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Based on 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 that one of 30 sampled patients (Patient 2), was informed, in a timely manner, regarding patients' rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) as a hospital patient, the conditions of admission (COA, is a contract between the hospital and the patient outlining the patient's obligations while receiving care), and provided with the standardized notice titled, "An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision)," within the required two days of admission or within 2 calendar days of discharge.

This deficient practice had the potential to hinder the patient's (Patient 2) or the patient's representative to exercise their rights (example: the right to refuse treatment and the right to receive necessary information about their medical condition). (Refer to A-0117)

2. The facility failed to ensure that the exercise of patients' rights (the fundamental entitlements and protections granted to individuals receiving healthcare services. These rights aim to ensure that patients receive safe, respectful, and informed care while upholding their autonomy and dignity) requirements were met, when:

2.a. The facility failed to ensure that one of 30 sampled patient's (Patient 2) and/or Patient 2's designated representative, received regular updates including documentation of communication from the attending physician regarding consultant findings (evaluations or recommendations provided by specialists or other healthcare providers) as well as any adjustments/modifications in Patient 2's plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey), in accordance with the facility's policy regarding "Medical Rules and Regulations (R&R)" and "Patient Rights and Responsibilities."

This deficient practice had the potential to hinder a coordinated and patient-centered care due to lack of involvement of Patient 2 and/or Patient 2's designated representative in Patient 2's medical care and medical decision-making, which may impact Patient 2's treatment outcome. (Refer to A-0129)

2.b. The facility failed to ensure one of 30 sampled patient's (Patient 3), Accu-Chek (a brand of blood glucose testing system used to measure blood sugar levels), ordered to be done 4 times a day (before meals and at bedtime), was discontinued, due to lack of medical indication for continuously monitoring Patient 3's blood sugar four times a day for over a month during Patient 3's stay at the facility, in accordance with the facility's policy regarding Patient Rights and "Medical Rules and Regulations (R&R)."

This deficient practice had the potential to result in unnecessary discomfort, increased risk of skin irritation or infection at the blood sampling site, and increased healthcare costs for Patient 3. In addition, this deficient practice had the potential for inappropriate treatment or missed opportunities for necessary intervention, thereby compromising Patient 3's safety. (Refer to A-0129)

3. The facility failed to ensure that one of 30 sampled patient's (Patient 1) validation of identity, was completed, in accordance with the facility's protocol when registering patients, performing medical procedures, and administering medications in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries), when Patient 1 was registered under the incorrect first name and was provided incorrect patient identifiers (a piece of information, such as wristband and labels, used to reliably and uniquely identify an individual to ensure they receive the correct care and treatment).

This deficient practice had the potential to compromise Patient 1's safety, and resulted in misidentification of Patient 1 (Patient 1 was registered under the medical record profile of Patient 1's twin sister), prolonged stay in the Emergency Department (ED) and unnecessary repeats of venipuncture (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) which may lead to a potential psychological distress for Patient 1. (Refer to A-0142)

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 for Nursing Services was met, as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 8), was discharged safely, when Patient 8's discharge order was written by mistake. Nursing staff failed to clarify the order which indicated to discharge Patient 8 to a shelter via uber (a transportation and ride-sharing company), even though nursing staff noted Patient 8 would be discharged home and transported by family. In addition, Nursing staff failed to a complete a full set of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen). The respiratory rate and oxygen saturation (without oxygen) were not assessed prior to Patient 8's discharge, in accordance with the facility's policy and procedure regarding Discharge of Patient.

This deficient practice resulted in the unsafe discharge of Patient 8. Patient 8 passed away a few hours after discharge. (Refer to A-0395)

2. The facility failed to ensure one of 30 sampled patient's (Patient 9) VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Assessment was performed, in accordance with the facility's policy and procedure regarding VTE Assessments. A full VTE assessment was not performed when Patient 9 was transferred to another unit or had a change of condition. In addition, per documentation, sequential compression devices (leg squeezers) were not removed from Patient 9's left leg, when Patient 9 developed a blood clot to the left leg on 4/10/2025.

This deficient practice had the potential for incorrect VTE risk assessments and had the potential for inappropriate interventions to be implemented for Patient 1, which could result in dislodgement of the blood clot, and possibly traveling to other organs, such as the heart or lungs, which may result in a pulmonary embolism (PE, a blockage in one of the pulmonary arteries (carry blood from the heart to the lungs] of the lungs which can cause death). (Refer to A-0395)

3. The facility failed to ensure one of 30 sampled patient's (Patient 13) vital signs and reassessment was completed and documented every two hours, in accordance with the facility's policy regarding "Documentation in the ED (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) Patient Care Record" and "Standard of Nursing Care."

This deficient practice resulted in delayed or missed opportunities for appropriate medical interventions, potentially resulting in negative outcomes (example, low blood pressure) for Patient 13. (Refer to A-0395)

4. The facility failed to ensure one of 30 sampled patient's (Patient 9) pain level was assessed, prior to administering hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever, used to relieve moderate to severe pain), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for Patient 9 to be medicated unnecessarily and the possibility of experiencing unnecessary side effects, such as drowsiness (feeling unusually sleep or tired), lack of energy, or even slowed or shallow breathing. (Refer to A-0395)_

5. The facility failed to ensure one of 30 sampled patients (Patient 26), was repositioned (regularly changing a patient's body position to relieve pressure on specific areas, especially those at risk of or affected by pressure injuries) every two hours, in accordance with the facility's policy and procedure regarding "Skin Integrity (the overall health and condition of the skin)."

This deficient practice had the potential to result in the worsening of Patient 26's pressure injury (localized damage to the skin and/or underlying tissue, usually over a bony prominence) leading to prolonged healing and/or hospitalization. (Refer to A-0395)

6. The facility failed to ensure one of 30 sampled patient's (Patient 26) vital signs was assessed and documented prior to discharge, in accordance with the facility's policy regarding "Discharge of Patient."

This deficient practice had the potential of not being able to detect a change of Patient 26's condition such as low blood pressure or low heart rate, which may compromise Patient 26's safety upon discharge. (Refer to A-0395)

7. The facility failed to update a plan of care (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 9), when Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep veins) to the left leg, in accordance with the facility's policy and procedure regarding plan of care.

This deficient practice resulted in the lack of appropriate interventions for Patient 9, such as removal of the Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) from the left leg, after Patient 9 was diagnosed with DVT to the left leg. This deficient practice also had the potential to result in complications such as pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death). (Refer to A-0396)

8. The facility failed to ensure one of 30 sampled patient's (Patient 18) plan of care regarding infection prevention/control (a set of evidence-based practices and procedures designed to prevent the transmission of infections in healthcare settings), was developed and implemented on admission, in accordance with the facility's policy regarding plan of care. Patient 18 had a peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) on his (Patient 18) left arm.

This deficient practice had the potential for Patient 18's care needs and risk not to be addressed which may lead to complications such as infection resulting from the use of a PICC. (Refer to A-0396)

9. The facility failed to ensure one of 30 sampled patient's (Patient 25) plan of care on infection prevention/control, was developed and implemented, in accordance with the facility's policy regarding plan of care. Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection).

This deficient practice had the potential for Patient 25's care needs and risks not to be addressed which may lead to worsening of infection, delayed recovery, and prolonged hospitalization. (Refer to A-0396)

10. The facility failed to ensure two of 30 sampled patients' (Patient 29 and Patient 30) plan of care on Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control), was developed and implemented, in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for Patient 29 and Patient 30's diabetic care needs and risks to not be addressed, which may lead to complications of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). (Refer to A-0396)

11. The facility failed to ensure, for one of 30 sampled patients (Patient 25), nursing staff adhered to the facility's policy and procedure (P&P) titled, "Active Surveillance Strategies," when Patient 25 was not swabbed (collecting samples like a throat swab) for Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria that does not respond to antibiotics) of the nares (nose).

This deficient practice had the potential for Patient 25 to receive delayed treatment and/or interventions and potentially expose other patients to the MRSA bacteria. (Refer to A-0398)

12. The facility failed to ensure one of 30 sampled patients (Patient 20), received blood pressure medication (Hydralazine Hydrochloride [HCL], medication to lower blood pressure), as ordered by the physician.

This deficient practice resulted in Patient 20's increased blood pressure level and placing the patient (Patient 20) at risk for possible stroke (when blood flow to the brain is interrupted) or aortic dissection (artery in the heart that tears due to pressure). (Refer to A-0405)

13. The facility failed to ensure one of 30 sampled patient's (Patient 22) intravenous antibiotics (Cefepime, used to treat/prevent infection) and a medication used to control stomach bleeding (Octreotide [medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin]), were administered, as ordered by the physician.

This deficient practice had the potential to result in worsening of infection or delay in healing from infection (from delayed administration of the Cefepime antibiotic) as well as the potential for stomach bleed (from not administering the Octreotide) for Patient 22. (refer to A-0405)

14. The facility failed to ensure one of 30 sampled patients (Patient 9), was medicated with the correct pain-relieving medication based on Patient 9's assessed pain level, in accordance with the physician's order, and the facility's policy regarding medication administration. Patient 9 was assessed with moderate pain and was medicated with a medication ordered for severe pain.

This deficient practice had the potential for Patient 9 to be overmedicated and possibly suffering unnecessary side effects for the elderly, such as drowsiness, dizziness, urinary retention (the inability to completely empty the bladder), delirium (a temporary state of confusion or disorientation), or respiratory depression (a condition where breathing becomes abnormally slow and shallow). (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 a discharge summary (a document that provides a concise overview of a patient's hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) was promptly completed, within 10 days of discharge, as per the facility's policy and procedure regarding Medical Records, for one of 30 sampled patients (Patient 8).

This deficient practice resulted in Patient 8's discharge summary being completed 15 days after discharge, which can negatively affect patient safety and continuity of care. (Refer to A-0438)

2. The facility failed to ensure documentation in the medical record was accurate, for one of 30 sampled patients (Patient 9), when Patient 9's VTE (Venous Thromboembolism, blood cloth forms in a vein, usually deep in the legs) Assessment inaccurately indicated medicinal prophylaxis (medication to prevent a condition) to prevent blood clot formation, had been ordered for Patient 9 on 4/7/2025.

This deficient practice resulted in an inaccurate description of interventions to prevent blood clot formation for Patient 9 and had the potential for not implementing additional interventions to prevent blood clots. (Refer to A-0438)

3. The facility failed to ensure one of 30 sampled patient's (Patient 12), nursing documentation accurately reflected Patient 12's Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) assessment (evaluation) being completed in the "Infectious Disease Bundle (set of questions related to invasive tubes necessary for patient care)," in accordance with the facility's policy regarding nursing documentation.

This deficient practice had the potential for Patient 12 to not receive the appropriate evaluation and care. (Refer to A-0467)

4. The facility failed to ensure that for one of 30 sampled patients (Patient 2), the attending physician communicated and documented the outcome of the hospitalization, including follow-up care and provisions for post-hospital care (after hospital care) such as any upcoming appointments, patient care needs, durable medical equipment (DMEs such as wheelchair), and plans for ongoing care by providers like home health services, in accordance with the facility's policy regarding "Medical Rules and Regulations (R&R)."

This deficient practice resulted in unmet care needs for Patient 2, when Patient 2 was discharged with no wheelchair and no means for mobility to follow-up on necessary appointments, thus potentially compromising Patient 2's safety and increasing risk of readmission and complications. (Refer to A-0468)

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 that one of 30 sampled patients (Patient 2) was informed, in a timely manner, regarding patients' rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) as a hospital patient, the conditions of admission (COA, is a contract between the hospital and the patient outlining the patient's obligations while receiving care), and provided with the standardized notice titled, "An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision)," within the required two days of admission or within 2 calendar days of discharge.

This deficient practice had the potential to hinder the patient's (Patient 2) or the patient's representative, the exercise of their rights (example: the right to refuse treatment and the right to receive necessary information about their medical condition).

Findings:

During an interview on 8/7/2025 at 1:03 p.m. with Patient 2's family member (FM), the FM stated that during Patient 2's admission at the facility, Patient 2 did not receive a copy of "An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision)," during Patient 2's stay in the facility. The FM stated that the facility never attempted to contact the designated representative regarding the condition of admission (COA, is a contract between the hospital and the patient outlining the patient's obligations while receiving care) or the "Important Message from Medicare." The FM said that the facility first attempted to discharge Patient 2 on 7/8/2025, but the rights to appeal the discharge were never provided and/or explained to Patient 2 and/or FM. The FM also said that the FM never received a copy of the Important Message from Medicare (IM), and the patient's rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) notice, was never provided to FM or Patient 2.

During a review of Patient 2's History and Physical (H&P, a comprehensive assessment of a patient's health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2025 due to abdominal pain and nausea (an urge to throw up).

During a concurrent interview and record review on 8/7/2025 at 3:07 p.m. with the administration supervisor (ADS 2), Patient 2's electronic medical record (EMR, a digital collection of a patient's medical history, diagnoses, medications, immunizations, and other health information that is stored and accessed electronically) for the admission from 7/6/2025 through 7/18/2025, was reviewed. The EMR titled, "Patients' rights as a hospital patient, the conditions of admission (COA), and a notice titled "An Important Message from Medicare (IM)," were reviewed. The COA and IM indicated that on 7/6/2025, Patient 2 was provided with the COA and IM, but was unable to sign. The ADS 2 said that a follow-up from registration was required since the patient (Patient 2) was not able to sign on the first attempt.

