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Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights (The Patient's Bill of Rights is a document that outlines what patients can expect when receiving health care) was met as evidenced by:

1. The facility failed to ensure postings/notice of Patient Rights were posted at three of three registration windows (Window 1, 2 and 3) in the facility's admitting department (a department that handles the initial process of admitting patients, collect patient's information including demographics, insurance details, and process for proper medical care), where the notice of Patient Rights can be seen and read by 31 of 31 sampled patients, in accordance with the facility's policy regarding Patient Rights and Responsibilities.

This deficient practice had the potential for patients not knowing and understanding their rights as patients and allow them to ask questions. (Refer to A-0116)

2. The facility failed to ensure a resolution letter was issued for two of 31 sampled patients (Patient 11 and Patient 31), in response to a grievance (a written or verbal complaint that is made to the hospital by a patient, or patient representative that cannot be resolved promptly by staff) submitted by both patients (Patients 11 and 31), in accordance with the facility's policy and procedure regarding the grievance process.

This deficient practice resulted in the violation of Patient 11's and Patient 31's rights when they (Patients 11 and 31) were not made aware of the outcome of the investigation pertaining to the grievance they (Patients 11 and 31) filed with the facility and not being informed what action they could take if they were not satisfied with the resolution. (Refer to A-0123)

3. The facility failed to ensure facility staff assisted two of 31 sampled patients (Patient 11 and Patient 13) on how to formulate and execute advance directives (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values), in accordance with the facility's policy and procedure regarding advance directives when:

3.a. The social worker (SW 2) did not provide education and information about advance directives to Patient 11 per Patient 11's request.

This deficient practice resulted in Patient 11 not receiving any information on how to formulate an advance directive during the hospitalization. In addition, this deficient practice did not preserve Patient 11's right to self-determination at any time Patient 11 was unable or lacked immediate capacity to state his or her wishes for medical treatment. (Refer to A-0132)

3.b. The facility staff failed to obtain a copy of advance directive and keep in Patient 13's medical record for reference.

This deficient practice resulted in Patient 13's advance directive not being readily available in Patient 13's medical record, which had the potential to result in Patient 13's advance directive not being executed and Patient 13's designee not being notified to make medical decisions when needed. (Refer to A-0132)

4. The facility failed to ensure that one of one sampled cabinet (Cabinet 1) dedicated for wound care for 22 of 31 sampled patients, containing medical supplies and instruments (in a medical or occupational context, refers to materials that can cause injury, illness, or adverse effects if not handled properly) such as sharp instruments (includes needles, scalpel blades, lancets, etc.) and irrigation solutions (used to cleanse wounds, body cavities, tissues and to flush out debris or prepare sites for further treatment) such as normal saline (a sterile solution of sodium chloride in water used for various medical purposes, including wound irrigation) and betadine (an antiseptic solution containing providing-iodine used for disinfecting skin and surfaces to prevent infection), was securely locked and accessible only by authorized personnel.

This deficient practice had the potential to compromise patients' safety resulting in misuse or mishandling of medical supplies that can be hazardous for patients and visitors in the emergency department (ED, a specialized area within a hospital dedicated to providing immediate medical care). (Refer to A-0144)

5. The facility failed to ensure that facility staff provided a call light device (a device to enable patients to communicate their needs to healthcare staff) for three of 31 sampled patients (Patients 18, 19, and 20), who were in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), in accordance with the facility's policy titled "Scope of Service - Emergency and Trauma Services," which referenced the provision of a safe environment of care.

This deficient practice resulted in Patients 18, 19 and 20 having no means to call for help and had the potential to put the patients at risk for injury such as a fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs), which may result in complications such as fracture (broken bone), bleed, etc. (Refer to A-0144)

6. The facility failed to ensure nursing staff placed a fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) risk magnet outside the patients' door and fall risk wrist band for two of 31 sampled patients (Patient 14 and Patient 17), who were both assessed as moderate risk for fall, in accordance with the facility's policy and procedure regarding fall prevention.

This deficient practice had the potential for other team members not being made aware of Patient 14 and Patient 17's fall risk status, which may lead to delay in providing necessary interventions to prevent Patient 14 and Patient 17 from falling and hurting themselves. (Refer to A-0144)

7. The facility failed to ensure there was a clear description of a patient's behavior to explain restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 31 sampled patients (Patient 16), when nursing staff did not document Patient 16's specific behavior regarding interfering with medical care that warrants the use of restraints to ensure Patient 16's immediate physical safety, in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to result in unnecessary use of restraints, which may lead to physical and psychological harm to a patient such as circulatory and skin problems, loss of strength and mobility, etc. (Refer to A-0185)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

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

1. The facility failed to ensure that nursing staff provided ongoing assessment (the systematic evaluation of patient's health status and needs) and evaluation of the care and treatment provided for one of 31 sampled patients (Patient 1) in the Emergency Department (ED, an area in the hospital dedicated to providing care and treatment for patients experiencing medical emergencies), when Patient 1 started demonstrating a decline in respiratory status (a significant alteration in a patient's clinical status requiring reevaluation and potential intervention), in accordance with the facility's policies regarding Emergency Services- Standards of Care, Patient Assessment and Care Planning, and Nursing Care Model. In addition, nursing staff failed to notify the physician regarding Patient 1's change of condition in respiratory status, in accordance with the facility's policy regarding physician notification of change of condition (a significant and often sudden deviation from a patient's normal or baseline state of health).

These deficient practices had the potential to result in delayed care and treatment for Patient 1, which may have contributed to Patient 1's worsening respiratory status (a serious condition where the lungs cannot provide enough oxygen to the body) leading to subsequent intubation (the medical procedure inserting a tube into the airway to assist with breathing mechanically). (Refer to A-0395)

2. The facility failed to ensure that its nursing staff notified the physician when one of 31 sampled patients (Patient 23) continued to refuse the use of a Sequential Compression Device (SCD, a medical device that helps prevent blood clots by applying gentle pressure to the legs to improve circulation), in accordance with the facility's policy regarding the use of SCDs and physician notification. Patient 23 was identified as high risk for developing a deep vein thrombosis (DVT, a blood clot that forms in a deep vein, usually in the legs, which can cause serious complications if untreated).

This deficient practice resulted in Patient 23 developing a DVT and required surgery to insert an inferior vena cava (IVC) filter (a small metal device implanted in the body's largest veins to prevent blood clots from traveling to the lungs and causing a life-threatening pulmonary embolism [a blood clot in the lung that creates a blockage]). Additionally, this deficient practice had the potential to place other high-risk patients at increased risk for undetected blood clot formation, leading to serious complications, including pulmonary embolism (a condition where a blood clot [embolus] travels from another part of the body, usually the legs [deep vein thrombosis], to the lungs and becomes life threatening), prolonged hospitalization, and the need for additional surgical interventions. (Refer to A-0395)

3. The facility failed to ensure its nursing staff developed individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) and reviewed nursing care plan to evaluate patient's progress for two of 31 sampled patients (Patient 4 and Patient 22), in accordance with facility's policy and procedure regarding care plans when:

3.a. Patient 4 did not have a care plan developed and implemented to address a diagnosis of postoperative (after operation) abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain.

This deficient practice had the potential for Patient 4's pain not to be managed effectively which can negatively impact patient's quality of life, emotional well-being, and recovery. (Refer to A-0396)

3.b. Patient 22 did not have a care plan developed or implemented to address pain management following a head trauma and a 3-centimeter facial wound closure, despite a medical history of musculoskeletal pain and an active order for Fentanyl (a potent pain medication used to treat severe pain).

This deficient practice had the potential to cause inadequate pain management for Patient 22, leading to unnecessary suffering, delayed healing, increased stress, and impaired recovery. (Refer to A-0396)

4. The facility failed to provide proper fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) prevention intervention for two of 31 sampled patients (Patient 14 and Patient 17), when nursing staff did not put a fall risk magnet outside the patients' door and apply yellow wrist band for Patient 14 and Patient 17, to alert team members that both patients were at moderate/high risk for fall, in accordance with the facility's policy regarding fall prevention.

This deficient practice had the potential to result in other team members not being made aware of Patient 14 and Patient 17's fall risk status and may lead to delay in providing interventions to prevent Patient 14 and Patient 17 from falling and hurting themselves. (Refer to A-0398)


5. The facility failed to address the elevated blood pressure (BP, a measure of the force of blood pushing against the walls of blood vessels) of 168/71 mmHg (millimeters of mercury, a unit used to measure blood pressure) for one of 31 sampled patients (Patient 21), who was receiving dialysis treatment (is a medical treatment that removes waste, extra fluids, and toxins from the blood when the kidneys are not functioning properly), in accordance with the physician's order and the facility's policy and procedure titled "Medication Administration and Timing."

This deficient practice resulted in Patient 21's high BP not being treated, which had the potential to cause uncontrolled high BP (hypertension), increasing the risk of stroke (a condition where blood flow to the brain is blocked or there is sudden bleeding in the brain), kidney damage (a condition where that kidneys cannot properly filter waste from the blood), and other serious heart-related complications. (Refer to A-0398)

6. The facility failed to ensure that there was consistent monitoring and documenting of a complete set of vital signs, including respiration rate (the number of breaths a person takes per minute), for one of 31 sampled patients (Patient 21), in accordance with the facility's policy and procedure regarding "Vital Signs."

This deficient practice resulted in missed opportunities to detect potential respiratory distress (when breathing becomes difficult or labored), delayed interventions, and incomplete medical records for Patient 21. Inconsistent vital sign documentation can lead to poor clinical decision-making, lack of timely treatment adjustments, and increased risk of undetected complications such as respiration failure, hypoxia (low oxygen levels in the blood), or worsening of the patient's underlying medical condition. (Refer to A-0398)

7. The facility failed to ensure that its nursing staff conducted and documented a complete pain assessment, including pain level, location, duration, and description of the pain, for one of 31 sampled patients (Patient 22), in accordance with the facility's policy and procedure regarding "Pain Management."

This deficient practice resulted in incomplete clinical records, missed opportunities for appropriate pain management interventions, and potential delays in treatment. Inadequate pain assessment can lead to increased suffering, impaired mobility, delayed healing, and ineffective pain relief, which can negatively impact Patient 22's overall recovery. (Refer to A-0398)

8. The facility failed to ensure timely administration of as-needed (PRN) pain medication for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding "Medication Administration and Timing."

This deficient practice resulted in prolonged suffering and inadequate pain relief for Patient 24. Delayed pain management can lead to increased stress, decreased mobility, impaired recovery, and worsening of the patient's condition. Additionally, this deficient practice had the potential to affect other patients requiring timely pain management by failing to ensure adherence to physician orders and facility policies. (Refer to A-0398)

9. The facility failed to ensure that its nursing staff followed physician orders for blood sugar monitoring for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding blood glucose monitoring and insulin (medication to help regulate blood sugar levels) administration.

This deficient practice resulted in a delay in monitoring Patient 24's blood sugar levels, creating a risk of undetected high or low blood sugar levels, which can lead to serious complications such as hypoglycemia (dangerously low blood sugar), hyperglycemia (dangerously high blood sugar), confusion, dizziness, organ damage, and diabetic ketoacidosis (a life-threatening condition caused be severe high blood sugar). Additionally, this deficient practice had the potential to affect other patients requiring blood sugar monitoring by failing to ensure consistent adherence to physician orders and facility policies. (Refer to A-0398)

10. The facility failed to ensure timely administration of as-needed (PRN) pain medication (Morphine- a strong pain medication that works by blocking pain signals to the brain) for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding "Medication Administration and Timing."

This deficient practice resulted in prolonged suffering and inadequate pain relief for Patient 24. Delayed pain management can lead to increased stress, decreased mobility, impaired recovery, and worsening of the patient's condition. Additionally, this deficient practice had the potential to affect other patients requiring timely pain management by failing to ensure adherence to physician orders and facility policies. (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 and potentially placing patients at risk of not receiving necessary care and treatments

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

1. The facility failed to ensure that the medical records for three (3) of 31 sampled patients (Patient 1, Patient 4, and Patient 22) were completed and promptly filed in the patients' medical records in order to be readily available to the physician and other providers to use in making assessments of Patient 1, Patient 4, and Patient 22's condition and in making decisions on the provision of care/treatment to the patient when:

1.a. Patient 1 had no telemetry strips (graphical representation of a patient's heart rhythm recorded during monitoring with a telemetry system [an automated process that measures and wirelessly transmits data from remote sources to a central location for monitoring and analysis]) filed in Patient 1's electronic medical records (EMR, digital version of paper chart) for the time Patient 1 spent in the Emergency Department (ED, an area in the hospital where patients receive immediate medical care ) from 10/4/2024 to 10/5/2024, in accordance with the facility's regarding patient assessment and care planning documentation.

This deficient practice had the potential for Patient 1's heart rhythm record not to be readily available for review, assessment, and evaluation for cardiac (heart) issues or complications, potentially delaying delivery of timely care and necessary interventions. (Refer to A-0449)

1.b. Patient 4 did not have a documented care plan (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care) developed and implemented to address a diagnosis of postoperative abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 4's pain not to be managed effectively which can negatively impact patient's quality of life, emotional well-being, and recovery. (Refer to A-0449)

1.c. Patient 22 did not have a documented individualized nursing care plan (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care) to assess, manage, and monitor pain, in accordance with the facility's policy regarding care planning.

