements: surgeon's name (performing the procedure), date and time when the consent was obtained, and QM also stated that the name of the surgeon should be documented. The QM also said the facility would need to review the facility's policy regarding Informed Consent Forms to ensure compliance and completeness of the medical record (Informed Consent form).

During an interview on 4/29/2025 at 2:45 p.m. with the Quality Management (QM), the QM stated that according to the facility's policy and procedure (P&P) regarding informed consent, the date and time should be documented on the informed consent form because the Informed Consent Form was only valid for the duration of the patient's admission (meaning the consent provides authorization for treatment during the current hospital stay or specific procedure, and it may need to be re-obtained).

During an interview on 5/2/2025 at 11:18 a.m. with the Clinical Educator (CE 2), the CE 2 stated that nurses should document the date and time and all other necessary elements of the informed consent when the informed consent form was obtained to demonstrate that the patient agreed to the specific procedure, acknowledging the fact that the physician explained the nature of the procedure/treatment and its expected outcomes at that exact moment. The CE 2 then stated that proper documentation should provide evidence that the patient (or patient's legal representative) was informed and actively involved in the decision-making process in real time and ensures that the informed consent remains valid for the entire hospital stay.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent," dated 8/10/2020, the P&P indicated the following: " V. Informed consent may be considered to have continuing force and effect until the patient revokes the consent or until circumstances change so as to materially affect the nature of, or the risks of, the procedure/treatment and/or the alternatives to the procedure/treatment to which the patient consented. VI. The role of the hospital is limited to verifying that informed consent has been given. The consents obtained by employees shall not go beyond simply naming the intended procedure/treatment and obtaining the patient acknowledgement that the physician explained the nature of the procedure/treatment, its expected benefits and risks, and possible alternatives and their benefits and possible risks."

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

1. Ensure one of 30 sampled patient's (Patient 1) medical reconciliation (process of reviewing and comparing a patient's current medications, treatments, and medical history to ensure accuracy and continuity of care) was recorded on two consecutive Emergency Department (ED) visits (2/23/2025 and 2/24/2025), in accordance with the facility's policy and procedure regarding medication reconciliation and assessment.

This deficient practice had the potential to compromise Patient 1's continuity of care and increase the risk of harm to the patient (Patient 1). In addition, this deficient practice had resulted in a gap in Patient 1's medical record completeness violating Patient 1's right to transparency, accountability, and accurate and complete medical records.

2. Ensure that one of 30 sampled patient's (Patient 22), medication reconciliation (involves creating the most complete and accurate list of a patient's medications-including prescriptions, over-the-counter drugs, vitamins, and supplements-and comparing this list to the medications ordered or prescribed during a transition of care), was reviewed during Emergency Department (ED) visits (from 3/9/2025 and 3/11/2025), in accordance with the facility's policy and procedure titled, "Medication Reconciliation."

This deficient practice had the potential to result in an incomplete or inaccurate list of Patient 22's medications. Without this information, doctors and nurses may not have had everything they needed to safely monitor Patient 22's condition or give the right care, and had the potential for missed doses, drug interactions, receiving the wrong medicine, or serious side effects.

3. Ensure that one of 30 sampled patient's (Patient 3) total enteral feeding intake (refers to the amount of feeding formula consumed by a patient) of feeding formula, was consistently documented, in accordance with the facility's policy regarding documentation of enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) administration.

This deficient practice had the potential to compromise Patient 3's nutritional status and care, by preventing accurate assessment of nutritional and fluid status needs of Patient 3, increasing Patient 3's risk for dehydration (a condition that occurs when your body loses more fluids than it takes in, resulting in a shortage of water and other necessary fluids), undernutrition (a condition where the body does not receive enough nutrients to meet its needs, often due to insufficient food intake or poor absorption of nutrients), overhydration (the body takes in more water than it loses), and other complications, hindering interventions necessary to maintain optimal patient (Patient 3) health.