During the same interview on 8/7/2025 at 3:07 p.m. with the administration supervisor (ADS 2), the ADS 2 said, "The registration staff should keep trying to present the COA and the IM to the patients and obtain the signature as proof that the patient was provided with the information. When a patient is unable to sign, clinical documentation should demonstrate why the patient is unable to sign the COA and IM. The next of kin should be contacted when the patient is not capable of making decisions." The ADS 2 then reviewed clinical documentation made by the registration staff and said that there was no documentation to indicate the registration staff's attempt to contact the next of kin for Patient 2. The ADS 2 said, "I can see documentation that the patient (Patient 2) was 'weak' when the attempt to present the information (the COA, the Patient Rights, and the IM), to Patient 2, was made on 7/6/2025. She (the registration staff member) also did not upload the 'Follow-up log,' which should be kept for patients unable to sign their COA and IM, and the log should indicate documented reason why signatures for the COA and IM were not obtained.
Based on this record (Follow-up log), the registration staff member attempted to obtain Patient 2's signature on 7/7/2025 and 7/8/2025, but the reason why the patient was not able to sign was not indicated in the log." The ADS 2 then confirmed that Patient 2 signed the COA and IM on 7/9/2025 (3 days after admission and 1 day after the first "cancelled" order for discharge on 7/8/2025).

During a review of the facility's policy and procedure (P&P) titled, "Admitting," dated 7/2023, the P&P indicated, "The Conditions of Admission (COA) contains twenty topic items with detailed legal and informational elements ... The completion of this legal and binding document is essential. The patient or patient's representative agrees that by signing this document that they understand the terms and conditions and acknowledges his/her agreement by signing the document in the presence of Registration Representative. By signing the COA document the patient or the patient's legal representative certifies that they have read and received a copy of this document ...If patient is unable to sign: the registration representative must indicate the reason ...An Important Message from Medicare ... is a mandated form that reviews the patients' rights as a Medicare or Senior recipients while in-patient and provides contact resources for the patients if needed. The Form provides Medicare Discharge Rights for the patients about their discharge rights from the facility ..."

During a review of the Federal Regulations 42 CFR 489.27(a) and 42 CFR 405.1205(c), the Federal Regulations indicated "each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, 'An Important Message from Medicare' (IM), within 2 days of admission..." and "requires that hospitals present a copy of the signed IM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge."

Based on interview and record review the facility failed to ensure that the exercise of patients' rights (the fundamental entitlements and protections granted to individuals receiving healthcare services. These rights aim to ensure that patients receive safe, respectful, and informed care while upholding their autonomy and dignity) requirements were met, when:

1. The facility failed to ensure that one of 30 sampled patients (Patient 2) and/or Patient 2's designated representative, received regular updates including documentation of communication from the attending physician regarding consultant findings (evaluations or recommendations provided by specialists or other healthcare providers) as well as any adjustments/modifications in Patient 2's plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey ), in accordance with the facility's policy regarding "Medical Rules and Regulations (R&R)" and "Patient Rights and Responsibilities."

This deficient practice had the potential to hinder a coordinated and patient-centered care due to lack of involvement of Patient 2 and/or Patient 2's designated representative in Patient 2's medical care and medical decision-making, which may impact Patient 2's treatment outcome.

2. The facility failed to ensure one of 30 sampled patient's (Patient 3), Accu-Chek (a brand of blood glucose testing system used to measure blood sugar levels), ordered to be done 4 times a day (before meals and at bedtime) was discontinued, due to lack of medical indication for continuously monitoring Patient 3's blood sugar four times a day for over a month during Patient 3's stay at the facility, in accordance with the facility's policy regarding Patient Rights and "Medical Rules and Regulations (R&R)."

This deficient practice had the potential to result in unnecessary discomfort, increased risk of skin irritation or infection at the blood sampling site, and increased healthcare costs for Patient 3. In addition, this deficient practice had the potential for inappropriate treatment or missed opportunities for necessary intervention, thereby compromising Patient 3's safety.

Findings:

1. During a review of Patient 2's History and Physical (H&P, a comprehensive assessment of a patient's health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2026 due to abdominal pain and nausea (urge to throw up).

During an interview on 8/7/2025 at 1:03 p.m. with Patient 2's family member (FM), the FM stated that during Patient 2's admission at the facility, the attending physician rarely communicated the plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey) with the family. The FM also reported that the facility attempted to discharge Patient 2 multiple times without having the attending physician speak with the family prior to placing the discharge order. Additionally, the FM said that the physician never communicated with the family that Patient 2 could not walk and required a wheelchair. FM 1 said that after Patient 2 was discharged home via ambulance, Patient 2 had no means of mobility (ability to move freely) or transportation to attend appointments, as the facility discharged Patient 2 without arranging for a wheelchair at home.

During an interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ stated that when Patient 2 was admitted to the facility on 7/5/2025, Patient 2 was able to walk with a walker. However, based on the physical therapy (PT) evaluation, dated 7/14/2025 (completed after Patient 2 underwent surgical hernia [a condition where an internal organ or tissue bulges through a weak spot in the surrounding muscle or tissue] repair), Patient 2 could no longer walk and was significantly below functional baseline (Patient 2's usual level of independence and mobility), thus would require a wheelchair. DDQ also said that the PT Evaluation indicated that there was no recommended discharge DME (Durable Medical Equipment, medical equipment that is primarily and customarily used to serve a medical purpose, is durable enough to withstand repeated use, and is generally only useful to a patient due to illness or injury and in the home environment. Examples include wheelchairs) need, because Patient 2 confirmed ownership of a wheelchair. However, the PT Evaluation also indicated that Patient 2 "was a poor historian and confused, and wheelchair ownership may need to be confirmed with the son (which was not done)." The DDQ also said that the physician (MD 2) did not order a wheelchair (DME) for Patient 2 prior to discharge.

During further interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the following regarding case management (a collaborative process focused on coordinating patient care to ensure efficient, effective, and safe transitions through the healthcare system) and discharge planning (a coordinated process of preparing patients to leave the hospital and transition to the next level of care, whether that's home, a rehabilitation facility, or another setting) for Patient 2, "The case management (CM) team responsible for the patient's (Patient 2) insurance group was involved and participated in rounds (a structured process where medical professionals visit patients to assess their condition, review their care plan, and address any needs) with the physician; all relevant medical records for Patient 2 were faxed to the medical insurance group CM. The CM team from the insurance group was responsible for following up on the DME needs for patient (Patient 2)."

During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ explained that the facility was not contracted with the medical group that insured Patient 2, and the CM team from that group did not share the information about communications or decision made between the case management team and the physician. "For instance, after entering an order for home health services post-discharge and communicating this to the insurance group, the facility's case management has no way of knowing if the home health services were arranged or set-up for the patient (Patient 2)."

During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said, "I review physical therapy recommendations before discharge. For example, if a patient needs a walker, I place an order for discharge planning department, and then they identify the need for a durable medical equipment (DME). The discharge planning team will communicate this need to the contracted insurance case management (CM) to arrange for the DME, but they (referring to the contracted insurance CM) do need to have an order for a walker to arrange for it."

During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said the following regarding communication requirements with patients and families: "I communicate with patients and families daily. I discuss the plan of care, goals of care, and prognosis (the predicted future course and outcome of a disease or medical condition) ... I document to the best of my ability, and documenting the communication in a patient's medical record is a medical record-keeping requirement." MD 2 also said that during Patient 2's admission, MD 2 documented communication with Patient 2's son in the progress notes.

During a review of Patient 2's Attending physician progress notes, dated 7/6/2025 through 7/18/2025, the progress notes indicated that on:

-7/6/2025- there was no documentation of discussing an admission plan or plan of care with Patient 2 or Patient 2's family.

-7/7/2025- there was no documentation indicating that Patient 2 and/or family were updated regarding their (Patient 2) plan of care.

-7/8/2025-the note indicated that Patient 2 was going to be discharged back to home on 7/8/2025

-7/9/2025-there was documentation indicating that the plan of care was discussed with Patient 2's son at the bedside

-7/10/2025- the note indicated that Patient 2 was pending being evaluated by general surgeon; no documentation was found in the note regarding the plan of care and the plan for surgery having been discussed with Patient 2 and/or their family.

-7/11/2025- the note indicated that Patient 2 was scheduled for "hernia repair today," but no documentation of the plan of care and consultation evaluation results discussed with Patient 2 and/or their family was found recorded in the 7/11/2025 progress note.

-7/18/2025-Discharge Summary-no documentation of what diet Patient 2 should follow at home, no documentation of DME needs at home, and no documentation of Home Health arrangements being discussed with Patient 2 and/or their family having been recorded in the Discharge Summary dated 7/18/2025.

-The Attending physician progress notes, dated 7/6/2025 through 7/18/2025, were reviewed on 8/7/2025 at 10:30 a.m., with the stroke (when blood flow to the brain is interrupted) coordinator (SC) and the Director of Data Quality (DDQ) and the information indicated in the physician progress notes were verified by the SC and DDQ.

During an interview on 8/8/2025 at 2:52 p.m. with the Chief Medical Officer (CMO), the CMO made a statement regarding documentation and discussion of the plan of care with patients and families: "Communication-every physician is mandated to communicate with the family regarding admission, discharge, and whenever there is a change in the patient's condition, a need for a procedure, or tests and/or outcomes. The expectation is for the physicians to communicate and document these interactions in the patients' medical records."

During a review of the facility's "Medical Rules and Regulations (R&R)," dated 10/2024, the Medical R&R indicated, "1.8 Duties of Attending physicians: 1.8-4:Communication with the family regarding the findings of consultants and alterations to the plan of care is the duty of the Attending physician ...1.8.-6: Coordinating the management of the patient with nursing ... 1.8-7: reassessing the patient at regular intervals ....1.8-8: Working closely with case management staff to assure that the record contains sufficient information to support coverage and resource use decisions ...1.8-10: Working with discharge planning to assure a smooth transition of the patient to the appropriate after care setting ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 1/2025, the P&P indicated, "Patients have the right to 2. Have effective communication for critical information in a manner you understand ... information from your physician about your diagnosis, prognosis, treatment or consent for treatment, discharge planning ...5. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care ..."

2. During a review of Patient 3's History and Physical (H&P, a comprehensive assessment of a patient's health status), dated 10/13/2024, the H&P indicated that Patient 3 was admitted to the facility on 10/13/2024 due to altered mental status (AMS, a change in a person's level of consciousness [a person's state of awareness and responsiveness to their surroundings), awareness, and cognitive function [the mental processes involved in acquiring, processing, and using information]).

During a review of Patient 3's nursing narrative notes , dated 11/7/2024, the nursing narrative notes indicated that on 11/7/2024 at 1:30 p.m., Patient 3's blood sugar level was 230 milligram per deciliter (mg/dL, measuring unit, normal range for blood glucose level is 70-99 mg/dl fasting [not eating and drinking anything, except water, for a period of time], and below 140 mg/dL non-fasting), with a documented order to give Patient 3 a total of 10 units (U, measuring unit for insulin) of insulin (a hormone produced by the pancreas that regulates blood sugar levels) intravenously (IV, give directly into the vein).The nursing narrative notes further indicated that the nurse contacted the resident physician (Resident Physician 1) regarding the inability to administer IV insulin due to the level of care (the intensity and type of medical services provided to a patient based on the complexity and severity of their condition).

During further review of Patient 3's nursing narrative notes , dated 11/7/2025, the nursing narrative notes indicated that on 11/7/2024 at 2:07 p.m., the registered nurse documented that the physician who ordered the insulin did not call back, and an order to discontinue blood sugar checks was obtained from a different resident physician (Resident Physician 2) to stop all blood sugar testing (called Accu-Chek, brand name of blood glucose [sugar] meters used to monitor blood sugar levels) altogether because Patient 3 was not diabetic (a condition characterized by high blood sugar levels due to the body's inability to produce or use insulin effectively).

During an interview on 8/8/2025 at 11:24 a.m. with the clinical educator (CE), the CE stated the following regarding nurses' expectations when clarifying orders that may seem medically unnecessary, " It would be prudent for the nurses to ask why they are checking blood sugars in patients with no history of diabetes and when there is no sliding scale (a protocol that outlines insulin doses to be administered based on specific blood sugar levels) ordered to address the blood sugars that are out of range."

During a concurrent interview and record review on 8/8/2025 at 1:30 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 3's electronic medical record (EMR, a digital collection of a patient's medical history, diagnoses, medications, immunizations, and other health information that is stored and accessed electronically) for the visit dated 10/13/2024-through 12/6/2025, was reviewed. The CNS 5 confirmed that Patient 3 had no documented diagnosis of diabetes. The CNS 5 also confirmed that Patient 3 had no order for insulin sliding scale. The CNS 5 said the physician placed an order for blood sugar checks - (before meals and at bedtime, 4 times a day) on 10/13/2024. The CNS 5 said that the order for the Accu-Chek did not include a rationale (a reason or justification) for monitoring the patient's (Patient 3's) blood sugar. The CNS 5 also verified that Patient 3's Accu-Chek order was discontinued on 11/7/2024.