This deficient practice can lead to breakdowns in communication among healthcare providers, resulting in inconsistent pain assessment, delays in medication administration, and missed opportunities to adjust treatment based on the patient's response. Without a documented pain care plan, nurses, physicians, and other care team members may lack access to critical information regarding Patient 22's pain status, interventions performed, and the effectiveness of treatment. (Refer to A-0449)

2. The facility failed to ensure there was a clear description of patient behavior documented to explain restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 31 sampled patients (Patient 16), when nursing staff did not document what was Patient 16's specific behavior regarding interfering with medical care , that warrants the use of restraints to ensure Patient 16's immediate physical safety, in accordance with the facility's policy regarding restraints use and documentation.

This deficient practice had the potential to result in incomplete medical record that does not reflect Patient 16's need for restraints, which may lead to unnecessary use of restraints and other complications such as circulatory (blood flow) and skin breakdown (when prolonged pressure or friction damages the skin and underlying tissues), etc. (Refer to A-0450)

3. The facility failed to demonstrate that Precedex (dexmedetomidine is a drug used to manage pain and sedation in the Intensive Care Unit [ICU, a specialized hospital ward that provides treatment and monitoring for people who are very ill)] and in the operating room [where surgical procedures are done]) order set was safe to be used on patients outside of the intensive care setting, in accordance with current Food and Drug Administration (FDA, the regulatory agency responsible for overseeing the safety and efficacy of mediation and medical devices) guidelines. In addition, the facility failed to demonstrate how the use of Precedex for an extended period (exceeding 24 hours recommended by the FDA period), when used for off-label indications (medications for an indication, or using a dosage or dosage form, that has not been approved by the FDA) was consistent with indications and usage for Precedex as outlined in nationally recognized and evidence-based (a decision-making approach that integrates the best available research evidence with clinical expertise and patient values to improve healthcare outcomes) guidelines.

This deficient practice had the potential to compromise patient safety, placing patients at risk for potential side effects and complications associated with prolonged use of Precedex when the Precedex order set was not administered in a controlled ICU environment where patients were closely monitored. (Refer to A-0457)

4. The facility failed to ensure that the medical records for three of 31 sampled patients (Patient 10, Patient 21, and Patient 22) contained the pertinent medical information documented and filed in the patients' medical charts so that the health care staff involved in the patients' care could access and retrieve the information in order to monitor the patients' condition when:

4.a. Patient 10 had no copies of transfer documents retained and uploaded in Patient 10's electronic medical record (EMR, digital version of paper chart) to demonstrate that specific consistent information was forwarded to the receiving providers to ensure continuity of care and services when Patient 10 was transferred to another facility, in accordance with the facility's policy regarding patient transfers.

This deficient practice had the potential for Patient 10's essential medical information not to be communicated effectively, potentially leading to gaps in Patient 10's care, medication errors, and delays in necessary interventions. (Refer to A-0467)

4.b. Patient 10 had no timely discharge summary (a comprehensive medical document that summarizes a patient's hospitalization, outlining their diagnosis, treatment, progress, and recommendations for ongoing care, ensuring a smooth transition to the next level of care) filed prior to Patient 10's discharge and transfer to another facility, in accordance with the facility's policy regarding patient transfers.

This deficient practice had the potential for Patient 10's important medical information contained in the discharge summary to be missing from the patient's (Patient 10's) medical records potentially compromising continuity of care increasing Patient 10's risks to adverse health outcomes. (Refer to A-0467)

4.c. Patient 21's vital sign assessment was incomplete, did not include respiration rate (the number of breaths a person takes per minute) in accordance with the facility's policy and procedure regarding "Vital Signs" and Medical Record Documentation Standards

This deficient practice resulted in missed opportunities to detect potential respiratory distress (when breathing becomes difficult or labored), delayed interventions, and incomplete medical records for Patient 21. Inconsistent vital sign documentation can lead to poor clinical decision-making, lack of timely treatment adjustments, and increased risk of undetected complications such as respiratory failure, hypoxia (low oxygen levels in the blood), or worsening of the patient's underlying medical condition. (Refer to A-0467)

4.d. Patient 22's pain assessment was not performed consistently and documented as a complete pain assessment, including pain level, location duration, and description of the pain, in accordance with the facility's policy and procedure regarding "Pain Management."

This deficient practice resulted in incomplete clinical records, missed opportunities for appropriate pain management interventions, and potential delays in treatment. Inadequate pain assessment can lead to increased suffering, impaired mobility, delayed healing, and ineffective pain relief, which can negatively impact Patient 22's overall recovery. (Refer to A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on observation, interview and record review, the facility failed to ensure postings/notice of Patient Rights were posted at three of three registration windows (Window 1, 2 and 3) in the facility's admitting department (a department that handles the initial process of admitting patients, collect patient's information including demographics, insurance details, and process for proper medical care), where the notice of Patient Rights can be seen and read by 31 of 31 sampled patients, in accordance with the facility's policy regarding Patient Rights and Responsibilities.

This deficient practice had the potential for patients not knowing and understanding their rights as patients and allow them to ask questions.

Findings:

During a concurrent observation and interview on 3/5/2025 at 11:43 a.m. with the Patient Access Representative (PAR 1) at the facility's admitting department (a department that handles the initial process of admitting patients, collect patient's information including demographics, insurance details, and process for proper medical care), there were three registration windows with no Patient Rights poster at each window. PAR 1 stated the following: someone changed the posters couple months ago when painting the wall. There should be Patient Rights poster in English and Spanish at each registration window so patients would know about their rights.

During an interview on 3/7/2025 at 10:55 a.m. with the Patient Access Representative (PAR 4), PAR 4 stated the following: there was a leak in the admitting department and the department had some painting done. It was possible someone removed the Patient Rights posters. It was required to post the Patient Right posters at every registration window so that patients could reference and ask questions. They (facility staff) would put back the posters.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 2/2025, the P&P indicated, "Consistent with Federal and State law, [the facility] informs each patient, or when appropriate, the patient's representative of the patient's rights and responsibilities, in advance of furnishing or discontinuing patient care whenever possible ... Patient Rights will be posted in appropriate access areas of the hospital ... References ... This Patient Rights listed in this document incorporate the requirements of the: Title 22, California Code of Regulations, Section 70707 ..."

During a review of the State regulation titled, "Title 22, California Code of Regulation Section 70707," undated, the state regulation indicated, "70707 Patients' Rights ... (b) a list of these patients' rights shall be posted in both Spanish and English in appropriate places within the hospital so that such rights may be read by patients."

Based on interview and record review, the facility failed to ensure a resolution letter was issued for two of 31 sampled patients (Patient 11 and Patient 31), in response to a grievance (a written or verbal complaint that is made to the hospital by a patient, or patient representative that cannot be resolved promptly by staff) submitted by both patients, in accordance with the facility's policy and procedure regarding the grievance process.

This deficient practice resulted in the violation of Patient 11's and Patient 31's rights when they (Patients 11 and 31) were not made aware of the outcome of the investigation pertaining to the grievance they (Patients 11 and 31) filed with the facility and not being informed what action they could take if they were not satisfied with the resolution.

Findings:

1. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/23/2024, the H&P indicated, Patient 11 was admitted to the facility with diagnoses including but not limited to upper gastrointestinal (part of the digestive system which includes the mouth and esophagus) bleed, hematemesis (vomiting blood), and acute (new onset) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). The H&P also indicated Patient 11 was intubated (the process of inserting a tube into the mouth or nose and then into the airway to support breathing) in the Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care) on 2/23/2024 for airway protection.

During an interview on 3/7/2025 at 2:44 p.m. with the Compliance Officer Risk Manager (CORM), CORM stated the facility would send a grievance (a written or verbal complaint that is made to the hospital by a patient, or patient representative that cannot be resolved promptly by staff) notification letter to contact the complainant within first ten (10) days to notify him or her that facility would need more time up to thirty (30) days to investigate if the facility could not resolve the grievance within 10 days. CORM stated the facility would issue a grievance resolution letter once the investigation was over to inform the complainant what the facility did to address the grievance, result of the grievance and what patients could do if they were not satisfied with the resolution, such as escalating it to regulatory agencies.

During a concurrent interview and record review on 3/7/2025 at 3:08 p.m. with the Compliance Officer Risk Manager (CORM), the facility's grievance record titled, "Feedback (grievance record)," dated 3/5/2024, was reviewed. The grievance record indicated, Patient 11's representative filed a grievance via telephone on 3/4/2024 for Patient 11's missing tooth which was noticed after Patient 11 was extubated (removing a tube from a patient's airway allowing the patient to breathe on their own) at the facility. CORM stated there was no grievance resolution letter issued to Patient 11. CORM stated the facility should have issued a grievance resolution letter to Patient 11.

During a review of the facility's policy and procedure titled, "Grievance Process," dated 3/2025, the P&P indicated, "It is the policy of [the facility] that patient grievances be resolved in a timely, appropriate and reasonable manner in compliance with Centers for Medicare and Medicaid Services (CMS) guidelines ... The Patient Experience Department will acknowledge receipt of complaint within seven (7) business days and notify the patient when a resolution may be expected ... Upon resolution of the grievance but not longer than 30 days after receipt, a written response will be sent to the patient or representative notifying them of the outcome. The notice will include the contact information of a person at [the facility], the steps taken to investigate the grievance, the date and the outcome or resolution to the grievance ... The grievance resolution letter should include information on filing a formal complaint with the appropriate regulatory, certification, or accreditation agencies."

2. During a review of Patient 31's "Face sheet (face sheet, document that provides a patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance)," dated 2/15/2025, the face sheet indicated, Patient 31 was admitted to the facility with diagnosis of third-degree heart block (a condition where the electrical impulse generated in the upper chamber of the heart fail to reach the lower chambers of the heart) and status post implanted chronotropic device (a device that helps manage or address heart rate and rhythm).

During an interview on 3/7/2025 at 2:44 p.m. with the Compliance Officer Risk Manager (CORM), CORM stated the facility would send a grievance notification letter to contact the complainant within first ten (10) days to notify him or her that facility would need more time up to thirty (30) days to investigate if the facility could not resolve the grievance within 10 days. CORM stated the facility would issue a grievance resolution letter once the investigation was over to inform the complainant what the facility did to address the grievance, result of the grievance and what patients could do if they were not satisfied with the resolution, such as escalating it to regulatory agencies.

During a concurrent interview and record review on 3/7/2025 at 3:12 p.m. with the Compliance Officer Risk Manager (CORM), the facility's grievance record titled, "Feedback (grievance record)," dated 2/19/2025, was reviewed. The grievance record indicated, Patient 31 filed a grievance via telephone on 2/19/2025 for missing card or booklet which should have been sent with Patient 31 upon discharge after Patient 31 received a pacemaker (a small implantable device that regulates heart rhythm). The grievance record also indicated, "Patient (Patient 31) came to surgery and received information about the pacemaker... Patient (Patient 31) was satisfied with information handed to him." CORM stated as of 3/7/2025, there was no grievance resolution letter issued to Patient 31 regarding the grievance Patient 31 filed on 2/19/2025 (12 business days).

During a review of the facility's policy and procedure titled, "Grievance Process," dated 3/2025, the P&P indicated, "It is the policy of [the facility] that patient grievances be resolved in a timely, appropriate and reasonable manner in compliance with Centers for Medicare and Medicaid Services (CMS) guidelines ... The Patient Experience Department will acknowledge receipt of complaint within seven (7) business days and notify the patient when a resolution may be expected ... Upon resolution of the grievance but not longer than 30 days after receipt, a written response will be sent to the patient or representative notifying them of the outcome. The notice will include the contact information of a person at [the facility], the steps taken to investigate the grievance, the date and the outcome or resolution to the grievance ... The grievance resolution letter should include information on filing a formal complaint with the appropriate regulatory, certification, or accreditation agencies."

Based on interview and record review, the facility failed to ensure facility staff assisted two of 31 sampled patients (Patient 11 and Patient 13) on how to formulate and execute advance directives (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values), in accordance with the facility's policy and procedure regarding advance directives when:

1. The social worker (SW 2) did not provide education and information about advance directives to Patient 11 per Patient 11's request.

This deficient practice resulted in Patient 11 not receiving any information on how to formulate an advance directive during the hospitalization. In addition, this deficient practice did not preserve Patient 11's right to self-determination at any time Patient 11 was unable or lacked immediate capacity to state his or her wishes for medical treatment.

2. The facility staff failed to obtain a copy of advance directive and keep in Patient 13's medical record for reference.

This deficient practice resulted in Patient 13's advance directive not being readily available in Patient 13's medical record, which had the potential to result in Patient 13's advance directive not being executed and Patient 13's designee not being notified to make medical decisions when needed.

