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Based on interview and record review, the hospital failed to ensure the admitting assessment was performed for one of two sampled patients (Patient 2) as per the hospital's P&P, creating a risk of substandard care.

Findings:

Review of the hospital's P&P titled Admitting Assessment dated 3/8/24, showed admit-arrival navigator in the hospital's EHR documentation is initiated for all inpatient admissions (critical care, med-surg, adolescents 16 years old and over) within 2 hours of arrival on the unit and documented in four hours.

Review of the hospital's P&P titled Fall Prevention and Management dated 10/2/24, showed the following:

* The purpose of the P&P is to maintain a safe environment for inpatients and outpatients, the fall prevention procedure is intended to increase awareness and identify patients who are at risk of falling.

* Patient will be assessed for fall risk on admission/transfer to another unit.

On 7/28/25, Patient 2's open medical record was reviewed with the Patient Relations. Patient 2's medical record showed Patient 2 was admitted to the hospital on 7/28/25 at 0640 hours. The Patient Relations showed Patient 2's nursing assessment on 7/28/25 at 1330 hours. There was no documented admitting assessment.

On 7/28/25 at 1415 hours, the Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the medication was administered as per the hospital's P&P for one of two sampled patients (Patient 2), creating the risk of medication errors and poor health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Medication Administration dated 10/24/23, showed unless the administration is time critical, scheduled medications shall be administered no more than 60 minutes before and 60 minutes after its computer scheduled time.

On 7/28/25 at 1110 hours, RN 1 was observed administering aspirin (a medication used to treat pain, reduce fever, and treat or prevent heart attack or stroke) 81 mg 1 tablet by mouth to Patient 2.

On 7/28/25, Patient 2's open medical record was reviewed with Patient Relations. Patient 2's medical record showed Patient 2 was admitted to the hospital on 7/28/25.

Review of the Summary showed Patient 2 arrived on the unit on 7/28/25 at 0709 hours.

Review of the Physician's Order dated 7/28/25 at 0640 hours, showed:

- Aspirin chewable tablet 81 mg
- Scheduled Start Date/Time: 7/28/25 at 0900 hours
- "First Dose: As Scheduled"

At 0647 hours, the medication order was acknowledged by the nurse.

On 7/28/25 at 1415 hours, the Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.