During an interview on 8/8/2025 at 12:11 p.m. with the physician (MD 3), MD 3 stated that he (MD 3) did not know why the blood sugar checks were ordered by one of the resident physicians. MD 3 said, " Accu-Chek was probably ordered because patient (Patient 3) came in as a stroke patient (an individual who has experienced a cerebrovascular accident [CVA], commonly known as a stroke, where blood flow to the brain is disrupted, leading to potential brain damage and loss of function)," but MD 3 could not explain why an insulin sliding scale was not ordered.

During an interview on 8/8/2025 at 2:52 p.m. with the Chief Medical Officer (CMO), the CMO stated that the facility had been aware of this case (referring to the unnecessary ordering of glucose checks for Patient 3). The CMO further clarified that this medical case (Patient 3's stay from 10/13/2024 through 12/6/2024 ) had undergone peer review (a process where healthcare professionals review and evaluate each other's clinical decisions and practices to ensure quality and adherence to standards). The peer review confirmed that blood sugar checks on Patient 3 should have been discontinued since they were never medically required. The CMO stated that the physician should have never ordered the glucose checks, and additionally, the CMO said that nurses-patient advocates, should have raised concerns and questioned the order with the physician, but they did not.

During an interview on 8/8/2025 at 2:32 p.m. with the Program Director for internal Medicine-Residency Program (MD 4) and the Chief medical Officer (CMO), MD 4 said that MD 3 was the supervising physician for the resident physicians overseeing care for Patient 3. MD 4 said that the duty of a supervising physician was to know their patients well to ensure that the care delivered to the patients was appropriate and not compromised. MD 4 also said that attending supervising physicians must be familiar with all orders made by resident physicians during their rounds. The CMO emphasized that supervising physicians were expected to know their patients, and it was unacceptable for a supervising physician to have no idea why the Accu-Chek was ordered in the first place and/or insulin sliding scale was not.

During a review of Patient 3's History and Physical (H&P, a comprehensive assessment of a patient's health status), dated 10/13/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of a person's previous medical conditions, illnesses, surgeries, hospitalizations, and treatments) of hypertension (elevated blood pressure), pacemaker (a small, battery-powered electronic device that helps regulate a slow heart rate [bradycardia] by sending electrical impulses to the heart), blindness in the right eye and dementia (a broad term describing a decline in mental abilities, including memory, thinking, and reasoning, severe enough to interfere with daily life).
The H&P also indicated that Patient 3's sugar level was 108 mg/dL (milligram per deciliter, a unit of measure) and hemoglobin A1C (HgA1C, a blood test that reflects a person's average blood sugar levels over the past 2-3 months) was pending to rule out diabetes; Accu-Chek was ordered; if positive for diabetes, add insulin.

During a review of Patient 3's medical record titled, "Laboratory Results," dated 10/13/2024, the MR indicated that Hemoglobin A1C resulted on 10/13/2024 and was 5.3 % (Below 5.7% is healthy).

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Care," dated 7/2023, the P&P indicated, "Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 1/2025, the P&P indicated, "Considerate and respectful care, and to be made comfortable ..."

During a review of the facility's policy and procedure (P&P) titled, "Internal Medicine Residency Program," dated 4/2025, the P&P indicated, " The Policy applies to the residents in the Internal Medicine Residency Program and the supervising faculty at the [name] Medical Center ...It is the policy of [Name} medical center to ensure that residents are appropriately supervised by the teaching staff ...Supervising Attending Physician is ultimately responsible for the care of the patient ..."

During a review of the facility's "Medical Rules and Regulations (R&R)," dated 10/2024, the Medical R&R indicated, "The attending physician is the MD or DO who is responsible for the care of the principal diagnosis, that clinical condition which is the main reason the patient was hospitalized ...Duties of the Attending Physician include, but not limited to: Coordinating the management of the patient with nursing ...Reassessing the patient at regular intervals ..."

Based on interview and record review, the facility failed to ensure that one of 30 sampled patient's (Patient 1) validation of identity, was completed, in accordance with the facility's protocol when registering patients, performing medical procedures, and administering medications in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries), when Patient 1 was registered under the incorrect first name and was provided incorrect patient identifiers (a piece of information, such as wristband and labels, used to reliably and uniquely identify an individual to ensure they receive the correct care and treatment).

This deficient practice had the potential to compromise Patient 1's safety, and resulted in misidentification of Patient 1 (Patient 1 was registered under the medical record profile of Patient 1's twin sister), prolonged stay in the Emergency Department (ED) and unnecessary repeats of venipuncture (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) which may lead to a potential psychological distress for Patient 1.

Findings:

During a review of Patient 1's Emergency Department Physician Documentation, dated 7/16/2025, the ED Physician Documentation indicated that Patient 1 was seen in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) on 7/16/2025 for low back and pelvic (The bones between the lower abdomen and upper thighs that connect the spine to the legs) pain after a Motor Vehicle collision (MVC, any incident where a vehicle [or vehicles] comes into contact with another vehicle, a pedestrian, an animal, or a stationary object) one (1) hour before the arrival in the ED. The ED Physician Documentation also indicated Patient 1 was 16 weeks pregnant and wanted to check the health of the baby after being in an accident.

During a concurrent interview and record review on 8/6/2025, at 10:48 a.m. with the STEMI Coordinator (MIC, a healthcare professional, often a registered nurse, who is responsible for the organization, development, planning, management, and evaluation of a hospital's ST-segment elevation myocardial infarction [STEMI, a severe type of heart attack where a major artery supplying blood to the heart is completely blocked, causing significant damage to the heart muscle] program), Patient 1's electronic medical record (EMR) titled, "Emergency Department Visit," dated 7/16/2025, was reviewed. The EMR indicated that Patient 1 completed registration in the emergency department (ED) on 7/15/2025 at 9:15 p.m. The registration form titled, "Medical Screening Patient Information Sheet," dated 7/15/2025, indicated that Patient 1's first name was different from the name on the label created for Patient 1 by the registration staff. The MIC confirmed that Patient 1's first name, did not match the first name recorded on the label.

During an interview on 8/6/2025 at 11:18 a.m. with the Administration Supervisor (AS 1), the AS 1 stated, "When a patient first arrives at the emergency department, they are provided with the intake forms (a document used to collect essential information from a patient upon their arrival), which are later reviewed by registration staff and patient's identity is verified by the patient either verbalizing their name and date of birth and/or providing their physical identification card (ID card) and/or driver's license (DL). Once the personal information has been validated, the medical record for the visit is typically created. The registration staff creates a digital encounter visit profile (electronic medical record) and prints labels for the patient (adhesive tags printed with important information, used to accurately identify the patient and ensure correct matching records, samples, medications, and wristbands). The registration personnel then creates a wristband and forwards it to the printer in the triage area (the process of quickly assessing patients in an emergency to determine the severity of their condition and prioritize their care), which is printed by the triage nurse for patient identification purposes."

During an interview on 8/6/2025 at 11:20 a.m. with the emergency department registered nurse (RN) 15, RN 15 said the following regarding validation of patients' identity in triage (and emergency department): "We verify the patient's identity against their wristband. We ask the patient their first and last name, as well as their date of birth and verify the obtained information against what is recorded on the wristband and digital medical records. If the information does not match or is incorrect, we contact registration staff to re-do the labels and the wristband. Once the patient is moved inside the emergency department from triage area, anyone who meets the patient, prior to performing any procedures or administering medication, must ensure they are identifying the right patient by verifying the information against the wristband and confirming verbally with the patient their name and date of birth. We can then scan the barcode printed on the label to administer medication, for example. I am not sure phlebotomists (healthcare personnel who specializes in drawing blood from patients) do it, but when nurses draw blood, they have to make sure this is the correct patient before they complete any procedure or administer a treatment or medications."

During further review of Patient 1's "Emergency Department Physician Documentation," dated 7/16/2025, the ED Physician Documentation indicated that Patient 1 was originally registered under the twin sister's name. The initial physician's orders (venipuncture [medical procedure to withdraw a blood sample from a vein for laboratory testing], Tylenol [acetaminophen, medication used for pain], and pelvic ultrasound [a non-invasive medical imaging test that uses high-frequency sound waves to create pictures of the organs and structures within the pelvic area]), were placed under the wrong account (an account that was created under the twin's sister name for the visit on 7/15/2025) before the patient (Patient 1) realized that her (Patient 1) name was incorrect on the wristband (a band worn by patients, typically around their wrist, to facilitate quick and accurate patient identification). The ED Physician Documentation also indicated that Patient 1 was later re-registered under the correct name and medical account, but the phlebotomy department (the department responsible for the practice of drawing blood from a patient, typically for diagnostic testing, medical research, or blood donation) refused to process the blood draw that had been previously collected under the incorrect name, as a result, Patient 1's blood draw had to be repeated.

During a concurrent interview and record review on 8/6/2025 at 11:20 a.m. with STEMI Coordinator (MIC), Patient 1's twin sister's electronic medical record (EMR) titled, "ED Summary Report," dated 7/15/2025, was reviewed. The MIC reviewed the EMR titled, "ED Summary Report," and verified that there was a documentation under the incorrect EMR (Patient 1's twin sister's EMR) indicating that Patient 1 received 650 milligrams (mg, measuring unit) Tylenol (medication for mild pain), had venipuncture, urinalysis (a laboratory test that involves examining a patient's urine to assess its physical properties, chemical composition, and microscopic components), and pelvic ultrasound all completed while registered under Patient 1's twin sister's medical profile.

During a review of the facility's policy and procedure (P&P) titled, "Patient Identification," dated 7/2023, the P&P indicated that "at least two identifiers are used when preparing to collect specimens and when processing specimens. The use of any two of the following .... Is considered acceptable when validating a patient's identity:
-Patient name
-Patient account number
-Patient medical record number
-Patient date of birth
Before drawing blood specimen, ask the patient to state his or her name and spell it, if in doubt. Verify by checking armband, comparing two identifiers with the information on the collection document (labels) ...Do not assume that the armband is correct if patient states his name is different, go verify with nurse ..."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 6/2024, the P&P indicated, "4. Prior to administration, the 6 R's must be verified:
a. Right drug -Verify that the medication selected for administration is the correct one based on the medication order and product label by reading the medication label at least 3 times
i. When selecting the medication
ii. Just prior to administration
iii. Just after administration
b. Right dose
c. Right time (30-60 min before or after scheduled administration time)
d. Right route
e. Right patient (using 2 identifiers, not including room number)
f. Right documentation ..."

Based on interview and record review the facility failed to:

1. Ensure one of 30 sampled patients (Patient 8) was discharged safely, when Patient 8's discharge order was written by mistake. Nursing staff failed to clarify the order which indicated to discharge Patient 8 to a shelter via uber (a transportation and ride-sharing company), even though nursing staff noted Patient 8 would be discharged home and transported by family.
In addition, Nursing staff failed to a complete a full set of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen). The respiratory rate and oxygen saturation (without oxygen) were not assessed prior to Patient 8's discharge, in accordance with the facility's policy and procedure regarding Discharge of Patient.

This deficient practice resulted in the unsafe discharge of Patient 8. Patient 8 passed away a few hours after discharge.

2. Ensure one of 30 sampled patient's (Patient 9) VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Assessment was performed, in accordance with the facility's policy and procedure regarding VTE Assessments. A full VTE assessment was not performed when Patient 9 was transferred to another unit or had a change of condition. In addition, per documentation, sequential compression devices (leg squeezers) were not removed from Patient 9's left leg, when Patient 9 developed a blood clot to the left leg on 4/10/2025.

This deficient practice had the potential for incorrect VTE risk assessments and had the potential for inappropriate interventions to be implemented for Patient 1, which could result in dislodgement of the blood clot, and possibly traveling to other organs, such as the heart or lungs, which may result in a pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death).

3. Ensure one of 30 sampled patient's (Patient 13) vital signs and reassessment was completed and documented every two hours, in accordance with the facility's policy regarding "Documentation in the ED (Emergency Department, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) Patient Care Record" and "Standard of Nursing Care."

This deficient practice resulted in delayed or missed opportunities for appropriate medical interventions, potentially resulting in negative outcomes (example, low blood pressure) for Patient 13.

4. Ensure one of 30 sampled patient's (Patient 9) pain level was assessed, prior to administering hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever, used to relieve moderate to severe pain), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for Patient 9 to be medicated unnecessarily and the possibility of experiencing unnecessary side effects, such as drowsiness (feeling unusually sleep or tired), lack of energy, or even slowed or shallow breathing.

5. Ensure one of 30 sampled patients (Patient 26), was repositioned (regularly changing a patient's body position to relieve pressure on specific areas, especially those at risk of or affected by pressure injuries [localized damage to the skin and/or underlying tissue, usually over a bony prominence]) every two hours, in accordance with the facility's policy and procedure regarding "Skin Integrity (the overall health and condition of the skin)."

This deficient practice had the potential to result in the worsening of Patient 26's pressure injury leading to prolonged healing and/or hospitalization.

6. Ensure one of 30 sampled patient's (Patient 26) vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood]), was assessed and documented prior to discharge, in accordance with the facility's policy regarding "Discharge of Patient."