Findings:

1. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/23/2024, the H&P indicated, Patient 11 was admitted to the facility with diagnoses including but not limited to upper gastrointestinal (part of the digestive system which includes the mouth and esophagus) bleed, hematemesis (vomiting blood), and acute (new onset) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). The H&P also indicated Patient 11 was intubated (the process of inserting a tube into the mouth or nose and then into the airway to support breathing) in the Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care) on 2/23/2024 for airway protection.

During a concurrent interview and record review on 3/5/2025 at 3:18 p.m. with the Nurse Manager (NM 1) of Intensive Care Unit (ICU, specialized hospital ward that provides treatment and monitoring for people who are very ill) and Definitive Observation Unit (DOU, hospital unit providing close monitoring care to patients), Patient 11's medical record titled, "Advance Directive (advance directive assessment, questions asked by admitting nurse if patient has an existing advance directive [legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values])," dated 2/23/2024, was reviewed. The advance directive assessment indicated, on 2/23/2024 at 9:15 a.m., Patient 11 did not have an existing advanced directive and was requesting information on advance directive. NM 1 stated when a patient wanted information about advance directives, nursing staff would direct social worker to talk to the patient about advance directives.

During an interview on 3/6/2025 at 10:58 a.m. with the Charge Nurse (CN) 2, CN 2 stated the following: advance directive assessment was part of admission assessment by admitting nurse. It was the admitting nurse's responsibility to ask patient/family about advance directive upon admission. If patient had an advance directive, nurse would ask patient/family to bring a copy to the hospital. If patient did not have an advance directive but would like to obtain more information, nurse would refer the patient to social worker for follow up. The advance directive was to let the facility know who the appointed person would be for the patient if the patient could not make (medical related) decision anymore.

During an interview on 3/6/2025 at 2:03 p.m. with the Registered Nurse (RN) 10, RN 10 stated the purpose of advance directive was for the patient to communicate with the healthcare team the patient's wishes when they could not speak for themselves. RN 10 stated everyone had a right to formulate an advance directive.

During a concurrent interview and record review on 3/6/2025 at 4:28 p.m. with the Social Worker Lead (SW 1), Patient 11's "Social Work Psychosocial (social worker notes, notes written by social worker)," dated 2/23/2024, was reviewed. The social worker notes indicated the following: SW 2 saw Patient 11 on 2/23/2024 and completed the psychosocial assessment. Patient 11 was oriented (a patient is aware of their identity, location, current time, and current situation). The social worker notes did not indicate any discussion about advance directive with Patient 11. SW 1 stated the advance directive discussion was not done during Patient 11's admission. It was the responsibility of the social worker to talk to patients about advance directive.

During a review of the facility's policy and procedure (P&P) titled, "Advance Directive," dated 3/2025, the P&P indicated, "The purpose of this policy was to provide guidance to [the facility] staff related to the patient's right to receive information regarding Advance Healthcare Directives, to formulate advance directives and to have hospital staff implement and comply with the patient's advance directive as required under Federal and State law ... For patient with an existing Advance Health Care Directive, during the admission process the healthcare provider will document the existence of the directive and request a copy. For patient presenting an Advance Health Care Directive and/or valid Power of Attorney for Health Care, hospital staff will photocopy the form with 2 copies and place one copy in the patient's chart, and one copy placed in the tray for Health Information Management (HIM), also known as Medical Records, to scan into the patient's electronic record (EMR) ... Admitted patient that did not have an Advance Healthcare Directive will be given the opportunity to speak to a social worker, if desired, on formulating an advance directive. The nurse will document the patient's request for advance directive information during the admission process which will send an electronic notification to the Social Services department for follow-up."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 2/2025, the P&P indicated, "Consistent with Federal and State law, [the facility] informs each patient, or when appropriate, the patient's representative of the patient's rights and responsibilities, in advance of furnishing or discontinuing patient care whenever possible ... 10. Formulate advance directives. This includes designating a decision maker if patient becomes incapable of understanding a proposed treatment or become unable to communicate wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients' rights apply to the person who has the legal responsibility to make decisions regarding medical care on the patient's behalf."

2. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/20/2024, the H&P indicated, Patient 13 was admitted to the facility with diagnoses including but not limited to subcapital (below the femoral [thigh] head) fracture (broken bone) of neck of left femur (thigh bone) and status post fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs).

During an interview on 3/6/2025 at 10:58 a.m. with the Charge Nurse (CN) 2, CN 2 stated the following: advance directive (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values)
assessment was part of admission assessment by admitting nurse. It was the admitting nurse's responsibility to ask patient/family about advance directive upon admission. If patient had an advance directive, nurse would ask patient/family to bring a copy to the hospital. If patient did not have an advance directive but would like to obtain more information, nurse would refer patient to social worker for follow up. The advance directive was to let the facility know who the appointed person would be for the patient if the patient could not make decision anymore.

During an interview on 3/6/2025 at 2:03 p.m. with the Registered Nurse (RN) 10 RN 10 stated the purpose of advance directive was for the patient to communicate with the healthcare team regarding patient's wishes when they could not speak for themselves. RN 10 stated everyone had a right to formulate an advance directive.

During a concurrent interview and record review on 3/6/2025 at 5:32 p.m. with the Registered Nurse (RN) 11, Patient 13's medical record titled, "Advance Directive (advance directive assessment, questions asked by admitting nurse if patient has an existing advance directive)," dated 8/20/2024, was reviewed. The advance directive assessment indicated, Patient 13 had an existing advance directive. The advance directive assessment also indicated Patient 13's advance directive document was on file. RN 11 stated the following: she (RN 11) was not able to find Patient 13's advance directive in Patient 13's medical record. The only scanned document found was a POLST (Physician Orders for Life Sustaining Treatment, a medical order form that tells medical staff what to do if the patient has a medical emergency and unable to speak for self). POLST was not the same as advance directive. The nurse should have asked Patient 13's family to bring a copy of advance directive to the facility then send it to medical record department to scan into Patient 13's electronic medical record.

During a review of the facility's policy and procedure (P&P) titled, "Advance Directive," dated 3/2025, the P&P indicated, "The purpose of this policy was to provide guidance to [the facility] staff related to the patient's right to receive information regarding Advance Healthcare Directives, to formulate advance directives and to have hospital staff implement and comply with the patient's advance directive as required under Federal and State law ... For patient with an existing Advance Health Care Directive, during the admission process the healthcare provider will document the existence of the directive and request a copy. For patient presenting an Advance Health Care Directive and/or valid Power of Attorney for Health Care, hospital staff will photocopy the form with 2 copies and place one copy in the patient's chart, and one copy placed in the tray for Health Information Management (HIM), also known as Medical Records, to scan into the patient's electronic record (EMR) ... Admitted patient that did not have an Advance Healthcare Directive will be given the opportunity to speak to a social worker, if desired, on formulating an advance directive. The nurse will document the patient's request for advance directive information during the admission process which will send an electronic notification to the Social Services department for follow-up."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 2/2025, the P&P indicated, "Consistent with Federal and State law, [the facility] informs each patient, or when appropriate, the patient's representative of the patient's rights and responsibilities, in advance of furnishing or discontinuing patient care whenever possible ... 10. Formulate advance directives. This includes designating a decision maker if patient becomes incapable of understanding a proposed treatment or become unable to communicate wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients' rights apply to the person who has the legal responsibility to make decisions regarding medical care on the patient's behalf."

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

1. Ensure that one of one sampled cabinet (Cabinet 1) dedicated for wound care for 22 of 31 sampled patients, containing medical supplies and instruments (in a medical or occupational context, refers to materials that can cause injury, illness, or adverse effects if not handled properly) such as sharp instruments (includes needles, scalpel blades, lancets, etc.) and irrigation solutions (used to cleanse wounds, body cavities, tissues and to flush out debris or prepare sites for further treatment) such as normal saline (a sterile solution of sodium chloride in water used for various medical purposes, including wound irrigation) and betadine (an antiseptic solution containing providing-iodine used for disinfecting skin and surfaces to prevent infection), was securely locked and accessible only by authorized personnel.

This deficient practice had the potential to compromise patients' safety resulting in misuse or mishandling of medical supplies that can be hazardous for patients and visitors in the emergency department (ED, a specialized area within a hospital dedicated to providing immediate medical care).

2. Ensure that facility staff provided a call light device (a device to enable patients to communicate their needs to healthcare staff) for three of 31 sampled patients (Patients 18, 19, and 20), who were in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), in accordance with the facility's policy titled "Scope of Service - Emergency and Trauma Services," which referenced the provision of a safe environment of care.

This deficient practice resulted in Patients 18, 19 and 20 having no means to call for help and had the potential to put the patients at risk for injury such as a fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs), which may result in complications such as fracture (broken bone), bleed, etc.

3. Ensure nursing staff placed a fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) risk magnet outside the patients' door and fall risk wrist band for two of 31 sampled patients (Patient 14 and Patient 17), who were both assessed as moderate risk for fall, in accordance with the facility's policy and procedure regarding fall prevention.

This deficient practice had the potential for other team members not being made aware of Patient 14 and Patient 17's fall risk status, which may lead to delay in providing necessary interventions to prevent Patient 14 and Patient 17 from falling and hurting themselves.

Findings:

1. During a concurrent observation and interview on 3/4/2025 at 2:25 p.m. in the Emergency Department (ED, a specialized area within a hospital dedicated to providing immediate medical care), with the ED manager (EDM), an ED intravenous (IV, refers to the administration of fluids, medications, or nutrients directly into a vein) supply cart, located in the hallway (accessible to staff, patients, and visitors) was observed unlocked and the door was slightly open. The nursing personnel was observed approaching the cart, taking the supplies, and leaving without locking the cart. The EDM stated that the cart should be kept locked because it contains sharps (includes needles, scalpel blades, lancets, etc.) and proceeded to lock the cabinet.

During an observation on 3/5/2025 at 11:54 a.m., in the emergency department (ED) hallway, the ED Wound Cart (accessible to staff, patients, and visitors) was observed to contain the following materials and supplies:

-Staple Removal instruments: a specialized tool used to remove a surgical staple from a wound site. The instrument is considered sharp, as it has pointed edges that contact the staples.
-Suture Removal instruments: referred to as suture removing scissors, a specialized tool designed to safely cut and remove sutures (stitches) from a wound or incision and is considered sharp.
-Scissors: a common handheld tool used for cutting tissues and are considered sharp.
-Iodine: a chemical element often used in the form of antiseptic solutions, for disinfecting skin and surfaces. It is effective in killing bacteria and viruses and is considered as medical supplies.
-Peroxide: a chemical compound used as disinfectant and antiseptic; effective in killing bacteria and is often used to clean wounds to promote healing and is considered as medical supplies.
-Wound Irrigation Solution (Normal Saline: a sterile solution of sodium chloride (elements) in water, used for wound irrigating and cleansing and is considered medical supplies.

During a concurrent observation and record review on 3/5/2025 at 11:54 a.m. in the Emergency Department (ED), with ED Manager (EDM), an ED Wound Cart, containing medical supplies and materials necessary for wound care, was observed in the ED hallway, located by the treatment rooms 23-25. The EDM opened the cabinet glass door and stated that the ED Wound Cart was never locked and has never been locked.

During an interview on 3/7/2025 at 11:18 a.m. with the Accreditation, Regulatory and Licensing Coordinator (ARLC), the ARLC stated that the facility does not have a policy regarding the secure storage of medical supplies and sharps to ensure they are kept away from unauthorized population in easily accessible areas.

2. During a review of Patient 18's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Physician Documentation (ED physician notes, a formal and complete assessment of the patient and the problem by ED physician)," dated 3/5/2025, the ED physician notes indicated, Patient 18 came to the facility's ED with chief complaint of left sided chest pain. The ED physician notes also indicated Patient 18 was alert, oriented (a patient is aware of their identity, location, current time, and current situation) and was able to speak in full sentences.

During a review of Patient 19's "Emergency Department Physician Documentation (ED physician notes)," dated 3/5/2025, the ED physician notes indicated, Patient 19 came to the facility's ED with chief complaint of right foot infection. The ED physician notes also indicated Patient 19 was alert and oriented.

During a review of Patient 20's "Emergency Department Physician Documentation (ED physician notes)," dated 3/5/2025, the ED physician notes indicated, Patient 20 came to the facility's ED with chief complaint of chest pain and status post fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs).

During a concurrent observation and interview on 3/5/2025 at 11:49 a.m. with the Patient Access Representative (PAR 2) at Patient 19's room, the call light device (a device to enable patients to communicate their needs to healthcare staff) was observed located on the wall behind Patient 19 who was in a gurney. PAR 2 stated the call light should be with Patient 19.

During a concurrent observation and interview on 3/5/2025 at 11:50 a.m. with the Director of Quality (DQ) at Patient 18 and Patient 20's rooms, the call lights were on the wall behind Patient 18 and Patient 20. DQ confirmed the call light devices were not within reach for Patient 18 and Patient 20.

During an interview on 3/5/2025 at 11:54 a.m. with the Charge Nurse (CN 4) of ED, CN 4 stated the following: every patient should be provided with a call light device so he or she could call for help. Call light should not be on the wall.