4. Consistently perform and document neurological assessments (a systemic evaluation of a patient's nervous system function, including mental status, motor and sensory responses, and reflexes to detect abnormalities), every 4 hours as ordered by the physician, for one of 30 sampled patients (Patient 4), after Patient 4 was diagnosed with a stroke (sudden interruption of blood flow to the brain that can cause neurological deficits, impairments, or death), in accordance with the facility's policy regarding assessments and documentation.
This deficient practice had the potential to result in delayed recognition of neurological deterioration of Patient 4's condition, increasing the risk for adverse outcomes for Patient 4 such as neurological deficits (permanent impairment or loss of function in the nervous system such as difficulty with coordination, paralysis, numbness, inability to speak or understand language) or death.


Findings:

1. During a review of Patient 1's medical record (MR) titled, "Emergency Documentation-Physician Note," dated 2/23/2025, the MR indicated the following: "Patient (Patient 1) found ALOC ([Altered Level of Consciousness],refers to a state where a person's level of awareness and responsiveness is significantly reduced, ranging from mild confusion or drowsiness to a state of coma [a state of prolonged unconsciousness where a person is unresponsive, unable to react or respond to external stimuli like touch, sound, or visual cues, or to express themselves, to their surroundings and environment]) in hotel room by family ...was combative, and now lethargic (a state of drowsiness, sluggishness, and a lack of energy or alertness) per EMS (Emergency Medical Services) report ...potential Baclofen (medication used to treat pain and certain types of muscle spasticity) overdose (to take an overdose = a dangerously large amount) of a drug."

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation-Physician Note," dated 2/23/2025, the MR also indicated that Patient 1 was not able to provide past medical history (PMH, a record of a patient's previous illnesses, surgeries, medications, and other health-related events) and/or to participate in medical exam, "at the time of initial assessment ...The MR further indicated that Patient 1 was described [by family] to be found with a "pile of prescription drugs," and had markings on abdomen that were "related to being in a hot tub."

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's "Triage (refers to the detailed record of an initial, rapid assessment of a patient's condition and the prioritization of care needed based on their presenting complaint and urgency) record, dated 2/23/2025 at 11:38 a.m., was reviewed. The record indicated that the triage registered nurse (RN 1), documented that Patient 1 had history of being prescribed dextroamphetamine-amphetamine (Adderall, used to treat attention-deficit hyperactivity disorder [ADHD] and narcolepsy [a condition characterized by an extreme tendency to fall asleep]).

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's medical record (MR) titled, "Emergency Department (ED) Visit" summary, dated 10/23/2024, was reviewed. The QC stated that Patient 1 had documented past medical history of (PMH, a comprehensive record of a patient's past and present health conditions):
- ADHD, a neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity, and impulsivity, which are excessive, pervasive, and developmentally inappropriate.
-Anxiety, a mental condition characterized by excessive apprehensiveness about real or perceived threats.
-Carpal tunnel syndrome, a condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist.
- Cholelithiasis, the formation of gallstones.
-Chronic pain, persistent pain that lasts for more than three months.
-Cognitive disorder, a mental disorder characterized by impaired cognitive (the mental processes involved in thinking, learning, remembering, and problem-solving) abilities and daily functioning, caused by factors that affect brain function.
-Fibromyalgia, a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia (difficulty falling asleep or staying asleep).
-Hypertension (HTN), a condition where the force of your blood against your artery walls is consistently too high.
-Hypothyroidism, a condition where the thyroid gland doesn't produce enough thyroid hormones (regulates how the body uses energy) to meet the body's needs.
-Multiple sclerosis (MS), a chronic, inflammatory disease of the central nervous system (brain and spinal cord [a long, tubular structure made of nerve tissue that extends from the brainstem down the center of the back to the tail bone]).
-Multilevel Degenerative Disk disease, the breakdown or deterioration of the discs between the vertebrae (bones that make up the spine) in the spine
-Muscle spasms, an involuntary, sudden contraction of a muscle, often resulting in pain.
-Neuropathy, refers to any condition that affects the nerves outside your brain or spinal cord.
-Osteomyelitis- a bone infection, usually caused by bacteria, mycobacteria, or fungi, that can spread through the bloodstream or from a nearby infection.