This deficient practice had the potential of not being able to detect a change of Patient 26's condition such as low blood pressure or low heart rate which may compromise Patient 26's safety upon discharge.

On 8/07/2025 at 10:38 a.m., the survey team called an immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Director of Quality Improvement (DQI), Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO). Patient 8 was admitted to the facility for shortness of breath (being unable to breath normally) and swelling to both legs, on 6/3/2025. The facility failed to ensure Patient 8 was discharged safely, when Patient 8's discharge order was written by mistake on 6/5/2025, indicating to discharge patient (Patient 8) to a shelter via uber (a transportation network company that provides a platform for users to request rides), with home medications. Patient 8's discharge order was not clarified by Registered Nurse (RN 1), who documented that Patient 8 would be discharged home, not a shelter, and transportation would be provided by a family member, not by uber. Earlier, on the day of discharge on 6/5/2025, Patient 8's nursing assessment indicated Patient 8 was noted with bilateral (both) wheezing (a high-pitched whistling sound produced during breathing, caused by narrowed airways) to the upper chest, short of breath, had difficulty breathing, was receiving 3 - 4 Liters of supplemental oxygen, had a distended abdomen, and pitting edema (a type of swelling [edema] where a pit or indentation remains in the skin after pressure is applied and then released) to the bilateral lower extremities. RN 1 also failed to take a full set of vital signs (blood pressure, heart rate, respiratory rate, Temperature, Oxygen saturation [a measure of how much oxygen is in the blood]) prior to discharging Patient 8. Patient 8's heart rate was 107 (elevated, normal is 60 - 100), the respiratory rate (the number of breaths a person takes per minute, typically measured at rest) was not assessed. The oxygen saturation was 95 %, while Patient 8 was receiving 3 L/min of supplemental oxygen. The oxygen saturation level was not assessed after Patient 8's supplemental oxygen was discontinued by RN 1. RN 1 did not clarify with the provider if Patient 8 should be discharged with or without oxygen. Patient 8 was discharged home, with family, without oxygen on 6/5/2025 at 3:32 p.m. Patient 8's discharge summary indicated Patient 8 needed further treatment and unfortunately had been discharged in error. A nurse's note dated 6/5/2025 at 8:23 p.m. indicated Patient 8 passed away at home (after being discharged in error).

On 8/08/2025 at 11:51 a.m., the IJ was removed in the presence of the DQI, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The acceptable IJ Removal Plan included the following: Clarification of any discharge orders by the provider that does not correlate with patient condition or discharge disposition. Discharge assessment with a full set of vital signs and assessment of patient's oxygen needs. Facility Discharge policy to include assessment of patient's oxygen needs; if patient is on oxygen at the time of discharge, ensure there is accommodation in place for home oxygen and clarify with the discharging provider. Modifications of the electronic medical record to include the Discharge Patient Assessment module to include "Respiratory Rate, oxygen saturation on room air, and Delivery Method, and applicable need for home oxygen. The charge nurse will notify the Nursing Director of all pending discharges. The Nursing Director will review all discharge orders and discharge assessments to ensure all elements of discharge are met, prior to discharging patients. All units are documenting the verification with initial, in the Safe Discharge Monitoring Tool. In addition, education and re-education on clarification of any discharge order that does not correlate with patient condition or discharge disposition, Safe Discharge progress, Discharge of Patient policy revision, notify provider if vital signs are out of range at discharge, if patients are on oxygen at time of discharge, ensure there are either arrangements made for home oxygen or notify provider for further instructions.

Findings:

1. During a concurrent interview and record review on 8/6/2025 at 9:56 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: RN 1 assumed care for Patient 8 on 6/5/2025 at 10:46 a.m. Patient 8 was admitted on 6/3/2025 for shortness of breath (being unable to breathe normally) and leg swelling. RN 1 confirmed that Patient 8 was not receiving oxygen at home, at the time of admission. Patient 8 required supplemental oxygen during his (Patient 8) hospitalization.
RN 1 received a physician's order on 6/5/2025 at 2:02 p.m., to discharge Patient 8 to a shelter, via uber (a transportation and ride-sharing company), and continue home medications. RN 1 did not question the order, to discharge to a shelter via uber. RN 1 only verified that Patient 8 was not homeless and would not be discharged to a shelter, instead Patient 8 would be discharged home with a family member (FM 1), who was present at the bedside. RN 1 checked Patient 8's vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen) prior to discharge. The heart rate was 107 (elevated, normal 60-100), the respiratory rate (the number of breaths a person takes per minute) was not checked, prior to discharge. The oxygen saturation level was 95 % while Patient 8 was still receiving oxygen at 3 liters. RN 1 discontinued Patient 8's oxygen and discharged Patient 8 home with FM 1.

During the same interview on 8/6/2025 at 9:56 a.m. with Registered Nurse (RN) 1, RN 1 stated Patient 8's oxygen saturation level was not assessed, after the supplemental oxygen was discontinued. RN 1 observed Patient 8 and determined Patient 8 was not in respiratory distress (a condition where a person has difficulty breathing, often characterized by rapid, shallow, or labored breathing) after discontinuing the oxygen, then RN 1 discharged Patient 8 home with FM 1 at 3:32 p.m. RN 1 did not contact the physician to question the discharge order or to question whether or not Patient 8 should be discharged without oxygen. RN 1 stated that on 6/5/2025 at 4 p.m., she (RN 1) received a call from Physician (MD) 5, who informed her (RN 1) that Patient 8's discharge order was written in error and to notify Patient 8 and family to return to the hospital. RN 1 called Patient 8 and left a voice mail to return to the hospital. RN 1 stated that later that day, on 6/5/2025 at 8:23 p.m., MD 5 informed RN 1 that MD 5 spoke to Patient 8's family member (FM 2), who stated that Patient 8 passed away.

During an interview on 8/6/2025 at 11:16 a.m. with the Director of Telemetry (DT 1), the DT 1 stated the following: A full set of vital signs were required upon discharge to determine if it was safe to discharge a patient. DT 1 verified that the Respiratory Rate was not documented upon discharge, and Patient 8's oxygen saturation was not checked when Patient 8's supplemental oxygen was discontinued. In addition, DT 1 stated that Patient 8's discharge order, to discharge to a shelter via uber, should have been questioned since it did not match what was observed with Patient 8, who had family at bedside to take Patient 8 home.

During an interview on 8/6/2025 at 1:14 p.m. with MD 5, MD 5 stated the following: Patient 8 was admitted due to shortness of breath and edema (swelling of body tissues due to an excessive buildup of fluid) to both legs. Patient 8 appeared to be in heart failure (heart does not pump blood as well as it should). Patient 8 required supplemental oxygen while hospitalized, and there was no previous history of Patient 8 receiving oxygen at home. Patient 8's plan included further workup per cardiology (a branch of medicine that deals with disease of the heart) and nephrology (a branch of medicine specializing in treating kidney conditions) recommendations.

During the same interview on 8/6/2025 at 1:14 p.m. with MD 5, MD 5 stated that on 6/5/2025, he (MD 5) had another patient who was to be discharged to a shelter. MD 5 meant to place an order for another patient to be discharged to a shelter but instead MD 5 placed a discharge order for Patient 8, in error. A little later that day, while MD 5 checked Patient 8's notes, MD 5 realized that Patient 8 had been discharged by mistake and immediately called RN 1 to notify Patient 8 to return to the hospital. MD 5 also called FM 1, who was crying at the time. FM 1 informed MD 5 that Patient 8 passed away at home. MD 5 stated nursing staff should advocate for patients. Nursing staff could have questioned the discharge order and should have checked Patient 8's oxygenation status without oxygen and informed him (MD 5) of the results. If oxygen saturation was less than 92 % on room air, MD 5 could have ordered an ABG (Arterial Blood Gas, measures the level of oxygen and carbon dioxide in the blood) to determine if Patient 8 needed oxygen at home, and that may have resulted in MD 5 realizing that Patient 8's discharge order was a mistake.

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/3/2025, the H&P indicated the following: Patient 8 was admitted to the facility on 6/3/2/2025 for shortness of breath and leg swelling. Patient 8 had a past medical history of Atrial fibrillation/flutter (irregular and rapid heart rate/heart's upper chambers beat too quickly), Hypertension (high blood pressure), Diabetes mellitus (high blood sugar), urinary retention (difficulty urinating and completely emptying the bladder), and COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe) exacerbation (increase in severity of illness). Patient 8 was admitted to the Telemetry ward (a specialized hospital area dedicated to continuous, remote monitoring of patients' vital signs, primarily focusing on cardiac [heart] activity) and consult with Cardiology and Nephrology (additional work ups (blood draw, diagnostic tests) were ordered but were not carried out due to Patient 8 being discharged inadvertently).

During a review of Patient 8's Initial Nursing Assessment, dated 6/3/2025, the Initial Nursing Assessment indicated Patient 8 did not reside in a temporary living situation or shelter.

During a review of Patient 8's Telemetry Nurse's Flow Sheet, dated 6/5/2025 at 8 a.m., the Flow Sheet indicated the following: Patient 8 had shortness of breath/difficulty breathing/ Labored respirations (difficulty/increased effort in breathing). Receiving oxygen via nasal cannula (a medical device used to deliver supplemental oxygen) at 4 L/min (Liters per minute, a unit of measure). Bilateral (both) wheezing (a high-pitched whistling sound produced during breathing, caused by narrowed airways) to the upper lungs ...Bilateral legs 4+ pitting edema (a type of swelling [edema] where a pit or indentation remains in the skin after pressure is applied and then released) ... Unsteady gait (an abnormal walking pattern characterized by a lack of balance or coordination). Distended abdomen (a noticeable increase in the size of the abdomen).

During a review of Patient 8's nurse's note, dated 6/5/2025 at 8:30 a.m., the nurse's notes indicated the following: Patient 8 noted with "wheezing bilaterally in upper chest. On 3 liters of oxygen ...Abdomen distended. Patient 1 noted with 4+ pitting edema bilaterally ..."

During a review of Patient 8's nurse's note, dated 6/5/2025 at 10:45 p.m., the nurse's note indicated the following: Patient 8 "is on 3 liters of oxygen. Declined using oxygen at home. Nurse (RN 1) received report, Patient 8 has lower extremity pitting edema ...Abdomen was distended)."

During a review of Patient 8's Discharge Order, dated 6/5/2025 at 2:05 p.m., the Discharge order indicated to discharge to shelter via Uber, continue home medications.

During a review of Patient 8's Patient Visit Summary, dated 6/5/2025 at 2:35 p.m., Patient Visit Summary indicated the following: Pulse rate: 107 (high, normal is 60 - 100), blood pressure 113/86 (normal 120/80), Oxygen saturation was 95 % (within normal limits), there was no documentation indicating if Patient 8 was receiving oxygen at that time of measuring. Respiratory rate was not assessed.

During a review of Patient 8's nurse's note, dated 6/5/2025 at 3:32 p.m., the nurse's note indicated Patient 8's daughter (FM 1) was in patient's room when the discharge order news was relayed to Patient 1. FM 1 drove Patient 8 home.

During a review of Patient 8's nurse's note, dated 6/5/2025 at 8:23 p.m., the nurse's note indicated MD 5 called back. MD 5 stated he (MD 5) spoke to Patient 8's family member (FM 2). MD 2 reported that Patient 8 passed away at home (soon after discharge from the facility).

During a review of Patient 8's Discharge Summary, dated 6/20/2025, the Discharge Summary indicated the following: Patient 8 was admitted on 6/3/2025 and discharged on 6/5/2025. Patient 8 was in need of diuresing (elimination of urine and excess body fluid) due to his (Patient 8) dependent edema (swelling that occurs in the lower parts of the body due to the effects of gravity) and pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) noted. Patient 8 needed further evaluation. Unfortunately, Patient 8 was discharged from the hospital in error. Upon realizing this, a call was immediately made to the patient (Patient 8) and family to instruct Patient 8 to return to the hospital immediately or go to the nearest hospital available for medical attention.

During a review of the facility's Policy and Procedure (P&P) titled, "Discharge of Patient," dated 10/2023, the P&P indicated the following: The nurse caring for patient is responsible to document the following. Condition of patient: Discharge vital signs.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Care," dated 7/2023, the P&P indicated, "Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units."

2. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 9's medical record, was reviewed. CNS 5 stated the following: VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Risk assessments should be done every shift, and could be documented with no change, if indicated. A complete VTE Assessment should also be documented when a patient was transferred to another unit or when the patient had a change of condition. Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). Patient 9's VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment, dated 4/7/2025, indicated Patient 9 had a VTE risk score of 10 (highest risk of developing a blood clot).

During the same concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, the VTE assessment also indicated that Intermittent Pneumatic Compression Devices (IPC device, used to help prevent blood clots in the deep veins of the legs) had been applied to both legs of Patient 9. CNS 5 stated that Patient 9 was transferred from the Medical Intensive Care Unit (a specialized unit that provides intensive 24-hour care for patients with severe, life-threatening medical conditions) to the Telemetry unit (a floor dedicated to patients who require continuous cardiac [heart] monitoring) on 4/9/2025. A full VTE assessment, indicating that Patient 9 had been transferred to another unit, should have been done, but was not.