During an interview on 3/7/2025 at 2:32 p.m. with the Director (DIR 2) of Emergency Department, DIR 2 stated the following: it was the facility's standard to provide a call light for every patient. He (DIR 2) was made aware there was a deviation, and the ED charge nurses made sure every patient had the call light within reach.

During an interview on 3/7/2025 at 4 p.m. with the Accreditation, Regulatory and Licensing Coordinator (ARLC), ARLC stated there was no policy regarding call light use.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Service - Emergency and Trauma Services," dated 10/2024, the P&P indicated, "Environment of Care: The Emergency and Trauma service line is committed to providing a safe, comfortable, and functional environment of care that supports the delivery of high-quality patient care."

3.a. During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/4/2025, the H&P indicated, Patient 14 was admitted to the facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by long-term poor airflow) with exacerbation (getting worse), and acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 14's "Fall Risk Assessment," dated 3/4/2025, the fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) risk assessment indicated, Patient 14 was at high injury risk.

During a concurrent observation and interview on 3/5/2025 at 10:38 a.m. with Registered Nurse (RN) 7 at Patient 14's room, there was no fall risk sign outside Patient 14's room and Patient 14 did not have a fall risk wrist band. RN 7 stated Patient 14 was at high risk for fall because Patient was deaf and blind. RN 7 stated there should be a yellow magnet outside the door (used to indicate a patient's fall risk) and a yellow wrist band on Patient 14 to identify Patient 14 was a fall risk.

During an interview on 3/6/2025 at 2:05 p.m. with Registered Nurse (RN) 10, RN 10 stated a yellow fall risk sign (yellow magnet) should be placed outside a patient's door for a patient with high fall risk to alert other team members that patient was at high risk for fall to provide timely intervention. RN 10 stated everyone was responsible to prevent patient falls.

During an interview on 3/7/2025 at 2:02 p.m. with the Nurse Manager (NM 2) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, NM 2 stated the following: nursing staff should put a fall risk magnet (yellow magnet) outside the patient door, and update on the status board in the patient's room, apply yellow wrist band and yellow socks for patients who were at moderate and high risk for fall. This was to alert other staff and team members that patient was at moderate to high fall risk. Fall prevention was everyone's responsibility.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention," dated 11/2024, the P&P indicated, "[the facility] is committed to providing a safe environment for patients and staff. The purpose of Fall Prevention is to identify patients who are at risk of falling, provide patient-specific interventions to prevent falls and reduce the harm resulting from falls ... Fall Prevention Interventions ... Moderate/High Risk Interventions: Visually identifying patient as a fall risk (i.e. magnet, status board) ... utilization of a bed and/or chair alarm ... utilize high visibility identification (i.e. yellow wrist bands, yellow socks)."

3.b. During a review of Patient 17's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/1/2025, the H&P indicated, Patient 17 was admitted to the facility with diagnoses including but not limited to diabetic (a condition characterized by high blood sugar) foot infection of right foot, and status post amputation (a surgical procedure that involves the removal of a limb or part of a limb) of right great toe.

During a review of Patient 17's "Fall Risk Assessment," dated 3/2/2025, the fall risk assessment indicated, Patient 17 was a moderate fall risk.

During a concurrent observation and interview on 3/5/2025 at 11:11 a.m. with Registered Nurse (RN) 8 at Patient 17's room, Patient 17 was observed in bed with bandage wrapped at the right leg. There was no fall risk sign/yellow magnet outside Patient 17's room and Patient 17 did not have a fall risk wrist band. RN 8 stated Patient 17 was at high risk for fall and interventions for fall prevention should include applying yellow wrist band, putting a fall risk sign outside the door, keeping call light within reach and activating bed alarm. RN 8 confirmed there was no fall risk sign outside the door and Patient 17 did not have the yellow wrist band.

During an interview on 3/6/2025 at 2:05 p.m. with Registered Nurse (RN) 10, RN 10 stated a yellow fall risk sign/magnet should be placed outside a patient's door for a patient with high fall risk to alert other team members that patient was a high risk for fall to provide timely intervention. RN 10 stated everyone was responsible to prevent falls.

During an interview on 3/7/2025 at 2:02 p.m. with the Nurse Manager (NM 2) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, NM 2 stated the following: nursing staff should put a fall risk magnet (yellow magnet) outside the door, and update on the status board in the patient's room, apply yellow wrist band and yellow socks for patients who were at moderate and high risk for fall. This was to alert other staff and team members that patient was at moderate to high fall risk. Fall prevention was everyone's responsibility.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention," dated 11/2024, the P&P indicated, "[the facility] is committed to providing a safe environment for patients and staff. The purpose of Fall Prevention is to identify patients who are at risk of falling, provide patient-specific interventions to prevent falls and reduce the harm resulting from falls ... Fall Prevention Interventions ... Moderate/High Risk Interventions: Visually identifying patient as a fall risk (i.e. magnet, status board) ... utilization of a bed and/or chair alarm ... utilize high visibility identification (i.e. yellow wrist bands, yellow socks)."

Based on observation, interview and record review, the facility failed to ensure there was a clear description of a patient's behavior to explain restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 31 sampled patients (Patient 16), when nursing staff did not document Patient 16's specific behavior regarding interfering with medical care that warrants the use of restraints to ensure Patient 16's immediate physical safety, in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to result in unnecessary use of restraints, which may lead to physical and psychological harm to a patient such as circulatory and skin problems, loss of strength and mobility, etc.

Findings:

During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/25/2025, the H&P indicated, Patient 16 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), new onset atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke [clot in the brain], or heart failure), alcohol use and hypertension (high blood pressure).

During a concurrent observation and interview on 3/4/2025 at 3:44 p.m. with Registered Nurse (RN) 5 in Patient 16's room, Patient 16 was observed in bed with eyes closed, calm, and with family at bedside. Patient 16 had a nasogastric tube (NGT, a thin flexible tube inserted through the nose into the stomach for feeding and medication) and bilateral (both) wrist restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on. RN 5 confirmed Patient 16 had bilateral wrists restraints on.

During a concurrent interview and record review on 3/6/2025 at 4:56 p.m. with Registered Nurse (RN) 11, Patient 16's "Restraints, Non-Violent (restraints flowsheet)," dated from 3/4/2025 to 3/5/2025, was reviewed. The restraints flowsheet indicated, Patient 16 was placed on bilateral (both) wrist restraints on 3/4/2025 at 9 a.m. and removed at 11:05 a.m. The restraints flowsheet also indicated, Patient 16 was placed on bilateral wrist restraints on 3/4/2025 at 3:06 p.m. and removed on 3/5/2025 at 9 a.m. RN 11 confirmed that Patient 16's restraints was removed at 11:05 a.m. and restraints were applied again at 3:06 p.m. (4 hours later)

During a concurrent interview and record review on 3/6/2025 at 5:10 p.m. with RN 11, Patient 16's physician orders dated 3/4/2025, was reviewed. The physician order indicated the following:

-"On 3/4/2025 at 8:52 a.m.: Restraint - nonviolent with indication of interfering with essential medical care and additional information: bilateral soft wrist restraints;
-On 3/4/2025 at 3:02 p.m.: Restraint - nonviolent with indication of interfering essential medical care."
-RN 11 stated physician order was required for each episode of restraints application.

During an interview on 3/7/2025 at 11:56 a.m. with the Nurse Manager (NM 1) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) and Definitive Observation Unit (DOU, hospital unit providing close monitoring care to patients), NM 1 stated soft wrists restraints would be used when a patient was interfering with care with behavior like removing lines and dressing or pulling off oxygen mask that were important to the patient.

During a concurrent interview and record review on 3/7/2025 at 11:56 a.m. with Nurse Manager (NM) 1, Patient 16's "Restraints, Non-Violent (restraints flowsheet)," dated 3/4/2025, was reviewed. The restraints flowsheet indicated the following:

-"On 3/4/2025 at 9 a.m.: restraint type: bilateral soft limb/foam; non-violent reason for restraint: interfering with care, removing medical device, restraint prevent strategy: de-escalation techniques, re-orientation techniques, explain plan of care, increased observation, reduce stimuli.
-On 3/4/2025 at 11:05 a.m.: restraints removed. Restraint monitoring note: patient pulled out nasogastric tube (NGT, a thin flexible tube inserted through the nose into the stomach for feeding and medication) two times ... no longer need restraints.
-On 3/4/2025 at 3:06 p.m.: restraints type: bilateral anchored mitten; non-violent reason for restraint: interfering with care; restraint prevent strategy: limit setting, explain of plan of care, medication review, non-anchored mittens, increased observation and reduce stimuli."
-The restraint flowsheet did not indicate what type of behavior was being referred to as interfering with medical care (example: was Patient 1 pulling out an intravenous line, removing a nasal cannula or mask, etc.). NM 1 stated Patient 16 pulled out NGT two times which implied Patient 16 continued to pull out the NGT, hence required restraints. NM 1 was unable to provide any documentation describing Patient 16's behavior when restraints was applied at 3:06 p.m. on 3/4/2025.

During a review of the facility's policy and procedure (P&P) titled, "Non-Violent and Violent Restraints and Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)," dated 7/2024, the P&P indicated, "non-violent or non-self destructive restraint use: restraints used to manage behaviors which interfere with medical/surgical healing. For example, the patient may be trying to pull out lines or tubes and less-restrictive methods or alternative measures have not worked ... Restraint or seclusion use is limited to situations necessary to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time ...The use of restraint or seclusion is based on assessment of the needs of the patient ... Restraints for Non-Violent and Non-Destructive Behavior. The patient may be restrained for non-violent reasons only if the patient's behavior is interfering with essential medical care ... Documentation: all restraint or seclusion use is documented in the electronic medical record (EMR). Documentation includes ... description of patient's behavior and intervention used ... patient's condition or symptoms(s) that warranted the use of restraint or seclusion ... patient's response to intervention(s) used, including rationale for continued use of the intervention."

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

1. Ensure that nursing staff provided ongoing assessment (the systematic evaluation of patient's health status and needs) and evaluation of the care and treatment provided for one of 31 sampled patients (Patient 1) in the Emergency Department (ED, an area in the hospital dedicated to providing care and treatment for patients experiencing medical emergencies). when Patient 1 started demonstrating a decline in respiratory status (a significant alteration in a patient's clinical status requiring reevaluation and potential intervention), in accordance with the facility's policies regarding Emergency Services- Standards of Care, Patient Assessment and Care Planning, and Nursing Care Model. In addition, nursing staff failed to notify the physician regarding Patient 1's change of condition in respiratory status, in accordance with the facility's policy regarding physician notification of change of condition (a significant and often sudden deviation from a patient's normal or baseline state of health).

These deficient practices had the potential to result in delayed care and treatment for Patient 1, which may have contributed to Patient 1's worsening respiratory status (a serious condition where the lungs cannot provide enough oxygen to the body) leading to subsequent intubation (the medical procedure inserting a tube into the airway to assist with breathing mechanically).

2. Ensure that its nursing staff notified the physician when one of 31 sampled patients (Patient 23) continued to refuse the use of a Sequential Compression Device (SCD, a medical device that helps prevent blood clots by applying gentle pressure to the legs to improve circulation), in accordance with the facility's policy regarding the use of SCDs and physician notification. Patient 23 was identified as high risk for developing a deep vein thrombosis (DVT, a blood clot that forms in a deep vein, usually in the legs, which can cause serious complications if untreated).

This deficient practice resulted in Patient 23 developing a DVT and required surgery to insert an inferior vena cava (IVC) filter (a small metal device implanted in the body's largest veins to prevent blood clots from traveling to the lungs and causing a life-threatening pulmonary embolism [a blood clot in the lung that creates a blockage]). Additionally, this deficient practice had the potential to place other high-risk patients at increased risk for undetected blood clot formation, leading to serious complications, including pulmonary embolism (a condition where a blood clot [embolus] travels from another part of the body, usually the legs [deep vein thrombosis], to the lungs and becomes life threatening), prolonged hospitalization, and the need for additional surgical interventions.

Findings:

1. During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED, a hospital area that treats patients who need immediate medical care) Summary Report," dated 10/4/2024, the MR indicated that Patient 1 came to the Emergency Department (ED) on 10/4/2024 at 10:32 p.m., with a chief complaint of shortness of breath and difficulty breathing (dyspnea) and was admitted to telemetry unit (a hospital unit that can provide continuous monitoring of vital sign [VS, measurements of the body's most basic functions] that continuously transmit data, such as the heart rate, breathing, and blood pressure to monitor medical condition) on 10/5/2024 at 12:25 a.m., but continued to remain in the ED until 3:46 p.m. on 10/5/2024 when Patient 1 was eventually physically transferred to the telemetry unit when an inpatient bed (for patients who get admitted to the hospital for treatment) became available.

During further review of Patient 1's medical record (MR) titled, "ED Physician Documentation," dated 10/4/2024, the MR indicated that the ED physician documented the following information prior to admitting the patient (Patient 1) on 10/5/2025 at 12:25 a.m.: "Patient 1 remains on 2 Liters (L, a unit of measurement) nasal cannula (NC, a thin, flexible tube that delivers oxygen through the nose), will hold off on BIPAP (Biventricular Positive Airway Pressure machine, a type of noninvasive ventilation that helps patients breath by keeping the airways open and improving breathing).