During the same interview on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), QC 1 o said that Patient 1's ED Visit medical record on 2/23/2025 had no documentation of patient's (Patient 1) medication reconciliation (the process of creating a list of all medications a patient is taking) performed, including prescription medications that Patient 1 might have been possibly taking at home for the medical conditions.

During further review of Patient 1's "ED Documentation-Physician Note," dated 2/23/2025, the note indicated that Patient 1 told the ED physician that they (Patient 1) had PMH of Ehlers-Danlos syndrome (a group of inherited connective tissue disorders that affect the skin, joints, and other organs. It can be painful, particularly due to joint hypermobility and the resulting instability).

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation (ED)-Physician Note," dated 2/24/2025, the MR indicated the following: [On 2/24/2025 at 11:25 a.m.] "Patient (Patient 1) was brought to the facility by the ambulance (from hotel) for overdose (refers to prescription medications and/or illegal drugs like heroin, overdose). Patient (Patient 1) was seen for the same (on 2/23/2025, first of two consecutive ED visits) a day ago. History (a record of a patient's previous illnesses) of HTN and MS."

During a concurrent interview and record review on 4/30/2025 at 10:15 a.m. with the Quality Coordinator (QC 1), Patient 1's emergency department (ED) visit, dated 2/23/2025, was reviewed. The ED visit record indicated that Patient 1's medication reconciliation was not recorded. This was verified with the QC 1 during a concurrent interview. The QC 1 also said that nurses should do medication reconciliation in the emergency department (ED).

During an interview on 4/30/2025 at 12:29 p.m. with the Quality Management (QM), QM stated that the Chief Medical Officer (CMO) confirmed (on 4/30/2025) that medical providers should perform medication reconciliation on admission and discharge.

During a concurrent interview and record review on 5/1/2025 at 10:01 a.m. with the emergency department (ED) provider (MD 3), Patient 1's ED visit medical record (MR), dated 2/24/2025, was reviewed. The "ED Documentation-Provider Note," dated 2/24/2025, indicated that Patient 1 was diagnosed with opiate overdose, toxic encephalopathy (a brain disorder resulting from exposure to toxic substance), and methamphetamine use (identifying and confirming the use of methamphetamines [a powerful stimulant, known as crystal meth]). The MD 3 stated the following regarding Patient 1's diagnoses and medication reconciliation: "[On 2/24/2025] Patient (Patient 1) was diagnosed with an opiate overdose because she (Patient 1) responded to an antidote (Narcan) administered during her (Patient 1) treatment in the field, on the way to the emergency department, but this was not clearly documented in the patient's (Patient 1) medical chart. Regarding methamphetamine use, the patient's history from 2018 ED visit must have automatically generated methamphetamine use history into the record. The Patient's (Patient 1) visit on 2/23/2025 demonstrated that she (Patient 1) tested positive for amphetamines and opiates. However, medication reconciliation was not completed for this patient, and it is possible that the positive results were due to prescription medications-such as prescribed opioids and Adderall (amphetamine-containing medication)-which patient [Patient 1] may have been using as a part of her treatment plan." MD 3 also stated that urine toxicology (a laboratory test that analyzes a urine sample to detect the presence of drugs or other substances) cannot differentiate between amphetamines use and methamphetamine use.

During an interview on 5/1/2025 at 12:01 p.m. with the director of the Emergency Department (Dir 1), the Dir 1 stated the following regarding medication reconciliation process in the emergency department (ED): "When a patient arrives at the Emergency Department (ED), the expectation is for the nurses to conduct an initial assessment, which includes gathering the patients' past medical history and medication history. However, there is typically not enough time to review mediations during triage, and the medication reconciliation is typically done by the assigned nurse once the patient is stabilized. The physician also obtains additional medication history information during their assessment of the patient. Medication reconciliation is marked as complete after the physician reviewed and verifies the medication list. Not all patients require nurses to complete the medication history, but Patients with ESI (Emergency Severity Index, a system that categorizes patients into five levels based on how urgently they need medical attention and the resources required for their care) level of 3 and above (Patient 1 had an ESI level of 2 on both ED visits on 2/23/2025 and 2/24/2025) are expected to have the medication reconciliation performed during their ED visit." The Dir 1 also said that it's important to know what medications patient is currently taking, especially if patient is admitted on overdose.