During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 stated that on 4/10/2025, Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep vein of the leg) to the left leg. CNS 5 stated a full VTE assessment should have been done, for Patient 9's change of condition (development of DVT) but, was not. CNS 5 verified that VTE Risk Shift Assessments indicated "No Change of Condition," from 4/9/2025 through 4/14/2025, and this was incorrect because Patient 9 had been transferred to another unit, and also developed a DVT, which was a change of condition. CNS 5 stated full VTE assessments should have been done, and this would have triggered for possible medicinal prophylaxis (actions taken to prevent disease, illness, or injury), or the IPC device to be removed from the left leg. CNS 5 verified that per VTE assessments, which indicated "No Change of Condition," the IPC device had not been removed from the left leg. CNS 5 stated IPC device was contraindicated in left leg because of the risk of dislodging the blood clot and possibly traveling to the other organs, such as the lungs.

During a review of Patient 9's "VTE Risk Shift Assessment," dated 4/7/2025 at 11:30 a.m., the VTE Assessment indicated the following:
- Score patient at: Admission
-VTE Risk Factors: Age 60-74, patient immobile/anticipate >72 hours, COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe), Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight. A BMI between 18.5 and 24.9 is generally considered healthy, while a BMI of 30 or higher indicates obesity] > 30, Admitted to critical care (specialized medical care for patients with life-threatening illnesses or injuries).
-VTE Risk Score: 10 (score of 10 or greater is generally considered high risk for venous thromboembolism)
-VTE Risk Level: (highest risk of developing a blood clot)
-Mechanical Device Applied: Yes
-Mechanical Device Applied: Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs)
-Medicinal Prophylaxis Ordered: Yes (incorrect, verified by CNS 5)
-VTE Assessment Results: No Action Needed.

During a review of Patient 9's "VTE Risk Shift Assessment," dated 4/8/2025 at 8 a.m., the assessment indicated the following:
- Score patient at: s/p (status post [after]) Surgical Procedure
-VTE Risk Factors: Age 60-74, Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight] > 300, Admitted to critical care.
-VTE Risk Score: 9
-VTE Risk Level: (highest risk of developing a blood clot)
-Mechanical Device Applied: Yes
-Mechanical Device Applied: Intermittent Pneumatic Compression Device
-Medicinal Prophylaxis Ordered: No
-Reason For No Medicinal Prophylaxis: Complication medical care
-Medicinal Contraindication Reason: S/P Laminectomy
-VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/9/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/10/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/11/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/12/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/13/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's VTE Risk Shift Assessment, dated 4/14/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed.

During a review of Patient 9's nurse's notes, dated 4/9/2025 at 6:45 p.m., the nurse's notes indicated Patient 9 was transferred from the Medical Intensive Care Unit (a specialized unit that provides intensive 24-hour care for patients with severe, life-threatening medical conditions) to the Telemetry unit (a floor dedicated to patients who require continuous cardiac [heart] monitoring).

During a review of Patient 9's nurse's notes, dated 4/10/2025 10:43 p.m., the nurse's notes indicated the following: MD (physician) Communication. Called MD to inform him regarding Patient 9's ultrasound (medical imaging that uses high-frequency sound waves to create pictures of the inside of the body) results. Patient 9 was positive for deep vein thrombosis (DVT, blood clot forms in a deep vein) on the left leg.

During a review of Patient 9's nurse's notes, dated 4/10/2025 11:07 p.m., the nurse's notes indicated the following: Nurse reported the result of Patient 9's ultrasound and that Patient 9 was positive for DVT on the left leg; doctor said to await image results to be posted and inform the morning doctor team.

During a review of the facility's policy and procedure (P&P) titled, "Venous Thromboembolism Risk Assessment and Prophylaxis (VTE)," dated 7/2023, the P&P indicated the following: It is the policy of the Hospital that "all adults (age >18 years) will be assessed for venous thromboembolism (VTE) risk upon admission to the hospital, at key transitions in care, and that appropriate interventions will be used to prevent VTE ...Key Transitions in care include transfers to/from intensive care settings, changes of service, post-operatively or post-interventional procedure ...Upon inpatient admission, all hospitalized patients must be assessed for level of VTE risk and/or contraindications for VTE prophylaxis using the EMR-Approved VTE Risk Assessment Tool ...All contraindications to VTE prophylaxis will be documented in the medical record ...Repeat VTE risk assessment will occur with any change of condition and key transitions. If a patient refuses prophylaxis ...The prescriber should always be contacted when a patient is unable or unwilling to take a prescribed medication or mechanical device so that alternative interventions can be considered."

3. During a review of Patient 13's "Admission/Registration" record, undated, the record indicated that Patient 13 was admitted into the emergency department (ED) on 03/21/2025 at 2:50 p.m., with complaints of nausea (feeling an urge to vomit) as the reason for her (Patient 13) visit.

During a concurrent interview and record review on 8/05/2025 at 10:47 a.m. with the Clinical Nurse Supervisor (CNS) 2, Patient 13's medical record titled, "Notes" dated 03/21/2025 2:55 p.m. - 03/21/2025 9:57 p.m., were reviewed. Patient 13's medical record indicated that patient (Patient 13) was seen in the emergency department on 03/21/2025 and was triaged (a system used to rapidly assess and prioritize patients arriving at the emergency room based on the severity of their condition) at 2:55 p.m. Patient 13 was then sent to the ED navigator nurse (a nurse who guides, and facilitate communication and coordinates care within the ED) at 2:58 p.m. Patient 13's medical record indicated that call-out (to summon) to Patient 13 was made at 8:00 p.m., 8:30 p.m., and 8:50 p.m. It was then documented that Patient 13 "left without being seen (LWBS, patients who leave the ED before being evaluated by a physician)" at 8:00 p.m.

During the same interview on 8/05/2025 at 10:47 a.m. with the Clinical Nurse Supervisor (CNS) 2, CNS 2 stated that Patient 13 was sent to the waiting room by the nurse navigator until she (Patient 13) can be seen by the ED provider. The last patient vital signs were taken at 2:55 p.m., it was only established that the patient had left the hospital at 8:00 p.m. CNS 2 said that the ED staff should have checked on the patient (Patient 13) and reassessed her (Patient 13) vital signs earlier, prior to establishing Patient 13 as a LWBS patient at 8:00 p.m. CNS 2 added that ED staff should have reassessed Patient 13's vital signs every 2 hours (starting upon patient's arrival up to when a patient leaves), according to policy and procedure (Patient 13's vital signs was only assessed and documented once during Patient 13's ED stay).

During a review of the facility's Policy and Procedure (P&P) titled, "Documentation in the ED Patient Care Record," with last reviewed date of 09/2023, the P&P indicated the following:
"TRIAGE ASSESSMENT: An initial triage assessment by qualified personnel will be completed and documented for all patients checked into the Emergency Department. Documentation of re-assessment shall be done on all triaged patients in the waiting room every 2 hours or sooner as clinically indicated. The following information shall be entered in the patients Emergency Department Patient Care Record in the EHR. All areas must be completed, if not applicable, the NA (Not Applicable) box has to be checked."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Care," dated 7/2023, the P&P indicated, "Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units."

4. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 9's medical record, was reviewed. CNS 5 stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves).

During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 said that on 4/12/2025 at 3:14 a.m., Patient 9 received hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever- acetaminophen, used to relieve moderate to severe pain) 10/325 mg (milligram, a unit of measure), 1 tablet. CNS 5 verified Patient 9's pain level was not assessed prior to receiving hydrocodone/acetaminophen. CNS 5 stated that the pain level of Patient 9 should have been assessed by verbally asking the patient or by using the FLACC scale (a behavioral observation tool used to assess pain in children and non-verbal patients who cannot communicate their pain), if Patient 9 was not able to verbalize the pain. CNS 5 stated medicating patients without assessing the pain level could result in the unnecessary administration of pain medications.

During a review of Patient 9's Medication Orders, dated 4/7/2025, the orders

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

1. Update a plan of care (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 9), when Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep veins) to the left leg), in accordance with the facility's policy and procedure regarding plan of care.

This deficient practice resulted in the lack of appropriate interventions for Patient 9, such as removal of the Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) from the left leg, after Patient 9 was diagnosed with DVT to the left leg. This deficient practice also had the potential to result in complications such as pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death).

2. Ensure one of 30 sampled patient's (Patient 18) plan of care regarding infection prevention/control (a set of evidence-based practices and procedures designed to prevent the transmission of infections in healthcare settings), was developed and implemented on admission, in accordance with the facility's policy regarding plan of care. Patient 18 had a peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) on his (Patient 18) left arm.

This deficient practice had the potential for Patient 18's care needs and risks not to be addressed which may lead to complications such as infection resulting from the use of a PICC.

3. Ensure one of 30 sampled patient's (Patient 25) plan of care on infection prevention/control, was developed and implemented, in accordance with the facility's policy regarding plan of care. Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection).

This deficient practice had the potential for Patient 25's care needs and risks not to be addressed which may lead to worsening of infection, delayed recovery, and prolonged hospitalization.

4. Ensure two of 30 sampled patients' (Patient 29 and Patient 30) plan of care on Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control) was developed and implemented, in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for Patient 29 and Patient 30's diabetic care needs and risks to not be addressed which may lead to complications of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Findings:

1. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 reviewed Patient 9's medical record and stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). Patient 9's VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment, dated 4/7/2025, indicated Patient 9 had a VTE risk score of 10 (highest risk of developing a blood clot). The VTE assessment also indicated that Intermittent Pneumatic Compression Devices (IPC device, used to help prevent blood clots in the deep veins of the legs) had been applied to both legs.

During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 stated that on 4/10/2025, Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep vein of the leg) to the left leg. CNS 5 verified that VTE Risk Shift Assessments indicated "No Change of Condition," from 4/9/2025 through 4/14/2025, and this was incorrect because Patient 9 developed a DVT, which was a change of condition. CNS 5 verified that Patient 9's plan of care titled, "High Risk for VTE/DVT," was not updated to include appropriate interventions, such as removing the IPC device from the left leg. CNS 5 verified that per VTE assessments, indicating "No Change of Condition," implied that the IPC device was still placed on Patient 9's left leg and had not been removed. CNS 5 stated IPC device was contraindicated to be used on left leg because of the risk of dislodging the blood clot and possibly traveling to the other organs, such as the lungs.

During a review of Patient 9's "VTE Risk Shift Assessment," dated 4/7/2025 at 11:30 a.m., the VTE Assessment indicated the following:
- Score patient at: Admission
-VTE Risk Factors: Age 60-74, patient immobile/anticipate >72 hours, COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe), Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight. A BMI between 18.5 and 24.9 is generally considered healthy, while a BMI of 30 or higher indicates obesity > 300), Admitted to critical care (specialized medical care for patients with life-threatening illnesses or injuries).
-VTE Risk Score: 10
-VTE Risk Level: (highest risk of developing a blood clot)
-Mechanical Device Applied: Yes
-Mechanical Device Applied: Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs)
-Medicinal Prophylaxis Ordered: Yes (incorrect, verified by CNS 5)
-VTE Assessment Results: No Action Needed.

During a review of Patient 9's nurse's notes, dated 4/10/2025 10:43 p.m., the nurse's notes indicated the following: MD (physician) Communication. Called MD to inform him regarding Patient 9's ultrasound (medical imaging that uses high-frequency sound waves to create pictures of the inside of the body) results. Patient 9 was positive for deep vein thrombosis (DVT, blood clot forms in a deep vein) on the left leg.

During a review of Patient 9's nurse's notes, dated 4/10/2025 11:07 p.m., the nurse's notes indicated the following: Nurse reported the result of Patient 9's ultrasound that Patient 9 was positive for DVT on the left leg; doctor said to await image results to be posted and inform morning doctor team.

During a review of Patient 9's Plan of Care titled, "High Risk VTE (Venous Thromboembolism- It's a condition where blood clots form in the veins, most commonly in the deep veins of the legs [Deep Vein Thrombosis or DVT] or in the lungs )/DVT," initiated on 4/8/2025, the Plan of Care indicated the following: Goal: Remain free of VTE/DVT. Interventions included: Administer anticoagulant (a medication that reduces or prevents blood clotting) per MD order, Sequential Compression Device (SCD, leg squeezers, used to improve circulation and prevent blood clots), out of bed to chair, monitor for signs and symptoms of thrombophlebitis (a condition in which a blood clot in a vein causes inflammation and pain), and perform range of monitor exercises (movements performed to maintain or improve the flexibility and movement of joints and muscles).

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care: Patient, Interdisciplinary," dated 7/2023, the P&P indicated the following: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Identify the problem: problems are identified through analysis and assessment data. The problem can be actual or potential and should reflect consideration of the patients' physical ...needs. Choose the interventions: Interventions reflect the course of action that will be taken to move the patient towards the expected outcomes that have been established. They shall be consistent with established standards of care. The interventions should be specific; they are guidelines by which subsequent care providers will render care to the patient ...Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon change in patient's condition.

2. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem," dated 08/01/2025, the H&P indicated that Patient 18 suddenly experienced the onset of excruciating (intensely painful) right flank pain (pain felt on the right side of the body, between the upper abdomen and back, specifically below the ribs and above the hip bone). The H&P indicated Patient 18 denied any fever. Patient 18's family was concerned and called the paramedics.