During a review of Patient 1's medical record (MR) titled, "Nursing Assessments-Emergency Department (ED), "dated 10/4/2024, the MR indicated that (on 10/4/2024, at 1:00 a.m.), respiratory focused assessment (a detailed examination of the respiratory system, focusing on specific areas of concern or symptoms reported by the patient.This assessment includes collecting subjective data [patient's history, symptoms] and objective data [vital signs, physical examination] to evaluate respiratory function) was documented and indicated the following:

-Patient 1 had dyspnea (difficulty breathing), tachypnea (rapid breathing), accessory muscle use (the activation of muscles other than the diaphragm to assist in breathing, often seen as a sign of respiratory distress or increased effort during inhalation and exhalation); labored respiratory effort (breathing that requires more effort than usual, indicating potential respiratory distress), inspiratory (inhale) and expiratory (exhale) wheezes (a high-pitched, whistling sound heard during breathing) and crackles (sounds like rattling, bubbling or clicking) throughout all lung fields; Respiratory Assessment Notes: Respiratory Distress (a condition where breathing becomes labored and inadequate, and can be a life-threatening emergency).

During a concurrent interview and record review on 3/5/2025 at 3:25 p.m. with registered nurse (RN) 17, Patient 1's medical record (MR) titled, "Nursing Assessments," dated 10/4/2024 (at 10:32) through 10/5/2024 (3:46 p.m.), was reviewed. The MR indicated that only one focused respiratory assessment was documented to have been performed on 10/5/2024 at 1:00 a.m. RN 17 stated that nurses in the emergency department (ED) were not required to document focused assessments (a detailed evaluation of a specific body system or systems related to a patient's current concerns or medical condition) unless there was a change in condition (a change in condition can be a sudden or gradual alteration in a patient's health, indicating that their condition is either deteriorating or improving). RN 17 also said that the physician should be notified of a change in patient's condition, and this can be documented in the patient's medical record.

During a review of Patient 1's medical record (MR) titled, "Nursing Documentation," dated 10/5/2024, the MR indicated that no documentation of the physician being notified regarding Patient 1's worsening respiratory status (documented on 10/5/2024 at 1:00 a.m.), was present in Patient 1's medical record on 10/5/2024. The MR also indicated that no follow-up evaluation of Patient 1's respiratory status or other focused respiratory assessments were documented in Patient 1's medical record on 10/5/2024. This finding was verified by the Clinical Informaticist (CI) on 3/5/2025 at 2:10 p.m.

During an interview on 3/5/2024 at 3:25 p.m. with registered nurse (RN) 17, RN 17 stated that emergency department nurses typically document the re-evaluation of patients' condition in free text notes (written entries, allowing the user to input information in their own words without following a specific format) along with Vital Signs (VS) instead of documenting in the flowsheets designated for assessment documentation.

During a review of Patient 1's medical record (MR) titled, "Nursing Assessment," dated 10/5/2024, the MR indicated the following:

-At 1:33 a.m., registered nurse (RN) documented that Patient 1's respiratory rate was 20 breaths per minute, Patient 1 was short of breath, sitting up in gurney ... Patient 1 was placed on Oxymask (a medical device-mask, used to deliver supplemental oxygen to patients across a wide range of concentrations, ensuring the patients receive the exact level of support they need) and Patient 1's SpO2 (Peripheral Oxygen Saturation, measures the percentage of hemoglobin [blood molecule] that carries oxygen and is measured by pulse oximetry [Pulse Ox device]) was 94 percent (%, a unit of measurement; Normal SpO2 values typically range from 95% to 100%; if a patient has respiratory issues, a SpO2 reading of 94% may prompt healthcare providers to assess the patient further; it's significance must be interpreted).

-At 2:00 a.m., Patient 1's respiratory rate (RR, number of breaths taker per minute and is a vital sign of person's respiratory function. Normal rates for adults range from 12-20 breaths per minute) was 24 breaths per minute (bpm), SpO2 100%, on 3 liters (L, measuring unit of oxygen delivery) via Oxymask ...Patient (Patient 1) was getting confused at times, attempting to get out of bed ...

During a review of Patient 1's medical record (MR) titled, "Critical Results and MD (Medical Doctor) Communication," dated 10/5/2024, at 3:12 a.m., the MR indicated that Respiratory Therapist (RT) called the admitting physician on 10/5/2024 at 2:55 a.m. regarding Patient 1's critical ABGs results (a set of tests that measure the levels of oxygen (O2), carbon dioxide (CO2- indicates how well the lungs are removing carbon compound from the blood), and the pH (numerical scale that measures the acidity or alkalinity of blood) in arterial blood, but the physician did not place orders and the following response was documented in Patient 1's medical record: "pH compensated (refers to a situation where the body has adjusted its acid-based balance in response to an abnormal pH level, and the physician's response suggests that while the results of the ABGs [Arterial Blood Gas analysis, a test measures the levels of oxygen, carbon dioxide, and pH in your blood, providing insights into your body's acid-base balance and how well your lungs are functioning] are abnormal, the body has compensated for its abnormality leading to the decision not to intervene with additional orders), no orders for respiratory ..."

During a review of Patient 1's ABG (Arterial Blood Gas analysis) results, dated 10/5/2024 at 2:45 a.m., the results were as follows:

-ABG PCO2 (Partial Pressure of Carbon Dioxide (CO2): 64 mmHg (millimeters of mercury, measuring unit; the value indicates hypercapnia [elevated CO2, which can indicate inadequate ventilation or respiratory distress]).

-ABG PO2 (Partial Pressure of Oxygen): 69 mmHg (the value indicates hypoxemia, low oxygen levels and may indicate the patient is experiencing respiratory distress [when breathing becomes difficult or labored]; normal value 85-100 mm Hg)

-ABG HCO3 (Bicarbonate): 38.7 mEq/l (milliequivalent per liter, measuring unit); the value indicates metabolic alkalosis [caused by an increase in the bicarbonate ion -HCO3] concentration in the blood, leading to an elevated pH [hydrogen ion concentration] above the normal range of 7.35-7.45; can be a serious condition if left untreated or compensation for respiratory acidosis [a condition in which the body accumulates too much carbon dioxide (CO2) in the blood. This leads to a decrease in the pH of the blood, making it more acidic and indicates inadequate ventilation]).

-ABG O2 SAT (Oxygen Saturation in blood): 95.4% (generally considered within normal limits, but it is unknown if ABG test was performed while patient (Patient 1) was on room air or on oxygen which is crucial for interpretation; for patients with emphysema, a target oxygen saturation range of 88% to 92% is generally recommended, especially during exacerbations of COPD [Chronic Obstructive Pulmonary Disease, progressive respiratory disease characterized by chronic and obstruction of airflow in the lungs, making it difficult to breath]).

-ABG P/F RATIO (PaO2/FiO2, also known as the P/F ratio, is a crucial measure in respiratory medicine, calculated by dividing the partial pressure of oxygen in arterial blood (PaO2) by the fraction of inspired oxygen (FiO2), used to assess the severity of hypoxemia): 216 (this ratio suggests mild/moderate acute respiratory distress syndrome [ARDS), a lung condition caused by fluid buildup in the lungs and low oxygen level]).

During a review of Patient 1's medical record (MR) titled, "Critical Results and MD (Medical Doctor) Communication," dated 10/5/2024, at 3:12 a.m., the MR indicated that Respiratory Therapist (RT) called the admitting physician on 10/5/2024 at 2:55 a.m. regarding Patient 1's critical ABGs results (a set of tests that measure the levels of oxygen [O2], carbon dioxide [CO2], and the pH [numerical scale that measures the acidity or alkalinity of blood]) in arterial blood, but the physician did not place orders and the following response was documented in Patient 1's medical record: "pH compensated (refers to a situation where the body has adjusted its acid-based balance in response to an abnormal pH level, and the physician's response suggests that while the results of the ABGs [Arterial Blood Gas analysis, a test measures the levels of oxygen, carbon dioxide, and pH in your blood, providing insights into your body's acid-base balance and how well your lungs are functioning] are abnormal, the body has compensated for its abnormality leading to the decision not to intervene with additional orders), no orders for respiratory ..."

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/4/2024, the H&P indicated that Patient 1 was admitted with a diagnosis of COPD (Chronic Obstructive Pulmonary Disorder- a group of lung diseases that cause breathing difficulties) and Acute (sudden and severe in onset) hypoxic respiratory failure (a condition where the lungs fail to adequately provide oxygen to the blood, resulting in low blood oxygen levels [hypoxemia] with normal or low carbon dioxide levels). The H&P also indicated that Patient 1 had past medical history (PMH, records information about the patient's medical, personal and family history) of emphysema (a chronic lung disease that damages lungs) and long-standing history of smoking. The H&P further indicated that the admitting physician did not include the results for Patient 1's ABG analysis (critical results called back on 10/5/2024 at 2:51 a.m.) in the History and Physical report.

During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED) Notes," dated 10/5/2024 (documented by registered nurse (RN) 12], the MR indicated the following: "Patient (Patient 1) taken to the floor on cardiac monitor (a medical device used to continuously observe and display the electrical activity of the heart) on Venturi Mask (a medical device used to deliver a precise concentration of oxygen to patients and is commonly used in emergency situations and for patients requiring consistent, reliable oxygen delivery) SPO2 (peripheral capillary oxygen saturation, a device used to measure the oxygen level in a person's blood) 90% (percent;90% SpO2 indicates that only 90% of hemoglobin [a protein in the blood responsible for transporting oxygen from the lungs to the body] is saturated with oxygen and generally considered low; normal Spo2 typically ranges from 95-100%]). Patient (Patient 1) moved to hospital bed noted to be flaccid (refers to a state of reduced muscle tone) and unresponsive. Bedside nurse and charge nurse notified ... request RRT (Rapid Response Team, a group of healthcare professionals that is activated to provide immediate assessment and intervention for patients who show signs and symptoms of deterioration in a hospital setting) called ... nurse notified physician to intubate (a medical procedure in which a tube is inserted into a patient's windpipe to maintain an open airway and facilitate breathing)."

During a concurrent observation and interview on 3/4/2025 at 2:32 p.m. in the Emergency Department (ED) with Emergency Department technician (EMT 1), application and placement of SPO2 sensors was observed. SpO2 sensors were observed to be placed on patients' index finger. EMT 1 stated the following: "we (ED staff) don't place SpO2 probes (sensors) on forehead because it does not accurately pick up the measurements. If needed, there is a special sensor that can be applied to the earlobe and nose. We had a meeting about it a few months ago."

During a review of the facility's records titled, "Emergency department (ED) Huddle topics," dated 11/18/2024 through 11/25/2024, the records indicated that SpO2 sensors must be used in accordance with manufacturer's instructions and that the equipment for a finger cannot be used on other body areas (such as forehead).

During an interview on 3/6/2025 at 10:18 a.m. with registered nurse (RN) 12, RN 12 stated that they (RN 12) recalled the patient (Patient 1) and said that Patient 1 was not in distress prior to their (Patient 1) transport to the floor but was drowsy, sleepy. RN 12 stated that Patient 1 had an SpO2 (peripheral capillary oxygen saturation) sensor attached to the earlobe and the finger but not to the forehead and this was how the oxygen saturation reading was obtained. RN 12 also stated that using SpO2 sensor on the forehead was not allowed.

During a concurrent interview and record review on 3/6/2025 at 10:46 a.m., with registered nurse (RN) 13 who took care of Patient 1 on 10/5/2024, from 7 a.m. to 3:46 p.m., Patient 1's medical record titled, "Nursing Assessments," dated 10/5/2024, was reviewed. The MR indicated that on 10/5/2024 at 1:00 p.m., Patient 1 desaturated (refers to low blood oxygen saturation) to 82% while receiving 3 liters (L) of oxygen delivered by Venturi Mask (a medical device used to deliver a precise concentration of oxygen). The MR indicated there was no documentation of the physician being notified regarding Patient 1's desaturation to 82%. RN 13 stated that she recalled Patient 1 being very confused that day (on 10/5/2024) and said that per practice, typically the RN (RN 13) would consider the incident (low oxygen saturation rate) as a change in patient's condition but would attempt to increase the oxygen delivery first by titrating (adjust the rate) the oxygen. RN 13 then stated that if unable to improve the oxygen saturation rate, then would contact the physician and typically document in the notes. RN 13 also stated the following: "I can't remember what happened, I can only remember by what is documented." RN 13 then stated that on 10/5/2024 at 2:00 p.m., the MR documentation indicated that Patient 1 was already on 6 liters (L) oxygen delivered by a Venturi Mask and was not in respiratory distress prior to departure from the Emergency Department.

During a review of Patient 1's medical record (MR) titled, "Nurse Notes," documented by registered nurse (RN) 14), dated 10/5/2024, the MR indicated the following: " ...Upon entering the room, patient (Patient 1) was unresponsive and flaccid. No response to sternal rub (force applied to a patient's breastbone and used to assess the level of consciousness and responsiveness). Called for assistance. Tele monitoring (a system that allows to monitor patient's health data remotely) connected, SPO2 31% (peripheral capillary oxygen saturation percent; the level is low and signifies severe hypoxemia and a critical medical emergency that requires immediate intervention) on tele central monitoring connected ..."