During an interview on 5/2/2025 at 8:00 a.m. with the Registered Nurse (RN 6), the nurse who discharged Patient 1 on 2/25/2025, RN 6 stated that Patient 1 refused to sign discharge instructions (guidelines that patients have to follow after discharge to deal with any remaining illnesses that need to be taken care of personally by the patient) because of the diagnosis of methamphetamine use and opioid overdose, which Patient 1 disagreed with. RN 6 mentioned that when Patient 1 left the ED, she (Patient 1) was alert and oriented (meaning the patient was aware of person, place, and time), and able to walk independently. RN 6 also said that, according to the facility's policy, medication reconciliation should have been done for Patient 1. RN 6 could not recall whether the medication reconciliation was done for Patient 1 prior to discharge but stated that she (RN 6) did not complete medication history for Patient 1 prior Patient 1's discharge from the ED [on 2/25/2025].

During further review of Patient 1's "ED Documentation-Physician Note," dated 2/23/2025, the note indicated the following: [on 2/23/2025] "At 3:27 p.m. Patient 1 returned to baseline neurologic status (the condition of the nervous system, including the brain, spinal cord, and nerves, and how well it is functioning) and was able to answer questions."

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation," dated 9/2022, the P&P indicated the following: "Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists. It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources is expected. Medication reconciliation is done at point of entry including all inpatient and outpatient admissions to any nursing unit, department, or area where licensed personnel could, or would have the potential to, administer medications. Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record. Outpatients: In settings where medications are used minimally or prescribed for a short duration, a modified medication reconciliation process can be performed. In these settings, a medication list will be collected, recorded on the Outpatient Services Medication Reconciliation form and then reviewed by the physician and licensed staff. The list should contain all known and current medications. Any changes made to the medication list during the encounter will prompt reconciliation with the previous medications resulting in a revised complete medication list. The dose, route, frequency of use is not required for this area... Upon discharge, the ED physician and licensed staff will reconcile the medication list in electronic medical record and determine whether the medication list requires a change or not. This information is included in discharge teaching and the patient's written instructions."

2.During a review of Patient 21's "Emergency Documentation: ED Note Physician," dated 3/9/2025, the note indicated Patient 21 had a history of congestive heart failure (CHF, a condition where the heart cannot pump blood effectively), Crohn's disease (CD, a chronic inflammatory bowel disease that affects the digestive tract), and diabetes (a condition where your body can't regulate the amount of sugar in your blood). The patient was admitted with ongoing generalized weakness (reduced muscle strength) and fatigue (lack of energy). The patient (Patient 21) reported being unable to care for himself and requested placement in a care facility. He (Patient 21) had recently suffered a femur (thigh bone) fracture (break in the bone) and had not started physical therapy (treatment to help restore movement and strength).

During an interview on 4/29/2025 at 11:18 a.m. with Registered Nurse (RN) 13, in the Emergency Department (ED), RN 13 stated it was usually the admitting RN's responsibility to reconcile a patient's home medications (review and record the medications the patient was taking at home) when the patient was admitted to the ED, although pharmacy staff may also perform this medication reconciliation (process of reviewing and comparing a patient's current medications, treatments, and medical history to ensure accuracy and continuity of care). RN 13 further stated that patients arriving from a skilled nursing facility (SNF - a long-term care nursing facility) typically brought a printed list of their current medications. If a patient from a SNF did not have a medication list on arrival, the nurse should call the SNF to obtain the information. RN 13 further stated it was important to reconcile all patient medications to guide treatment decisions. For example, RN 13 stated that in critical cases, such as a patient with a "head bleed (a serious type of brain hemorrhage [bleeding])," it was vital to know whether the patient was on any blood thinners (anticoagulant drugs that increase bleeding risk). RN 13 said this medication information was essential because it directly impacted how the medical team would manage the patient's emergency treatment.