During further review of Patient 18's H&P, dated 8/01/2025, the H&P indicated Patient 18 was brought into the emergency room for evaluation. Computed Tomography (CT, a medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the body) scan was obtained, and it showed evidence of a right mid ureteral stone (a stone located in the urethra, the tube that carries urine from the bladder to the outside of the body) with hydronephrosis (the swelling of one or both kidneys due to a buildup of urine) of the right kidney. The patient (Patient 18) treatment plan included antibiotic therapy (the administration of antibiotics to treat infections).

During a review of Patient 18's "Diagnostic Imaging Report," dated 08/04/2025, the record indicated successful placement of a PICC (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line to Patient 18's left arm. The PICC was indicated for intravenous (IV, refers to the administration of fluids or medication directly into a patients vein) access for intravenous therapy.

During a concurrent interview and record review on 08/05/2025 at 3:05 p.m. with the Clinical Nurse Specialist (CNS 2), Patient 18's medical record titled, "Plan of Care," undated, indicated that a plan of care for infection prevention and control was not initiated. CNS 2 said that the nurse should have initiated a plan of care for Infection Prevention/Control (IPC). A plan of care on IPC was needed because the patient (Patient 18) would be on IV antibiotics, also there could be a risk for infection due to Patient18's PICC line insertion site.

During a review of the Policy and Procedure (P&P) titled "Plan of Care," with last reviewed date of 04/2023, the P&P indicated the following:
PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs.
POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient's care.
Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient's condition. Nursing notes shall reflect the interventions, and the patient's response to nursing care provided. This documentation may be in the narrative notes or on a checklist.

3. During a review of Patient 25's "History and Physical (H&P)," dated 3/23/2025, the H&P indicated Patient 25 was admitted to the facility for generalized weakness and slurred (not clear) speech. Patient 25 had a medical history of hypertension (HTN, high blood pressure), dementia (a progressive state of decline in mental abilities), and stroke (loss of blood flow to the brain) with the inability to move the right side of the body.

During a concurrent interview and record review on 8/5/2025 at 1:22 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 25's "Infectious Disease Note," dated 3/24/2025, was reviewed. The Infectious Disease Note indicated Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection).

During a concurrent interview and record review on 8/5/2025 at 2:27 p.m. with CNS 1, Patient 25's "Care Activity-Plan of Care (POC)," undated, was reviewed. The plan of care indicated Patient 25 did not have a POC related to infection other than "Urinary Tract Infection (UTI, bladder infection)." CNS 1 stated there was an "Infection Prevention/Control" POC that should have been applied to the patient (in order to address the condition of sepsis and possible pneumonia).

During an interview on 8/5/2025 at 2:33 p.m. with CNS 1, CNS 1 stated that the purpose of a plan of care was to have guidance for the patient's care. CNS 1 stated it was important to determine what interventions worked or did not work for the patient, and the outcomes were based on the POC. CNS 1 stated anytime a problem was identified, a POC should be added. CNS 1 also stated the POC should be started as soon as the nurse does their assessment and within 24 hours of admission.

During a review of the Policy and Procedure (P&P) titled "Plan of Care," with last reviewed date of 04/2023, the P&P indicated the following:
PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs.
POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient's care.
Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient's condition. Nursing notes shall reflect the interventions, and the patient's response to nursing care provided. This documentation may be in the narrative notes or on a checklist.

4.a. During a review of Patient 29's "History and Physical (H&P)," dated 8/2/2025, the H&P indicated Patient 29 was admitted to the facility for chest pain. Patient 29 had a medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Gastro esophageal reflux disease (GERD, chronic digestive disease where the contents of the stomach refluxes [backs up] and irritates the esophagus), and hyperlipidemia (HLD, high amount of fat in the blood).

During an interview on 8/5/2025 at 2:33 p.m. with the Clinical Nurse Supervisor (CNS) 1, CNS 1 stated the purpose of a plan of care (POC), was to have guidance on the patient's care. CNS 1 stated it was important to have a plan of care to see what interventions worked or did not work for the patient, and the outcomes were based on the POC. CNS 1 stated, anytime a problem was identified, a POC should be added. CNS 1 also stated the care plan should be started as soon as the nurse does their assessment and within 24 hours of admission.

During a concurrent interview and record review on 8/6/2025 at 3:10 p.m. with the Stroke Coordinator (SC), Patient 29's "Electronic Medical Record (EMR, a digital version of paper chart)," undated, was reviewed. The EMR indicated Patient 29 had orders for blood sugar checks, insulin (injectable medication used to control blood sugar) sliding scale (determines the amount to be given based on blood sugar values) and was on a diabetic diet.

During a concurrent interview and record review on 8/6/2025 at 3:20 p.m. with the SC and the ST-segment elevation myocardial infarction (STEMI, heart attack) coordinator (MIC), Patient 29's "Care Activity-Plan of Care," undated, was reviewed. The SC acknowledged Patient 29 did not have a POC for diabetes, and stated it was important for the patient to have one. The MIC was also asked if it was expected for a patient with diabetes to have a POC. The MIC stated it was expected because the patient's blood sugar was being managed.

During a review of the Policy and Procedure (P&P) titled "Plan of Care," with last reviewed date of 04/2023, the P&P indicated the following:
PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs.
POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient's care.
Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient's condition. Nursing notes shall reflect the interventions, and the patient's response to nursing care provided. This documentation may be in the narrative notes or on a checklist.

4.b. During a review of Patient 30's "History and Physical (H&P)," dated 8/2/2025, the H&P indicated Patient 30 was admitted to the facility for distended (swollen) abdomen and frequent paracentesis (a procedure that involves inserting a needle or catheter into the abdomen to remove fluid). The H&P also indicated Patient 30 had a medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), cirrhosis (liver disease), and breast cancer (cells grow out of control and affects how other normal cells work).

During an interview on 8/5/2025 at 2:33 p.m. with CNS 1, CNS 1 stated the purpose of a plan of care (POC) was to have guidance on the patient's care. CNS 1 stated it was important to have a POC to see what interventions worked or did not work for the patient (Patient 30), and the outcomes were based on the POC. CNS 1 stated, anytime a problem was identified, a POC should be added. CNS 1 also stated the POC should be started as soon as the nurse does their assessment and within 24 hours of admission.

During a concurrent interview and record review on 8/6/2025 at 3:30 p.m. with the Stroke Coordinator (SC), Patient 30's "Electronic Medical Record (EMR)," undated, was reviewed. The EMR indicated Patient 30 had orders for blood sugar checks, insulin (injectable medication used to control blood sugar) sliding scale (determines the amount to be given based on blood sugar values), and was on a diabetic diet.

During the same concurrent interview and record review on 8/6/2025 at 3:30 p.m. with the SC, Patient 30's "Care Activity-Plan of Care," undated, was reviewed. The SC acknowledged Patient 30 did not have a Diabetes Mellitus POC and should have had one.

During a review of the Policy and Procedure (P&P) titled "Plan of Care," with last reviewed date of 04/2023, the P&P indicated the following:
PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs.
POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient's care.
Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient's condition. Nursing notes shall reflect the interventions, and the patient's response to nursing care provided. This documentation may be in the narrative notes or on a checklist.

Based on interview and record review, the facility failed to ensure, for one of 30 sampled patients (Patient 25), nursing staff adhered to the facility's policy and procedure (P&P) titled, "Active Surveillance Strategies," when Patient 25 was not swabbed (collecting samples (like a throat swab) for Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria that does not respond to antibiotics) of the nares (nose).

This deficient practice had the potential for Patient 25 to receive delayed treatment and/or interventions and potentially expose other patients to the MRSA bacteria.

Findings:

During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/7/2025, the H&P indicated Patient 25 was admitted to the facility because the skilled nursing facility (SNF, facility for individuals with a need for lower level nursing care) was unable to accommodate Patient 25. Patient 25's medical history included hypertension (HTN, high blood pressure), sepsis (life-threatening bloodstream infection), urinary tract infection (UTI, bladder infection), stroke (loss of blood flow to the brain) and was unable to move the right side of their body.

During a concurrent interview and record review on 8/5/2025 at 2:56 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 25's medical record, was reviewed. CNS 1 stated patients needed to be swabbed for MRSA if they were readmitted to the facility within 30 days. CNS 1 stated Patient 25 should have been swabbed for MRSA (Methicillin-Resistant Staphylococcus Aureus, a bacteria that does not respond to antibiotics) on the day she (Patient 25) was readmitted (4/6/2025).

During a concurrent interview and record review on 8/5/2025 at 3:03 p.m. with CNS 1, Patient 25's "Specimen Inquiry," dated 4/11/2025, was reviewed. The record indicated Patient 25 had an order placed for MRSA nares (nose) to be collected. CNS 1 verified the order was not carried out until 4/9/2025, two days after the order was placed.

During a review of the facility's policy and procedure (P&P) titled, "Active Surveillance Strategies," dated 4/2024, the P&P indicated, "Each patient admitted to (name of the facility) shall be tested for MRSA in the following cases, within 24 hours of admission with a nares swab for MRSA: Patient with a history of hospitalization within the prior 30 days."

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

1. Ensure one of 30 sampled patients (Patient 20), received blood pressure medication (Hydralazine Hydrochloride [HCL], medication to lower blood pressure), as ordered by the physician.

This deficient practice resulted in Patient 20's increased blood pressure level and placing the patient (Patient 20) at risk for possible stroke (when blood flow to the brain is interrupted) or aortic dissection (artery in the heart that tears due to pressure).

2. Ensure one of 30 sampled patient's (Patient 22) intravenous antibiotics (Cefepime, used to treat/prevent infection) and a medication used to control stomach bleeding (Octreotide [medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin]), were administered, as ordered by the physician.

This deficient practice had the potential to result in worsening of infection or delay in healing from infection (from delayed administration of the Cefepime antibiotic) as well as the potential for stomach bleed (from not administering the Octreotide) for Patient 22.

3. Ensure one of 30 sampled patients (Patient 9), was medicated with the correct pain-relieving medication based on Patient 9's assessed pain level, in accordance with the physician's order, and the facility's policy regarding medication administration. Patient 9 was assessed with moderate pain and was medicated with a medication ordered for severe pain.

This deficient practice had the potential for Patient 9 to be overmedicated and possibly suffering unnecessary side effects for the elderly, such as drowsiness (feeling unusually sleep or tired), dizziness, urinary retention (the inability to completely empty the bladder), delirium (a temporary state of confusion or disorientation), or respiratory depression (a condition where breathing becomes abnormally slow and shallow).

Findings:

1. During a review of Patient 20's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 3/6/2025, the H&P indicated, Patient 20 was admitted for left leg fracture (broken bone) and thoracic aortic aneurysm (TAA- balloon-like bulge in aorta [artery in heart] due to weakened and stretching walls).

During a review of Patient 20's "Hydralazine Medication Order," dated 3/11/2025, the medication order indicated an order for Hydralazine Hydrochloride (HCL, medication used to lower blood pressure; also known as Apresoline-brand name of medication) 25 milligrams (mg, a unit of measure) 1 tablet oral (by mouth) every 8 hours, hold for systolic blood pressure (the top number in a blood pressure reading and represents the pressure in the arteries when the heart contracts and pumps blood out) less than 110 mmHg (Millimeters of Mercury, a unit of pressure).

During a concurrent interview and record review on 8/6/2025 at 9:57 a.m. with the House supervisor (HS), Patient 20's "Medication Administration" record, dated 3/11/2025 through 3/14/2025, was reviewed. The medication administration record indicated that on 3/13/2025 at 10:00 p.m., Hydralazine was not given to Patient 20 as ordered. The HS stated Patient 20 was transferred from one unit to another unit, however, it (referring to the Hydralazine) should have been administered by either the sending nurse or the receiving nurse before or after the transfer.

During a review of Patient 20's "Nurse Notes," dated 3/13/2025 at 10:21 p.m. and at 11:45 p.m., the receiving nurse documented receiving Patient 20 at 10:21p.m. with a blood pressure of 139/74. At 11:45 p.m., the receiving nurse documented Patient 20 did not receive hydralazine medication from transferring nurse or from receiving nurse.

During a review of Patient 20's "Vital Signs," record dated 3/13/2025 through 3/14/2025, the record indicated the following:
-On 3/13/2025 at 9:00 p.m. blood pressure 134/71
-On 3/13/2025 at 10:21p.m., blood pressure 130/65
-on 3/14/2025 at 12:00 a.m., blood pressure 148/76

During an Interview on 8/6/2025 at 10:25 a.m. with HS, the HS stated, the blood pressure medication should have been given before Patient 20 was transferred or administered to Patient 20 once arrived at the receiving unit by receiving nurse. HS further stated Patient 20's blood pressure was possibly high (at 12 a.m. on 3/14/2025) due to missing the 10:00 p.m. dose of Hydralazine (on 3/13/2025).

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications," revised 5/2024, the P&P indicated, "the administration of each dose of medication shall be accurately recorded in the patient's electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted."