During an interview on 3/6/2025 at 11:30 a.m. with registered nurse (RN) 14, RN 14 stated that on 10/5/2024, RN 14 found Patient 1 unresponsive after Patient 1 was transferred from the gurney to the hospital bed. RN 14 also stated that Patient 1 had two SPO2 (peripheral capillary oxygen saturation) sensors: one was attached to the forehead and the other one was attached to the finger.

During a review of Patient 1's medical record (MR) titled, "Nurse Notes," documented by charge nurse (CN 7), the MR indicated the following: "Patient (Patient 1) dusky, unresponsive to pain and stimuli. O2 sats (oxygen saturation) sensor noted on the forehead and read 98% on the vital signs machine (VS machine, a medical device used to automatically measure and monitor a patient's vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation rate). Attached patient to tele box and O2 sat showed that sats (saturations) were at 31%. RRT (Rapid Response Team) called. RRT nurse called code (code blue- an emergency code that signals a patient is experiencing a life-threatening medical event) due to [Patient 1's] respiratory arrest (a medical emergency condition in which a person's breathing stops or becomes insufficient to sustain life)."

During an interview on 3/6/2025 at 11:43 a.m. with charge nurse (CN) 7, CN 7 stated that on 10/5/2024, CN 7 recalled Patient 1 and the events leading to Patient 1's intubation that same day (10/5/2025). CN 7 stated that Patient 1 was transferred from the Emergency Department (ED) and was unresponsive upon arrival to the unit. CN 7 stated that they (CN 7) recalled that Patient 1 had an SPO2 (peripheral capillary oxygen saturation) sensor attached to the forehead, which when connected to the vital signs (VS) machine, read within normal limits (WNL); but when connected to the tele box, indicated that Patient 1's oxygen saturation rate was in the low 30's (%, percentage; O2 Sats of 30 refers to the percentage of blood saturated with oxygen, with normal levels usually ranging from 95% to 100%; a reading in the low 30s which can be life threatening and requires immediate medical attention).

During a review of Patient 1's medical record (MR) titled, "Progress Note-Hospitalist," dated 10/5/2024, the MR indicated that the attending physician documented the following on 10/5/2024: " ...This morning [10/5/2024] the patient [Patient 1] was reportedly agitated (a feeling of severe restlessness or uneasiness) and uncooperative with instructions and care. While in the Emergency Department (ED), the patient [Patient 1] was reportedly on 5 liters (L) nasal cannula (NC) and transitioned to Venturi Mask ...Patient [Patient 1] was then transferred to the medical floor but was unresponsive ...Per report, the O2 (oxygen saturation) sensor noted on the forehead read 98% (percent) on the vital signs (VS) machine, however this was not consistent with telemonitoring attached to the patient [Patient 1] on which O2 Sat showed 31% ...It's unclear what the patient's [Patient 1] VS were prior or en route to the medical floor as the patient [Patient 1] was presumed to be sleeping. Ultimately, CODE BLUE (a universal emergency code indicating a patient is experiencing a life-threatening medical emergency) was activated ...a decision was made to intubate ...shortly after intubation (10 minutes) patient [Patient 1] was noted with PEA (Pulseless Electrical Activity, a term used to describe a life-threatening condition where the heart continues to produce electrical activity, but there is no pulse or blood flow).

During a review of the facility's policy and procedure (P&P) titled, "Emergency Services-Standards of Care," dated 3/13/2024, the P&P indicated that the policy applies to the emergency department staff including providers: VIII. Nursing Assessment and Vital Signs
a. Nursing assessments for patients may be augmented or supplanted with assessments or evaluations by providers. Other nursing assessments and reassessments should be appropriate in content and frequency to the condition of the patient. I. Focused assessments should be completed in patients who present with isolated injuries or symptoms limited to one body system. ii. Head to-toe Assessments should be completed on critically ill or injured or those that have symptoms or injuries involving more that one body part or symptoms. b. Should occur every two hours at a minimum and more frequently as the acuity of the patient increases and whenever their condition changes.

During a review of the facility policy and procedure (P&P) titled, "Patient Assessment and Care Planning," dated 10/23/2024, the P&P indicated that this is an organization-wide policy: To ensure the consistency, each clinical discipline shall outline the specific information collected for screening, assessment, and reassessment. The depth and frequency of collecting this information depends on the patient's needs, scope of care, treatment, and services provided ...Information collected during initial screens or assessments may indicate the need for further assessment or reassessment ... Appendix A. Nursing [in the Emergency Care setting] shall assess and reassess patients every two hours and upon transfer and discharge.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Care Model," dated 12/13/2017, the P&P indicated the following: Registered nurse (RN) shall use direct observation to see, auscultate (to listen to the sounds of the heart, lungs, abdomen), palpate (to examine by touch), and percuss (a medical examination technique that involves tapping on the body surface to produce sounds and obtain information about underlying structures) ... An RN shall analyze, synthesize, and evaluate data and must directly observe the patient; verify and collaborate date collected by others. An RN is responsible for the evaluation of the clint's overall condition or response to treatment.

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification for Change of Condition," dated (no date), the P&P indicated the following: It is the policy of the [Facility] to maintain an effective communication process to maintain patients' safety, comfort and care needs. The primary physician will be notified of any changes in patient's condition as care progresses. 1. When a patient's care, safety or comfort need is identified, the primary physician is to be notified immediately.

During a review of the manufacturer's instructions for use (MIFU) for the [Brand] Adult SpO2 sensor, the MIFU indicated that [Brand] Adult SpO2 Sensor should be applied to an index finger (preferred location), or to a small thumb, smaller finger, or great toe. Failure to apply the sensor properly may cause incorrect measurements.
The facility did not provide the manufacturer's instructions for use (MIFU) for an Adult SpO2 sensor to be used for continuous monitoring of oxygen saturation rate in adult patients when applied to the earlobe.
The facility provided the manufacturer's instructions for use (MIFU) for the [Brand] Nasal SpO2 sensor indicated for single patient use for continuous monitoring of functional oxygen saturation of arterial hemoglobin (SpO2) and pulse rate from the nasal ala (side of the nose) of adult ...patients ...The sensor incorporates a small plastic clip with soft silicone pads to hold the sensor properly. The sensor is attached to the patient's nasal alar region-the fleshy region at the side of the nose.

2. During a review of Patient 23's "History and Physical (H&P)," dated 2/20/2025, the "H&P" indicated, Patient 23's medical history included hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rhythm that can increase the risk of heart-related complications), and congestive heart failure (CHF, a condition in which the heart dos not pump blood effectively, leading to fluid buildup in the body). The H&P also indicated Patient 23 had a pacemaker (a small device implanted in the chest to help control abnormal heart rhythms) and was taking Pradaxa (a blood thinner used to prevent blood clots in patients with atrial fibrillation). Patient 23 had a fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) from episode of near-syncopal (a brief loss of consciousness or fainting). The H&P also indicated Patient 23 was blind in the left eye.

During a concurrent observation and interview on 3/4/2025 at 3:28 p.m. with Nurse Manager (NM) 1 in Patient 23's room, a SCD (Sequential Compression Device, a medical device that helps prevent blood clots by applying gentle pressure to the legs to improve circulation) machine was observed on the floor by the side of the bed, with its tubing and electric cord unwrapped and all lines loosely laying on the floor. NM 1 picked up the SCD machine and wrapped up the tubing, stating that the machine should not be left on the floor.

During an interview on 3/4/2025 at 3:40 p.m. with Registered Nurse (RN) 22 outside Patient 23's room, RN 22 stated that Patient 23 refused the use of the SCD and that the machine was on the floor because Patient 23 had requested that the bed be moved to face the window. RN 22 also confirmed that the SCD machine should not be left on the floor.

During a concurrent interview and record review on 3/6/2025 at 1:12 p.m. with Registered Nurse (RN) 11, Patient 23's Electronic Medical Record (EMR, a digital medical chart used by healthcare provider) document titled, "Order," dated 2/20/2025, was reviewed. The EMR indicated that Patient 23 had a physician's order for continuous use of an SCD. RN 11 confirmed that the SCD order remained active unless the physician wrote an order to discontinue it.

During the same record review on 3/6/2025 at 1:12 p.m., Patient 23's "VTE (Venous Thromboembolism- blood clot) Risk Assessment (a process used to identify individuals at increased risk of developing a blood clot (VTE) in their veins)" document, was reviewed. The assessment, dated 2/20/2025, indicated that Patient 23 had a Thrombosis Risk Score of 8, indicating a "very high risk" for developing a deep vein thrombosis (DVT).
Despite this, RN 11 confirmed that there was no documented evidence that the physician was notified about Patient 23's repeated refusal (from 2/21/2025 through 2/27/2025) regarding use of the SCD. The EMR indicated the following:

- 2/21/2025 at 9:00 a.m. - SCD discontinued without any documented rationale.
- 2/21/2025 at 7:56 p.m. - SCD discontinued without any documented rationale.
- 2/22/2025 at 8:00 a.m. - SCD discontinued due to patient request.
- 2/22/2025 at 8:02 p.m. - SCD discontinued due to patient request.
- 2/23/2025 to 2/26/2025 - SCD discontinued for a.m. shift and p.m. shift (7:00 a.m. and 7:00 p.m.) due to patient request.
- 2/27/2025 at 9:00 a.m. - SCD discontinued due to patient request; IVC filter (inferior vena cava filter- a small, metallic device that is placed in the inferior vena cava (IVC), the large vein that carries blood from the lower body to the heart) placed (indicating a confirmed DVT).
- 2/28/2025 to 3/3/2025 - SCD discontinued for a.m. shift and p.m. shift due to patient request; IVC filter placed.
- 3/4/2025 at 9:00 p.m. - SCD initiated but later discontinued due to patient request; IVC filter remains in place.

During a review of Patient 23's EMR (Electronic Medical Record- digital version of paper chart) document titled, "VS Veins DPLX Lower EXT BIL (a duplex ultrasound examination of the veins in both lower extremities, to assess blood flow and identify potential issues like clots)," dated 2/26/2025, the EMR indicated Patient 23 developed a thrombus (blood clot) in the left popliteal vein (a deep vein located behind the knee), indicating an acute (sudden and severe in onset) thrombus formation.

During a concurrent interview and record review on 3/6/2025 at 2:30 p.m. with Registered Nurse (RN) 11, Patient 23's EMR document titled, "Special Procedures," dated 2/27/2025, indicated Patient 23 underwent a surgical procedure to insert a IVC filter due to thrombus development.

During an interview on 3/6/2025 at 2:40 p.m. with Charge Nurse (CN) 2, CN 2 stated that when a patient first refuses an SCD, nursing staff must document the refusal and include a free-text entry specifying that the physician was notified and include the physician's response or order.

During a review of the facility's educational guideline titled, "Nursing Skills: Using Sequential Compression Devices (SCDs)," dated 2025, the guideline indicated, "Sequential compression devices (SCDs) are applied to lower limbs to prevent venous blood stasis (pooling of blood) during periods of immobility and to keep blood flowing normally. Indications for SCDs include prevention of venous thromboembolism, which includes deep vein thrombosis and pulmonary embolism (a condition where a blood clot [embolus] travels from another part of the body, usually the legs [deep vein thrombosis], to the lungs and becomes life threatening), and treatment of lymphedema (swelling caused by a buildup of lymph fluid in the body's tissues, often

Based on interview and record review, the facility failed to ensure its nursing staff developed individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) and reviewed nursing care plan to evaluate patient's progress for two of 31 sampled patients (Patient 4 and Patient 22), in accordance with facility's policy and procedure regarding care plans when:

1. Patient 4 did not have a care plan developed and implemented to address a diagnosis of postoperative (after operation) abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain.

This deficient practice had the potential for Patient 4's pain not to be managed effectively which can negatively impact patient's quality of life, emotional well-being, and recovery.

2. Patient 22 did not have a care plan developed or implemented to address pain management following a head trauma and a 3-centimeter facial wound closure, despite a medical history of musculoskeletal pain and an active order for Fentanyl (a potent pain medication used to treat severe pain).

This deficient practice had the potential to cause inadequate pain management for Patient 22, leading to unnecessary suffering, delayed healing, increased stress, and impaired recovery.

Findings:

1. During a review of Patient 4's History and Physical (H&P, a comprehensive assessment of a patient that includes a thorough medical history and a physical examination), dated 3/4/2025, the H&P indicated that Patient 4 was admitted with a diagnosis of postoperative abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain.

During further review of Patient 4's History and Physical (H&P), the H&P indicated that Patient 4 underwent interventional radiology (IR, guided procedure involving the use of imaging techniques to assist in performing minimally invasive procedures) to drain the abscess with placement of a drainage catheter (a flexible tube placed to drain fluid or pus from body cavities) and was then admitted to telemetry monitoring unit (a unit that provides continuous monitoring of patient's vital signs, particularly heart rhythm and rate, using wireless devices that transmit data to a central monitoring system).