During a concurrent interview and record review on 4/30/2025 at 2:00 p.m. with the Sepsis and Quality Coordinator (CQ) 2, Patient 22's medical record (MR) document titled, "Documentation Medication by Hx (history)," for visit date 3/9/2025 through 3/11/2025, was reviewed. The MR had a message that indicated, "Medication history has not yet been documented. Please document the medication history for this patient encounters." CQ 2 confirmed that Patient 22's medication had not been reviewed by nursing or pharmacy.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation," dated 9/2022, the P&P indicated the following: "Medication reconciliation is the collaborative responsibility of physicians, nurses, and pharmacists. It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources is expected. Medication reconciliation is done at point of entry including all inpatient and outpatient admissions to any nursing unit, department, or area where licensed personnel could, or would have the potential to, administer medications. Electronic medication reconciliation will be utilized to document the medication reconciliation process for all in-patient admissions, outpatients, and discharges in the electronic medical record.

3. During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/24/2025, the H&P indicated that Patient 3 was admitted to the facility with diagnosis of severe sepsis (a stage of sepsis where an infection has caused a severe inflammation and damage to the body's organs, potentially leading to multiple organ failure). The H&P also indicated that Patient 3 had history of G-tube (a feeding tube that is inserted surgically through the abdomen directly into the stomach).

During a concurrent interview on 4/29/2025 at 12:12 p.m. with registered nurse (RN 9), RN 9 stated that patient 3 has a G-tube (gastrostomy tube, a surgically placed feeding tube directly into the stomach) and is on continuous enteral (feeding administered into the gastrointestinal tract ( GI Tract, a series of organs that process food from ingestion to excretion), typically through a feeding tube)], that is infused at 50 milters (ml, a unit of volume measurement) per hour through the G-Tube. RN 9 said that documentation of total enteral feeding intake (refer to the sum of all) per shift is not required and typically not documented, unless there is a specific order to do so. RN 9 then checked the documentation in Patient 3 chart and confirmed that no total intake for enteral had been documented for Patient 3 in the past 24 hours.

During a review of Patient 3's medical record (MR), titled "Order Sheet," dated 4/26/2025, the MR indicated that Patient 3 had an order for continuous administration of enteral feeding.

During a concurrent interview and record review on 5/1/2025, at 2:07 p.m. with Quality Coordinator (QC1), Patient 3's record, titled "GI-Tube," dated 4/26/2025 through 4/28/2025 was reviewed. The record indicated the following: [documentation of total intake (the overall amount of) of enteral feeding]:
-On 4/26/2025 from 7:00 a.m. to 7 p.m. -Total intake of tube feeding was not documented.
-On 4/26/2025 from 7:00 p.m. through 4/27/2025 at 7:00 a.m.-Total intake of tube feeding infused was not documented.
-On 4/27/2025 from 7:00 p.m. through 4/28/2025 at 7 a.m.-Total Intake of tube feeding was not documented.
QC 1 confirmed that Patient 3's record, titled "GI-Tube," [dated 4-26/2025 through 4/28/2025] contained only the documented total infused enteral feeding intake on 4/27/2025 [7 a.m. to 7 p.m.], totaling 500 ml for that shift.

During an interview on 5/2/2025 at 10:51 a.m. with the clinical educator (CE 2), the CE 2 stated the following: "I am not sure how often nurses should document the amount of infused enteral feeding on a regular floor, but the amount of enteral feeding infused, should be documented by the nurses, regardless of if there is a physician's order or not. We want to know if the patient is tolerating the feeding and to monitor the nutritional status [encompasses the balance between nutrient intake and the body's needs for optimal health, growth, and function]."