2. During a review of Patient 22's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 6/27/2025, the H&P indicated, Patient 22 was admitted to the facility for altered mental status (change in person's consciousness [a person's state of awareness and responsiveness to their surroundings], awareness and cognitive function [the mental processes involved in acquiring, processing, and using information]) after being found unresponsive (not reacting or responding to stimuli) and possible sepsis (a serious blood infection). The H&P also indicated Patient 22 had a history of liver cirrhosis (damage to the liver disrupting its ability to function including the risk of bleeding).

2.a. During a review of Patient 22's "Medication Orders," dated 7/2/2025, the Medication Orders indicated a physician order for Cefepime (antibiotic medication used to treat infection) 1 gram (gm-unit of measurement) every 12 hours intravenously (IV-through the vein).

During a concurrent interview and record review on 8/6/2025 at 2:59 p.m. with the house supervisor (HS), Patient 22's "Medication Administration" record, dated 7/2/2025 through 7/3/2025 for Cefepime, was reviewed. The Medication Administration record indicated the following:
-On 7/2/2025 at 10:56 p.m., Patient 22 received Cefepime. Next scheduled dose was on 7/3/2025 at 10:56 a.m. There was no documentation that Patient 22 received the next Cefepime dose on 7/3/2025 at 10:56 a.m. This finding was verified with the House Supervisor.
-On 7/3/2025 at 2:02 p.m. Patient 22 received Cefepime. Total delay of three hours and 6 minutes from the scheduled dose (10:56 a.m.).

During the same interview on 8/6/2025 at 2:59 p.m. with the house supervisor (HS), the HS stated, "I am unable to determine the reason for Cefepime not given as scheduled."

During an interview on 8/6/2025 at 3:35 p.m. with HS, the HS stated, the expectation was for nurses to administer antibiotics as scheduled, its implication had to do with effectiveness of medication for the patient.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications" revised 5/2024, the P&P indicated, "the administration of each dose of medication shall be accurately recorded in the patient's electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted. The appropriate times for medication administration may be established by the pharmacy and therapeutic committee. The committee may determine guidelines for the correct and appropriate times of administration of medication in response to the prescribers' orders."

2.b. During a review of Patient 22's "Medication Orders," dated 6/30/2025, the Medication Orders record indicated a physician order for Octreotide (medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin) 1000 microgram (mcg-unit of measurement) 5 milliliter (ml-unit of measuring fluid) per hour, continuously (without interruption) intravenously (IV-through the vein).

During a concurrent interview and record review on 8/6/2025 at 3:25 p.m. with the house supervisor (HS), Patient 22's "Medication Administration" record, dated 6/30/2025 through 7/13/2025, for Octreotide, was reviewed. The Medication Administration record indicated the following:
-On 7/2/2025, no documentation of Octreotide administration.
-On 7/8/2025, no documentation of Octreotide administration.
-On 7/9/2025, no documentation of Octreotide administration.
-On 7/11/2025, no documentation of Octreotide administration.
-The HS stated that medication should be given as ordered to ensure 24-hour coverage was effective.

During a review of Patient 22's "Physician Progress Note," dated 7/3/2025, the progress note indicated that the physician made the primary nurse aware that the continuous IV medication (Octreotide) was off and the order should have remained active. The progress note further indicated the physician requested for medication (Octreotide) to be continued as ordered.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications" revised 5/2024, the P&P indicated, "the administration of each dose of medication shall be accurately recorded in the patient's electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted. The appropriate times for medication administration may be established by the pharmacy and therapeutic committee. The committee may determine guidelines for the correct and appropriate times of administration of medication in response to the prescribers' orders."

3. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with Clinical Nurse Supervisor (CNS) 5, CNS 5 reviewed Patient 9's medical record and stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves).

During a review of Patient 9's Medication Orders, dated 4/7/2025, the orders indicated to give Morphine Sulfate 4 mg IV (in the vein) every three (3) hours as needed for severe pain (7-10).

During a review of Patient 9's Medication Administration Record (MAR), dated 4/11/2025 at 9:12 p.m., the MAR indicated Patient 9 received 4 mg of Morphine for a pain level of 6/10 on FLACC scale.

During the same concurrent interview and Medication Administration record review on 8/7/2025 at 1:50 p.m. with Clinical Nurse Supervisor (CNS) 5, CNS 5 said that on 4/11/2025 at 9:12 p.m., Patient 9 received 4 milligrams (mg, a unit of measure) of Morphine (a powerful opiate pain reliever used to treat moderate to severe pain) for a pain level of 6/10 (moderate pain) using the FLACC scale (a behavioral observation tool used to assess pain in children and non-verbal patients who cannot communicate their pain). CNS 5 also verified that Morphine was ordered for severe pain (7/10). CNS 5 confirmed that Norco (prescription painkiller that combines hydrocodone, an opioid analgesic, and acetaminophen, a non-opioid analgesic) was prescribed for moderate pain (4 - 6/10). CNS 5 stated Patient 9 was overmedicated (since Patient 9 received Morphine which was indicated for severe pain; Patient 9 only had moderate pain of 6/10 and should have received Norco and not Morphine) and did not receive the correct medication as ordered by the physician.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration (Management)," dated 1/2023, the P&P indicated the following: "4. Prior to administration, the 6 R's must be verified. 4.a., Right drug - verify that the medication selected for administration is the correct one based on the medication order ..."

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

1. Ensure a discharge summary (a document that provides a concise overview of a patient's hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) was promptly completed, within 10 days of discharge, as per the facility's policy and procedure regarding Medical Records, for one of 30 sampled patients (Patient 8).

This deficient practice resulted in Patient 8's discharge summary being completed 15 days after discharge, which can negatively affect patient safety and continuity of care.

2. Ensure documentation in the medical record was accurate, for one of 30 sampled patients (Patient 9), when Patient 9's VTE (Venous Thromboembolism, blood cloth forms in a vein, usually deep in the legs) Assessment inaccurately indicated medicinal prophylaxis (medication to prevent a condition) to prevent blood clot formation, had been ordered for Patient 9 on 4/7/2025.

This deficient practice resulted in an inaccurate description of interventions to prevent blood clot formation for Patient 9 and had the potential for not implementing additional interventions to prevent blood clots.

Findings:

1. During a concurrent interview and record review on 8/7/2025 at 12:28 p.m. with the Director of Medical Records (DMR), the DMR stated that the discharge summary (a document that provides a concise overview of a patient's hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) should be completed within 10 days after patients were discharged. The DMR verified that Patient 8 was discharged on 6/5/2025 and the discharge summary was completed on 6/20/2025, fifteen (15) days after discharge.

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/3/2025, the H&P indicated the following: Patient 8 was admitted to the facility on 6/3/2025 for shortness of breath (being unable to breathe normally) and leg swelling.

During a review of Patient 8's Discharge Order, dated 6/5/2025 at 2:05 p.m., the Discharge order indicated to discharge to shelter via Uber (a transportation network company that provides a platform for users to request rides), continue home medications.

During a review of Patient 8's nurse's note, dated 6/5/2025 at 3:32 p.m., the nurse's note indicated Patient 8's daughter (FM 1) was in patient's (Patient 8) room when the discharge order news was relayed to Patient 8. FM 1 drove Patient 8 home.

During a review of Patient 8's Discharge Summary, dated 6/20/2025, the Discharge Summary indicated the following: Patient 8 was admitted on 6/3/2025 and discharged on 6/5/2025. Patient 8 was in need of diuresing (elimination of urine and excess body fluid) due to his dependent edema (swelling that occurs in the lower parts of the body due to the effects of gravity) and pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) noted. Patient 8 needed further evaluation. Unfortunately, Patient 8 was discharged from the hospital in error. Upon realizing this, a call was immediately made to the patient and family to instruct Patient 8 to return to the hospital immediately or go to the nearest hospital available for medical attention.

During a review of the facility's policy and procedure (P&P) titled, "Medical Record, Content Of," dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient's medical status in such a manner as to allow another practitioner to assume care of the patient at any time. Discharge Summary / Transfer Summary / Death Summary: All inpatient medical records, regardless of length of stay, must have a discharge summary/death summary or transfer summary completed within 10 days after the patient's discharge, death, or transfer.

During a review of the facility's policy and procedure (P&P) titled, "Medical Record, Content Of," dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient's medical status in such a manner as to allow another practitioner to assume care of the patient at any time. It is the responsibility of the medical staff and other hospital care providers to document timely and accurately all treatment and care provided, all diagnosis reached and the outcomes of these processes in accordance with relevant laws, regulations, and accreditation standards.

2. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, Patient 9's medical record, was reviewed. CNS 5 stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves).

During the same interview on 8/7/2025 at 1:50 p.m. with the CNS 5, CNS 5 stated Patient 9's VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment indicated Patient 9 was at high risk of developing a blood clot. The VTE assessment also indicated that SCD (leg squeezers) had been applied and medicinal prophylaxis (medication to prevent blood clot formation) had been ordered. CNS 5 verified that no medication to prevent blood clots had been ordered on 4/7/2025 for Patient 9 and the documentation was inaccurate. CNS 5 stated Patient 9 just had surgery and medications to prevent blood clots should be avoided at this time.

During a review of Patient's History and Physical (H&P), dated 4/7/2025, the H&P indicated Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone to relieve pressure on the spinal cord or nerves).

During a review of Patient 9's "VTE Assessment," dated 4/7/2025 at 6:25 a.m., the VTE Assessment indicated a score of 10 (high risk of develop blood clot). SCD (Sequential Compression Device, leg squeezers, used to improve circulation and prevent blood clots) applied. Medicinal prophylaxis (preventative treatment) ordered: Yes. CNS 5 verified that no medicinal prophylaxis was ordered, and the documentation was incorrect.

During a review of Patient 9's Physician's Orders, dated 4/7/2025, there was no medicinal prophylaxis ordered for Patient 9. This was verified by CNS 5.

During a review of the facility's policy and procedure (P&P) titled, "Medical Record, Content Of," dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient's medical status in such a manner as to allow another practitioner to assume care of the patient at any time. It is the responsibility of the medical staff and other hospital care providers to document timely and accurately all treatment and care provided, all diagnosis reached and the outcomes of these processes in accordance with relevant laws, regulations, and accreditation standards.

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 12), nursing documentation accurately reflected Patient 12's Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) assessment (evaluation) being completed in the "Infectious Disease Bundle (set of questions related to invasive tubes necessary for patient care)," in accordance with the facility's policy regarding nursing documentation.

This deficient practice had the potential for Patient 12 to not receive the appropriate evaluation and medical care.

Findings:

During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/29/2025, the H&P indicated Patient 12 was admitted to the facility for being less responsive (a reduction in a person's ability to react to stimuli, whether verbal, physical, or environmental), had a left side facial droop (sagging), and was leaning towards the left side. Patient 12's medical history included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperlipidemia (HLD, high concentration of fat in the blood), Atrial Fibrillation (irregular heartbeat) and stroke (loss of blood flow to the brain).

During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 12's order for "Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) Line Insertion," dated 7/30/2025, was reviewed. Patient 12 needed the PICC line for poor intravenous (IV, into the vein) access and for fluids (hydration) and antibiotics (medication used to fight infection).

During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, Patient 12's "IV or Invasive Line Bundle," dated 7/30/2025, was reviewed. The record indicated Patient 12 had a PICC and was assessed (evaluated) on 7/30/2025 starting at 12:30 p.m. The record further indicated Patient 12 had the PICC on 7/31/2025 and 8/1/2025 and was assessed every four hours.

During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, Patient 12's "Infectious Disease Bundle (set of questions related to tubes or IVs that go into the patient and can cause infection)," dated 7/30/2025 to 8/1/2025, was reviewed. The record indicated "No" was marked under the question "Does patient have central line?" After marking "No," the next set of questions were about a Foley Catheter (tube that goes into the bladder to drain urine). The record indicated the following:
-On 7/30/2025 at 9:00 p.m., "No" was marked under the question "Does patient have central line?" No further questions related to a central line were present.
-On 7/31/2025 at 9:30 a.m. and at 9:00 p.m., "No" was marked under the question "Does patient have central line?" No further questions related to a central line were present.
-On 8/1/2025 at 9:00 a.m., "No" was marked under the question "Does patient have central line?" No further questions related to a central line were present.
-On 8/1/2025 at 9:00 p.m., the record indicated "Yes" was marked under "Does the patient have central line." Additional questions related to the central line were included such as, "Is central line still needed; Aseptic (clean) technique used for insertion, dressing changes; insertion site covered with transparent, semi-permeable dressing (special tape that covers the insertion site); scrubbed access port (where fluids and medication is put into) with antiseptic (cleaning agent) before each use." CNS 1 acknowledged Patient 12's "Infectious Disease Bundle" was not documented accurately.

During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, CNS 1 stated nurses needed to document under the "Infectious Disease Bundle" to ensure interventions (tasks) were carried out. CNS 1 also stated it was important to document correctly for the nurses to not miss anything, and the expectation was that everything should be completed.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Documentation," dated 1/2025, the P&P indicated, "The Licensed Nurse (RN/LVN) will document the nursing care provided using the nursing process ...Documentation will include implementation of physician orders & nursing actions, clinical observations & outcomes."