During a review of Patient 4's medical record (MR) titled, "Inpatient Plan of Care (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care), dated 3/4/2025, and updated on 3/6/2025, the MR indicated that Patient 4 did not have a care plan developed to address Patient 4's pain.

During an interview on 3/5/2025 at 3:10 p.m. with charge nurse (CN) 2, CN 2 stated that if a patient was admitted with pain and had orders for pain management, a nursing care plan must be developed. The CN 2 also stated that typically a care plan contained interventions and education for pain management (specific strategies and actions to assess, manage and alleviate a patient's pain, and education provides patients with information about pain management).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Care Planning," dated 10/23/2024, the P&P indicated the following: B. Developing and Implementing a Plan of Care:

1. Once needs have been identified and prioritized, members of the healthcare team develop, implement, and evaluate the plan of care, for the patient. This is documented in the patient's medical records.
2. The plan of care is developed, when possible, in conjunction with the patient and family, as appropriate. The plan of care should identify the following:
a. The need(s) to be addressed
b. The care goal(s) relative to the need identified
c. Interventions planned by the healthcare team to address the need and meet the care goals
d. Monitoring of the patient's progress toward achieving the care goals(s).

2. During a review of Patient 22's History and Physical (H&P, a comprehensive assessment including a patient's medical history and a physical examination), dated 3/3/2025, the H&P indicated Patient 22 was brought into the emergency department (ED, a hospital area that treats patients who need immediate medical care) due to a trauma injury (a serious physical injury caused by an external force, such as a fall [an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs], accident, or blow to the body, that can result in damage to bones, muscles, organs, or the brain). The H&P further indicated that Patient 22 had a head injury on the right scalp, which included a head laceration (a deep cut or tear in the skin, often requiring stitches to close the wound). The head laceration measured 3 centimeters (cm, a unit of measurement) and required a surgical procedure (a medical operation performed by a doctor to treat an injury, remove damaged tissue, or repaired a wound) to close the wound with staples. The H&P also indicated that Patient 22 had a history of musculoskeletal pain (pain affecting the muscles, bones, ligaments, tendons, and nerves, which can cause chronic discomfort, stiffness, or mobility issues). For pain management, the H&P indicated the physician order for Fentanyl (a powerful pain medication used to relieve severe pain by blocking pain signals in the brain).

During a concurrent interview and record review on 3/5/2025 at 2:27 p.m. with the Nurse Manager (NM) 4, Patient 22's Electronic Medical Record (EMR, a digital chart used by health care provider) document titled, "Inpatient Plan of Care (a detailed plan that outlines the medical, nursing, and other interventions required for a patient during their hospital stay to ensure safe and effective treatment)," was reviewed. The EMR, dated 3/5/2025 and updated on 3/5/2025, indicated that no care plan was developed to address Patient 22's pain, despite the patient's history of chronic pain and the need for post-surgical pain relief. NM 4 stated it was important that a care plan for pain was developed for Patient 22.

During an interview on 3/5/2025 at 3:10 p.m. with Charge Nurse (CN) 2, CN 2 stated that if a patient was admitted with pain and has a physician's order for pain management, a nursing care plan for pain management must be developed. CN 2 further stated this care plan should include: Nursing interventions (specific actions taken by nurses to help relieve pain, such as administering prescribed medications, repositioning the patient, or applying cold or warm compresses) and Patient education (teaching the patient about their pain management options and how to report pain effectively to healthcare providers).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Care Planning," dated 10/23/2024, the P&P indicated the following: B. Developing and Implementing a Plan of Care:

-Once needs have been identified and prioritized, members of the healthcare team develop, implement, and evaluate the plan of care, for the patient. This is documented in the patient's medical records.
-The plan of care is developed, when possible, in conjunction with the patient and family, as appropriate. The plan of care should identify the following:
The need(s) to be addressed
The care goal(s) relative to the need identified
Interventions planned by the healthcare team to address the need and meet the care goals
Monitoring of the patient's progress toward achieving the care goals(s).
-Once the plan of care is developed, the healthcare team implements it. Each discipline documents their interventions in the patient's medical record and the patient's response to these interventions.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated the following:

1. Pain is reassessed with new reports of pain, with procedures or activities that are expected to cause pain, and at appropriate intervals to evaluate the effectiveness of pain management interventions ...
4. The pain management treatment plan should consider the risks and benefits, and potential risk of dependency, addiction, and abuse (if applicable).
5. Involve patient/family and members of the multidisciplinary team in the pain management planning process through the following:
a. Developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain.
b. Establishing an individualized plan of care for pain management that addresses the patient's unique pain issues to include ongoing assessments and reassessments to evaluate response to interventions.
c. Establishing an acceptable pain management or comfort goal which includes a satisfactory level of pain that would allow him/her to carry out activities of daily living (ADLs, example hygiene, eating, etc.) and maintain an improved quality of life (e.g., ability to take a deep breath, turn, move, or walk with improved pain control).

Based on observation, interview and record review, the facility failed to ensure its nursing staff adhered to the facility's policy and procedure when:

1. The facility failed to provide proper fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) prevention intervention for two of 31 sampled patients (Patient 14 and Patient 17), when nursing staff did not put a fall risk magnet outside the patients' door and apply yellow wrist band for Patient 14 and Patient 17, to alert team members that both patients were at moderate/high risk for fall, in accordance with the facility's policy regarding fall prevention.

This deficient practice had the potential to result in other team members not being made aware of Patient 14 and Patient 17's fall risk status and may lead to delay in providing interventions to prevent Patient 14 and Patient 17 from falling and hurting themselves.

2.a. The facility failed to address the elevated blood pressure (BP, a measure of the force of blood pushing against the walls of blood vessels) of 168/71 mmHg (millimeters of mercury, a unit used to measure blood pressure) for one of 31 sampled patients (Patient 21), who was receiving dialysis treatment (is a medical treatment that removes waste, extra fluids, and toxins from the blood when the kidneys are not functioning properly), in accordance with the physician's order and the facility's policy and procedure titled "Medication Administration and Timing."

This deficient practice resulted in Patient 21's high BP not being treated, which had the potential to cause uncontrolled high BP (hypertension), increasing the risk of stroke (a condition where blood flow to the brain is blocked or there is sudden bleeding in the brain), kidney damage (a condition where that kidneys cannot properly filter waste from the blood), and other serious heart-related complications.

2.b. The facility failed to ensure that there was consistent monitoring and documenting of a complete set of vital signs, including respiration rate (the number of breaths a person takes per minute), for one of 31 sampled patients (Patient 21), in accordance with the facility policy and procedure regarding "Vital Signs."

This deficient practice resulted in missed opportunities to detect potential respiratory distress (when breathing becomes difficult or labored), delayed interventions, and incomplete medical records for Patient 21. Inconsistent vital sign documentation can lead to poor clinical decision-making, lack of timely treatment adjustments, and increased risk of undetected complications such as respiration failure, hypoxia (low oxygen levels in the blood), or worsening of the patient's underlying medical condition.

3. The facility failed to ensure that its nursing staff conducted and documented a complete pain assessment, including pain level, location, duration, and description of the pain, for one of 31 sampled patients (Patient 22), in accordance with the facility's policy and procedure regarding "Pain Management."

This deficient practice resulted in incomplete clinical records, missed opportunities for appropriate pain management interventions, and potential delays in treatment. Inadequate pain assessment can lead to increased suffering, impaired mobility, delayed healing, and ineffective pain relief, which can negatively impact Patient 22's overall recovery.

4.a. The facility failed to ensure timely administration of as-needed (PRN) pain medication for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding "Medication Administration and Timing."

This deficient practice resulted in prolonged suffering and inadequate pain relief for Patient 24. Delayed pain management can lead to increased stress, decreased mobility, impaired recovery, and worsening of the patient's condition. Additionally, this deficient practice had the potential to affect other patients requiring timely pain management by failing to ensure adherence to physician orders and facility policies.

4.b. The facility failed to ensure that its nursing staff followed physician orders for blood sugar monitoring for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding blood glucose monitoring and insulin (medication to help regulate blood sugar levels) administration.

This deficient practice resulted in a delay in monitoring Patient 24's blood sugar levels, creating a risk of undetected high or low blood sugar levels, which can lead to serious complications such as hypoglycemia (dangerously low blood sugar), hyperglycemia (dangerously high blood sugar), confusion, dizziness, organ damage, and diabetic ketoacidosis (a life-threatening condition caused be severe high blood sugar). Additionally, this deficient practice had the potential to affect other patients requiring blood sugar monitoring by failing to ensure consistent adherence to physician orders and facility policies.

Findings:

1.a. During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/4/2025, the H&P indicated, Patient 14 was admitted to the facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by long-term poor airflow) with exacerbation (getting worse), and acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 14's "Fall (an event where a patient comes to rest inadvertently on the ground, floor, or other lower level, whether or not an injury occurs) Risk Assessment," dated 3/4/2025, the fall risk assessment indicated, Patient 14 was at high injury risk.

During a concurrent observation and interview on 3/5/2025 at 10:38 a.m. with Registered Nurse (RN) 7 at Patient 14's room, there was no fall risk sign/yellow magnet outside Patient 14's room and Patient 14 did not have a fall risk wrist band. RN 7 stated Patient 14 was at high risk for fall because Patient 14 was deaf and blind. RN 7 stated there should be a yellow magnet outside the door and a yellow wrist band on Patient 14 to identify Patient 14 was a fall risk.

During an interview on 3/6/2025 at 2:05 p.m. with Registered Nurse (RN) 10, RN 10 stated a yellow fall risk sign/yellow magnet should be placed outside a patient's door for a patient with high fall risk to alert other team members that patient was at high risk for fall, to provide timely intervention. RN 10 stated everyone was responsible to prevent falls.

During an interview on 3/7/2025 at 2:02 p.m. with the Nurse Manager (NM 2) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, NM 2 stated the following: nursing staff should put a fall risk magnet (yellow magnet) outside the patient's door, update on the status board in the patient's room, and apply yellow wrist band and yellow socks for patients who were at moderate and high risk for fall. This was to alert other staff and team members that patient was a moderate to high fall risk. Fall prevention was everyone's responsibility.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention," dated 11/2024, the P&P indicated, "[the facility] is committed to providing a safe environment for patients and staff. The purpose of Fall Prevention is to identify patients who are at risk of falling, provide patient-specific interventions to prevent falls and reduce the harm resulting from falls ... Fall Prevention Interventions ... Moderate/High Risk Interventions: Visually identifying patient as a fall risk (i.e. magnet, status board) ... utilization of a bed and/or chair alarm ... utilize high visibility identification (i.e. yellow wrist bands, yellow socks)."

1.b. During a review of Patient 17's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/1/2025, the H&P indicated, Patient 17 was admitted to the facility with diagnoses including but not limited to diabetic (a condition characterized by high blood sugar) foot infection of right foot, and status post amputation (a surgical procedure that involves the removal of a limb or part of a limb) of right great toe.

During a review of Patient 17's "Fall Risk Assessment," dated 3/2/2025, the fall risk assessment indicated, Patient 17 was a moderate fall risk.

During a concurrent observation and interview on 3/5/2025 at 11:11 a.m. with Registered Nurse (RN) 8 at Patient 17's room, Patient 17 was observed in bed with bandage wrapped on the right leg. There was no fall risk sign/yellow magnet outside Patient 17's room and Patient 17 did not have a fall risk wrist band. RN 8 stated Patient 17 was at high risk for fall and interventions for fall prevention should include applying yellow wrist band, putting a fall risk sign outside the door, keeping call light within reach and activating bed alarm. RN 8 confirmed there was no fall risk sign outside the door and Patient 17 did not have the yellow wrist band.

During an interview on 3/6/2025 at 2:05 p.m. with Registered Nurse (RN) 10, RN 10 stated a yellow fall risk sign should be placed outside a patient's door for a patient with high fall risk to alert other team members that patient was at high risk for fall, to provide timely intervention. RN 10 stated everyone was responsible to prevent falls.

During an interview on 3/7/2025 at 2:02 p.m. with the Nurse Manager (NM 2) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, NM 2 stated the following: nursing staff should put a fall risk magnet (yellow magnet) outside the door, update on the status board in the patient's room, and apply yellow wrist band and yellow socks for patients who were at moderate and high risk for fall. This was to alert other staff and team members that patient was a moderate to high fall risk. Fall prevention was everyone's responsibility.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention," dated 11/2024, the P&P indicated, "[the facility] is committed to providing a safe environment for patients and staff. The purpose of Fall Prevention is to identify patients who are at risk of falling, provide patient-specific interventions to prevent falls and reduce the harm resulting from falls ... Fall Prevention Interventions ... Moderate/High Risk Interventions: Visually identifying patient as a fall risk (i.e. magnet, status board) ... utilization of a bed and/or chair alarm ... utilize high visibility identification (i.e. yellow wrist bands, yellow socks)."