During a review of the facility's policy and procedure (P&P), titled "Adult Feeding Tubes," dated 3/2022, the P&P indicated that: "The policy is developed to ensure that patients with feeding tubes shall be assessed, monitored, and maintenance provided. D. Documentation for patients with Enteral Nutrition: 5. Intake and Output (I&O, "intake" refers to the fluids a patient consumes, while "output" refers to the fluids a patient eliminates from the body), including rate and volume of feeding, number of flushes (free water), discarded residuals [refers to the amount of fluid that remains in the stomach after a feeding, must be documented for patients with enteral nutrition, fluid is aspirated from the stomach via the feeding tube to monitor gastric emptying and assess a patient's tolerance to enteral nutrition ]."

During a review of the facility's policy and procedure (P&P), titled "Intake and Output (I&O, "intake" refers to the fluids a patient consumes, while "output" refers to the fluids a patient eliminates from the body)," dated 8/2021, the P&P indicated that: "II. When indicated for the patient based upon condition or orders: A. l&O should be routinely recorded every 12 hours with a 24-hour total computed, or more frequently as patient's status dictates. IV. It is the Registered Nurse's responsibility to be aware of a positive or negative fluid balance and ensure that l&Os ...are documented when ordered or as appropriate for patient's condition. Any medically significant positive or negative fluid balances shall be reported to the physician."

During a review of the facility's policy and procedure (P&P), titled "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented ... ... Patients requiring Intake and Output documentation will have Intake and Output Recorded in the medical record every twelve hours, or as the physician dictates, and totaled at the end of the shift and every twenty-four (24) hours by the 7P-7A shift.

4. During a review of Patient 4's History and Physical (H&P, the most formal and complete assessment of the patient and the problem) dated 4/29/2025, the H&P indicated that Patient 4 was admitted to the facility with a diagnosis of paresthesia [an abnormal sensation, typically tingling or pricking ("pins and needles"), caused chiefly by pressure on or damage to peripheral nerves (other than spinal cord and the brain)], right-sided weakness, acute cerebrovascular accident (CVA, a medical term for a stroke, a sudden interruption of blood flow to the brain). The H&P also indicated that Patient 4 was admitted to neuro-telemetry unit (a specialized hospital unit that provides remote monitoring and care for patients with neurological conditions).

During a review of Patient 4 medical records (MR), titled "Admitting Orders, (orders specify the patient's diagnosis, initial treatment plan, and various other details needed for their care while in the hospital)," dated 4/29/2025, the MR indicated that on 4/29/2025 at 7:04 a.m., the admitting physician placed an order to monitor neurological status [of Patient 4] every 4 hours.

During a concurrent interview and record review on 5/2/2025 at 11:40 a.m., with the clinical educator (CE 1), Patient 4's medical record (MR), titled "Neurological Assessment," dated 4/29/2025 was reviewed. The MR indicated that a complete neurological assessment (a thorough evaluation of a patient's neurological function, including assessment of mental status, cranial nerves, motor and sensory responses, reflexes, and intracranial pressure signs) was performed and recorded on 4/29/2025 at 6:30 a.m. and 5:17 a.m. The CE 1 verified that Patient 4's medical record (MR), titled "Neurological Assessment," contained no documented neurological assessment recorded between 6:30 a.m. and 5:17 p.m. [every 4 hours, as ordered] on 4/29/2025. The CE 1 stated that the neurological assessment for Patient 4, conducted every 4 hours as ordered by the physician, should have been done in accordance with the order to ensure ongoing monitoring of neurological status and early detection of any worsening of signs and symptoms of a stroke.

During a review of the facility's policy and procedure (P&P), titled "Initial Patient Assessment and Reassessment," dated 3/2024, the P&P indicated that: "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population. Specialty unit's assessments shall be completed per unit specific criteria."

During a review of the facility's policy and procedure (P&P), titled "Documentation," dated 8/2024, the P&P indicated that: "All documentation shall contain accurate, truthful and pertinent documentation ... All measures performed by nursing relating to care and the patient's response to such measures shall be documented."