Based on interview and record review the facility failed to ensure that for one of 30 sampled patients (Patient 2), the attending physician communicated and documented the outcome of the hospitalization, including follow-up care and provisions for post-hospital care (after hospital care) such as any upcoming appointments, patient care needs, durable medical equipment (DMEs such as wheelchair), and plans for ongoing care by providers like home health services, in accordance with the facility's policy regarding "Medical Rules and Regulations (R&R)."

This deficient practice resulted in unmet care needs for Patient 2, when Patient 2 was discharged with no wheelchair and no means for mobility to follow-up on necessary appointments, thus potentially compromising Patient 2's safety and increasing risk of readmission and complications.

Findings:

During an interview on 8/7/2025 at 1:03 p.m. with Patient 2's family member (FM), the FM stated that during Patient 2's admission at the facility, the attending physician rarely communicated the plan of care (a comprehensive document that outlines a patient's health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey) with the family. The FM also reported that the facility attempted to discharge Patient 2 multiple times without having the attending physician speak with the family prior to placing the discharge order. Additionally, the FM said that the physician never communicated with the family that Patient 2 could not walk and required a wheelchair. FM 1 said that after Patient 2 was discharged home via ambulance, Patient 2 had no means of mobility or transportation to attend appointments, as the facility discharged Patient 2 without arranging for a wheelchair at home.

During a review of Patient 2's History and Physical (H&P, a comprehensive assessment of a patient's health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2026 due to abdominal pain and nausea (the urge to throw up).

During an interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ stated that when Patient 2 was admitted to the facility on 7/5/2025, Patient 2 was able to walk with a walker. However, based on the physical therapy (PT) evaluation, dated 7/14/2025 (completed after Patient 2 underwent surgical hernia [a condition where an internal organ or tissue bulges through a weak spot in the surrounding muscle or tissue] repair), Patient 2 could no longer walk and was significantly below functional baseline (Patient 2's usual level of independence and mobility).

During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said that the PT Evaluation indicated that there was no recommended discharge DME (Durable Medical Equipment) need, because Patient 2 confirmed ownership of a wheelchair. However, the PT Evaluation also indicated that Patient 2 "was a poor historian and confused, and wheelchair ownership may need to be confirmed with the son," (which was not done). The DDQ also said that the physician (MD 2) did not order a wheelchair (DME) for Patient 2 prior to discharge.

During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the following regarding case management (a collaborative process focused on coordinating patient care to ensure efficient, effective, and safe transitions through the healthcare system) and discharge planning (a coordinated process of preparing patients to leave the hospital and transition to the next level of care, whether that's home, a rehabilitation facility, or another setting) for Patient 2, "The case management (CM) team responsible for the patient's (Patient 2) insurance group was involved and participated in rounds (a structured process where medical professionals visit patients to assess their condition, review their care plan, and address any needs) with the physician; all relevant medical records for Patient 2 were faxed to the medical insurance group CM.

During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the CM team from the insurance group was responsible for following up on the DME needs for Patient 2. The DDQ explained that the facility was not contracted with the medical group that insured Patient 2, and the CM team from that group did not share the information about communications or decision made between the case management team and the physician. "For instance, after entering an order for home health services post-discharge and communicating this to the insurance group, the facility's case management had no way of knowing if the home health services were arranged or set-up for the patient (Patient 2)."

During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said, "I review physical therapy recommendations before discharge. For example, if a patient needs a walker, I place an order for discharge planning department, and then they identify the need for a durable medical equipment (DME). The discharge planning team will communicate this need to the contracted insurance case management (CM) to arrange for the DME, but they (referring to the contracted insurance CM) do need to have an order for a walker to arrange for it."

During the same interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said the following regarding communication requirements with patients and families: "I communicate with patients and families daily. I discuss the plan of care, goals of care, and prognosis ... I document to the best of my ability, and documenting the communication in a patient's medical record is a medical record-keeping requirement." MD 2 also said that during Patient 2's admission, MD 2 documented communication with Patient 2's son in the progress notes.

During a review of Patient 2's Attending physician progress notes, dated 7/6/2025 through 7/18/2025, the notes indicated that on:
7/18/2025-Discharge Summary-there was no documentation of what diet Patient 2 should follow at home, no documentation of DME needs at home, and no documentation of Home Health arrangements being discussed with Patient 2 and/or their family, recorded in the Discharge Summary dated 7/18/2025.

During a record review on 8/7/2025 at 10:30 a.m. with the stroke coordinator (SC) and the Director of Data Quality (DDQ), the Attending physician progress notes, dated 7/6/2025 through 7/18/2025, were reviewed. The SC and the DDQ verified the lack of documentation in Patient 2's discharge summary dated 7/18/2025.

During a review of the facility's "Medical Rules and Regulations (R&R)," dated 10/2024, the Medical R&R indicated, "1.8 Duties of Attending physicians: 1.8-4:Communication with the family regarding the findings of consultants and alterations to the plan of care is the duty of the Attending physician ...1.8.-6: Coordinating the management of the patient with nursing ... 1.8-7: reassessing the patient at regular intervals ....1.8-8: Working closely with case management staff to assure that the record contains sufficient information to support coverage and resource use decisions ...1.8-10: Working with discharge planning to assure a smooth transition of the patient to the appropriate after care setting ...2.1: A medical record will be created and maintained for the purpose of providing continuity of care for the patient ... and healthcare providers .... serving as a method of communication between healthcare providers serving the patient ...providing detailed and organized information for use in case management, quality assessment, and performance improvement...2.6-2: The Attending physician is responsible for documenting a discharge summary for all patients discharged from the hospital....the discharge summary shall contain, at a minimum: discharge instructions to patient and/or family (diet, activity, follow-up)..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 1/2025, the P&P indicated, "Patients have the right to 2. Have effective communication for critical information in a manner you understand ... information from your physician about your diagnosis, prognosis, treatment or consent for treatment, discharge planning ...5. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. The right to effective communication and to participate in the development and implementation of the plan of care ..."

Based on observation, interview, and record review, the facility failed to ensure staff compliance with the facility policies to prevent and control the transmission of infection within the facility, for two of 30 sampled patients (Patient 22 and Patient 28), in accordance with the facility's policies regarding infection prevention and control when:

1. Patient 22's intravenous (IV, administered through the vein) tubing (known as "piggyback," a flexible tube that administers medication) was not labeled with a date for change of IV tubing and the IV tubing was looped around itself connected to its distal port.

This deficient practice had the potential for Patient 22 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and/or improperly capped IV ports.

2. Patient 28's purewick (external device that uses suction to remove urine) was not kept off the floor, in accordance with basic infection control measures.

This deficient practice had the potential for germs to travel up the tubing from the floor into the bladder (a muscular, hollow organ that serves as a reservoir for urine), potentially leading to infection.

Findings:

1. During a review of Patient 22's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 6/27/2025, the H&P indicated, Patient 22 was admitted to facility for altered mental status (change in person's consciousness [a person's state of awareness and responsiveness to their surroundings], awareness and cognitive function [the mental processes involved in acquiring, processing, and using information]) after being found unresponsive (not reacting or responding to stimuli).

During a concurrent observation and interview on 8/5/2025 at 11:42 a.m., with Patient 22's Primary Nurse (RN) 3 and the Charge Nurse (CN) 3, on the medical floor unit, in Patient 22's room, there was an unlabeled, with no date of change IV piggyback (a flexible tube that administers medication) hanging, looped on itself with the entry port (section that attaches to patient) attached to the distal port (port normally capped if unused or connected to another IV line). The CN 3 stated it was not acceptable for the tubing to be connected or looped to itself through the distal port, it was not sanitary. The CN 3 further stated, the facility had caps with alcohol used to cover and protect the IV tubing or IV lines for purposes of infection prevention.

During an interview on 8/5/2025 at 11:45 a.m. with the CN 3, the CN 3 demonstrated the light and dark "Disinfecting Caps for Needle- free Valves" which were used to cover the IV ports and prevent infection. The CN 3 stated these caps were provided and made available to nurses and they hang from the IV pole for easy access when needed.

During an interview on 8/7/2025 at 3:25 p.m. with the Clinical Educator (CE) and the Director of Nursing (DN), CE stated nurses were expected to label IV tubing with date of next tubing change and initials, as well as to cap every unused open port with the disinfectant caps provided by facility. The DN stated that the expectation for nurses was to cap every port for prevention of infection, and it would not be acceptable for nurses to loop IV tubing on itself as this (the use of disinfectant caps for IV ports) was a standard nursing practice. The CE and DN both stated dating the IV tubing and capping the IV port were part of educational in-services provided to nurses upon hire.

During a review of the facility's policy and procedures (P&P) titled, "Infection control Policy and procedures Manual," revised 4/2024, the P&P indicated, "Tubing change label all lines and pumps with the IV medications and solutions that are infusing. The policy and procedures tables for line flushing, blood withdrawal, cap change and line removal must be strictly adhered to."

2. During a review of Patient 28's "History and Physical (H&P)," dated 7/31/2025, the H&P indicated Patient 28 was admitted to the facility for shortness of breath (being unable to breathe normally). Patient 28 had a medical history of Atrial Fibrillation (irregular heartbeat), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and renal (kidney) disease.

During a concurrent observation and interview on 8/5/2025 at 11:20 a.m., with Registered Nurse (RN) 4, in Patient 28's room, Patient 28's Purewick (external device that sucks up urine) tubing (plastic tube that connects to the patient), was observed on the floor. RN 4 confirmed Patient 28 had a purewick and the tubing was on the floor. RN 4 stated the tubing should not be on the floor and RN 4 moved the tubing off the floor.

During an interview on 8/7/2025 at 4:15 p.m. with the ST-Segment Elevation Myocardial Infarction (STEMI, heart attack [blood vessels to the heart are blocked and not receiving enough oxygen]) Coordinator (MIC), the MIC stated patient tubing should not be on the floor. MIC stated it was an infection control issue because the tubing was touching the dirty floor, and bacteria could get into the patient from the tubing.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention/Control," dated 4/2025, the P&P indicated, "The scope of the Infection Prevention and Control program for (name of the facility) includes the prevention, surveillance, and control of infection ...The purpose of the infection prevention and control program is to provide a safe and healthful environment for all who enter this facility."

Based on interviews and record review, the facility failed to ensure that a physician order for Neutropenic Precaution (isolation guidelines designed to protect patients with weak immunity) was implemented in a timely manner, for one of 30 sampled patients (Patient 19), who was immunocompromised (having a weakened immune system reducing ability to fight infections).

This deficient practice had the potential for Patient 19 being exposed to hospital acquired infections potentially leading to serious illness and/or death.

Findings:

During a review of Patient 19's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 2/7/2025, the H&P indicated, Patient 19 was admitted for generalized weakness with a medical history of Myeloid leukemia (aggressive form of blood cancer). Patient 19's admitting white blood cell (WBC-cells that fight infection. Normal count ranging from 4.5 to 11) count was 1.0.

During an interview on 8/5/2025 at 1:36 p.m. with the House supervisor (HS), the HS stated nurses knew to implement Neutropenic Precautions (isolation guidelines designed to protect patients with weak immunity) by reading the physician plan of care, and nurses were expected to put a sign up letting other staff/visitors know that patient was on Neutropenic Precautions which meant wearing a mask, gloves and gown when entering patient room and discouraging visitors to visit when sick.

During an interview on 8/5/2025 at 2:16 p.m. with the Clinical Supervisor (CNS) 1, CNS 1 added, nurses could implement Neutropenic Precautions and follow up with a physician order for Neutropenic Precaution.

During a concurrent interview and record review on 8/5/2025 at 2:18 p.m. with the House Supervisor (HS), Patient 19's "Orders," dated 2/7/2025, was reviewed. The record indicated, a physician order/instruction was given on 2/7/2025 at 4: 13 p.m., to place Patient 19 on Neutropenic Precautions/isolation.

During the same concurrent interview and record review on 8/5/2025 at 2:18 p.m., Patient 19's "Care Activity-Assessment," dated 2/7/2025 to 2/8/2025, were reviewed. The record indicated the following:
-On 2/7/2025 at 8:00 p.m., Nurse documented Patient 19 was not on Neutropenic Precautions/isolation.
-On 2/8/2025 at 8:00 a.m., Nurse documented Patient 19 was placed on Neutropenic precautions/isolation. A total of 15 hours and 47 minutes after the physician order was given.
-The HS stated, "I don't know why nurse documented no isolation," but the documented implementation of the Neutropenic Precaution was late.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention/Control Policy and Procedure Manual," revised 2/2025, the P&P indicated, "Neutropenic/Reverse Isolation Precautions- Place allogeneic hematopoietic stem cell transplant (HSCT)patients in a protective Environment as described in "Guidelines to Prevent Opportunistic Infections in HSCT patients," the Guidelines for Environmental infection Control in Health care Facilities," and the "Guidelines for Preventing Health-Care Associated Pneumonia, 2003" to reduce exposure to environmental fungi. When Neutropenic precautions are put into place: perform scrupulous hand hygiene and assist the patient to do the same, Do not allow roommates, visitors or staff with infections into room, no flowers or potted plants in the room, keep sinks and bathrooms fixtures dry, restrict uncooked fruits which cannot be unpeeled, uncooked vegetables(especially salads) and uncooked meats and fish from the diet. Document the type of isolation used in the medical record..."