2.a. During a review of Patient 21's "ED Physician Documentation" note, dated 1/16/2025, the ED Physician note indicated that Patient 21 had reported experiencing swollen hands and was lightheaded (sensation of dizziness or feeling faint) over the past three days. The note further indicated Patient 21 had a medical history of hypertension (high blood pressure) and dyslipidemia (a medical condition where there are abnormal levels of lipids [fats] in the blood increasing the risk of heart disease).

During a concurrent interview and record review on 3/6/2025 at 11:25 a.m. with Registered Nurse (RN) 11 (a nurse who has graduated from an accredited nursing program and passed a national licensing exam), Patient 21's Electronic Medical Record (EMR, a digital chart used by healthcare providers) document titled, "Dialysis (is a medical treatment that removes waste, extra fluids, and toxins from the blood when the kidneys are not functioning properly) Treatment Summary," dated 1/26/2025, was reviewed. The report, documented by dialysis nurse (RN 21), indicated that at 3:47 a.m. on 1/26/2025, Patient 21's BP was 168/71 mmHg at the completion of dialysis treatment. RN 11 confirmed that there was no documented evidence in the post treatment hand-off report (a formal communication between nurses during shift changes) indicating that Patient 21's high BP was reported to the primary RN (RN 20). RN 11 stated, "Dialysis nurses, even though from contracted services, must follow the facility's policy and procedure (referring to communicating the elevated BP to the primary nurse)."

During a concurrent interview and record review on 3/6/2025 at 11:30 a.m. with registered nurse (RN) 11, Patient 21's "Vital Signs (includes the heart rate, temperature, respiratory rate, and blood pressure)" EMR document, dated 1/26/2025, was reviewed. The document indicated that at 5:38 a.m. on 1/26/2025, Patient 21's BP remained high at 168/71 mmHg (normal BP is typically around 120/80 mmHg). RN 11 confirmed that Patient 21's usual BP range was between 120 to 140 mmHg and that a BP of 168/71 mmHg was considered high. RN 11 confirmed that there was no documented rationale explaining why the elevated BP (168/71) was not addressed, and confirmed that the physician was not notified, despite facility policy requiring notification of physician for abnormal vital signs.

During an interview on 3/6/2025 at 1:45 p.m. with registered nurse (RN) 20 (the primary nurse assigned to Patient 21 on 1/26/2025), RN 20 stated they did not recall RN 21 (the dialysis nurse) reporting a high blood pressure reading. RN 20 stated, "If the BP was 168/71, I would have administered the PRN (as-needed) BP medication and notified the physician." RN 20 further confirmed that if there were no PRN medications ordered, and the next scheduled BP medication was more than two hours later, they would have contacted the physician to request additional BP medication.

During an interview on 3/6/2025 at 5:25 p.m. with the Nurse Manager of Trauma Program (NM 4), NM 4 confirmed that a BP of 168/71 mmHg should have been addressed to prevent potential health risks. NM 4 confirmed that if a blood pressure was higher than their normal range, the nurse should check if there was a PRN BP medication order, administer it if available, and if no PRN medication was available, notify the physician.

During a concurrent interview and record review on 3/7/2025 at 5:00 p.m. with registered nurse (RN) 11, Patient 21's "Medication Administration Record (MAR, a record of all medications prescribed and given to a patient)," dated 1/26/2025, was reviewed. The MAR indicated that Patient 21 had a physician's order for PRN Hydralazine (a medication that relaxes blood vessels to lower blood pressure) with a dose of 25 milligram (mg, a unit of measurement) to be given if the systolic blood pressure (SBP, the top number in a blood pressure reading, representing pressure when the heart contracts) was greater than 160 mmHg. The MAR indicated that the medication was not administered on 1/26/2025, despite Patient 21's BP exceeding 160 mmHg. RN 11 stated Patient 21 had regularly scheduled BP medications three times a day (TID), but the next scheduled dose was not due until 8:00 a.m. (2 hours and 22 minutes after the last documented high BP reading).

During a review of the facility's policy and procedure (P&P) titled, "Medication administration and Timing," dated 10/23/2024, the P&P indicated, "To ensure medications are administered by authorized clinicians in a safe and timely manner to meet the needs of the patient ... Staff will use their professional judgement in organizing and prioritizing patient care to assure medications are delivered in a safe and timely manner. This includes Recognition of the complex nature and variability among medications, the clinical indications for which a medication is prescribed, and the needs of the patient receiving medications. Staff administering medications have an affirmative duty to prioritize additional activities necessary to the administration of a medication, such as vital sign assessment or review of blood work, to ensure safe and timely medication administration."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs," dated 3/13/2024, the P&P indicated, "All patients will have vital signs assessed in accordance with their specific condition, care needs and standard for the area where they are being cared for, or as importantly, the circumstances under which they are being cared for at the time. Patient vital signs will be assessed, collected, documented and communicated. All levels of practice from Patient Care Associates (PCA), Licensed Vocational Nurses (LVN) and Registered Nurses (RN) are competent to perform vital signs procedures. Vital signs which have changed or deviate from the patient's normal range or physician parameters are reported to physicians involved in the patient's care for further determination of further treatment."

During a review of the facility's policy and procedure (P&P) titled, "Dialysis General Policy," dated 11/25/2024, the P&P indicated, "This policy applies to patients receiving hemodialysis and the personnel, staff or contractor, assigned to provide care to the dialysis patient ... (name of the facility) is committed to providing safe patient care to those that require Hemodialysis during their hospital stay. Dialysis is provided as a contracted service at the hospital. Dialysis personnel will comply with all regulations and standards of (name of the facility) ... Dialysis nurses will communicate with the patient's primary nurse prior to the initiation of each dialysis treatment and document this in the patient's electronic medical record (EMR) under the dialysis pre-assessment intervention; please note the dialysis nurses will complete a pre and post dialysis intervention with the patients primary nurse."

During a review of the facility's policy and procedure (P&P) titled, "(name of the contracted dialysis organization) Pre (before) and Post (after) Treatment Patient Care Hand-Off (the transfer of patient care responsibility and information from one healthcare provider or team to another, ensuring continuity and safety during transitions of care) for Inpatient Services," dated 9/5/2023, the P&P indicated, "Patient monitoring and safety check guidelines: Patient Monitoring includes changes in the patient's status. Blood pressure, pulse, respirations ... Post treatment patient care hand-off report may include post treatment vital signs ..."

2.b. During a review of Patient 21's "ED Physician Documentation" note, dated 1/16/2025, the ED Physician note indicated that Patient 21 had reported experiencing swollen hands and was lightheaded (sensation of dizziness or feeling faint) over the past three days. The note further indicated Patient 21 had a medical history of hypertension (high blood pressure) and dyslipidemia (a medical condition where there are abnormal levels of lipids [fats] in the blood increasing the risk of heart disease).

During a concurrent interview and record review on 3/6/2025 at 11:35 a.m. with Registered Nurse (RN) 11, Patient 21's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) document titled, "Vital Signs," dated from 1/24/2025 through 1/28/2025, was reviewed. RN 11 stated Patient 21 had telemetry status which required vital signs to be checked every four hours. However, the EMR showed multiple gaps in documentation where the respiration rate was not recorded:

On 1/24/2025 at 11:30 p.m., no respiration rate was documented.
On 1/25/2025 at 11:38 a.m., no respiration rate was documented.
On 1/25/2025 at 3:46 p.m.., no respiration rate was documented.
On 1/25/2025 at 7:49 p.m., no respiration rate was documented.
On 1/27/2025 at 11:07 p.m., no respiration rate was documented.

During the same interview on 3/6/2025 at 11:35 a.m. with registered nurse (RN) 11, RN 11 confirmed that respiration rate should have been recorded during every vital sign assessment and that these gaps indicate incomplete documentation, which could lead to missed signs of respiratory distress or worsening health conditions.

During an interview with on 3/7/2025 at 11:00 a.m. with the Charge Nurse (CN) 7, CN 7 stated, "Respiration is part of the vital signs assessment and must be documented."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs," dated 3/13/2024, the P&P indicated, "Vital signs include; blood pressure, heart rate, respiratory rate, temperature, oxygen saturation and pain ...All patients will have vital signs assessed in accordance with their specific condition, care needs and standard for the area where they are being cared for, or as importantly, the circumstances under which they are being cared for at the time. Patient vital signs will be assessed, collected, documented and communicated."

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Documentation Standards," dated 6/11/2020, the P&P indicated, "Documentation integrity involves the accuracy and completeness of the health record. The procedure below provides guidance to (name of the facility) workforce members to ensure compliance with Federal and State laws, rules and regulations and accrediting standards in regard to documentation requirements within the medical record... All relevant documents and entries should be entered into the medical record at the time the service is rendered. The electronic medical record (EMR) must be used for documentation in areas where its implementation has been completed. Every individual documenting in the medical record is responsible for the entire content of his/her documentation, whether the content is original, copied, pasted, recalled or reused. Those who document are responsible for the accuracy, medical necessity, and documentation requirements of each of their notes."

During a review of the facility's policy and procedure (P&P) titled, "Standard Procedures for Nursing," dated 10/19/2023, the P&P indicated, "This is an organization-wide policy. It applies to all settings and services where Standardized Procedures may be initiated ...
A. California Code of Regulations
1. Standardized Procedures are the legal mechanism for Registered Nurses (RN) and Nurse Practitioners (NP) to perform functions which would otherwise be considered the practice of medicine pursuant to California Business and Professional Code § 2725 ... o (10) Specify patient record-keeping and other documentation requirements."

3. During a review of Patient 22's History and Physical (H&P, a comprehensive assessment including a patient's medical history and a physical examination), dated 3/3/2025, the H&P indicated Patient 22 was brought into the emergency department due to a trauma injury (a serious physical injury caused by an external force, such as a fall, accident, or blow to the body, that can result in damage to bones, muscles, organs, or the brain). The H&P further indicated that Patient 22 had a head injury on the right scalp, which included a head laceration (a deep cut or tear in the skin, often requiring stitches to close the wound). The head laceration measured 3 centimeters (cm, a unit of measurement) and required a surgical procedure (a medical operation performed by a doctor to treat an injury, remove damaged tissue, or repaired a wound) to close the wound with staples. The H&P also indicated that Patient 22 had a history of musculoskeletal pain (pain affecting the muscles, bones, ligaments, tendons, and nerves, which can cause chronic discomfort, stiffness, or mobility issues). For pain management, the H&P indicated the physician ordered Fentanyl (a powerful pain medication used to relieve severe pain by blocking pain signals in the brain).

During concurrent interview and record review on 3/5/2025 at 2:27 p.m. with Nurse Manager (NM) 4, Patient 22's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) document titled, "Pain Assessment," dated 3/4/2025, was reviewed. The EMR indicated for 3/4/2025 at 12:03 a.m. and at 4:03 a.m., "Current pain: Yes, and at right hip;" However, the pain location, duration, and description were left blank.

During concurrent interview and record review on 3/5/2025 at 2:35 p.m. with Nurse Manager (NM) 4, Patient 22's EMR document titled, "Medication Administration Record (MAR)," dated 3/4/2025, was reviewed. The MAR indicated that no pain medication was administered between 12:03 a.m. and at 4:03 a.m. on 3/4/2025. NM 4 was unable to determine from the documentation why there were blanks in the pain assessment during this period.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated, "It is the policy of (name of the facility) to recognize the patient's right to pain relief and supports a comprehensive approach to pain assessment and pain management ... Comprehensive Pain Assessment: An assessment process that includes an evaluation of, but is not limited to: the reported origin or cause of pain, signs and symptoms, aggravating and alleviating factors, onset, duration, location/site, intensity, quality, and response to prior treatment."

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Documentation Standards," dated 6/11/2020, the P&P indicated, "Documentation integrity involves the accuracy and completeness of the health record. The procedure below provides guidance to (name of the facility) workforce members to ensure compliance with Federal and State laws, rules and regulations and accrediting standards in regard to documentation requirements within the medical record... All relevant documents and entries should be entered into the medical record at the time the service is rendered. The electronic medical record (EMR) must be used for documentation in areas where its implementation has been completed. Every individual documenting in the medical record is responsible for the entire content of his/her documentation, whether the content is original, copied, pasted, recalled or reused. Those who document are responsible for the accuracy, medical necessity, and documentation requirements of each of their notes."

During a review of the facility's policy and procedure (P&P), titled "Standard Procedures for Nursing," dated 10/19/2023, the P&P indicated, "This is an organization-wide policy. It applies to all settings and services where Standardized Procedures may be initiated ...
A. California Code of Regulations
1. Standardized Procedures are the legal mechanism for Registered Nurses (RN) and Nurse Practitioners (NP) to perform functions which would otherwise be considered the practice of medicine pursuant to California Business and Professional Code § 2725 ... o(10) Specify patient record-keeping and other documentation requirements."

4.a. During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/3/2025, the "H&P" indicated, Patient 24 had a medical history of stomach adenocarcinoma (a type of cancer that originates if the stomach) and chronic kidney disease stage 3 (CKD stage 3, a condition where the kidneys have moderate damage and are less able to filter waste from the blood). Patient 24 presented to the emergency department for severe abdominal pain.

During a concurrent interview and record review on 3/6/2025 at 5:10 p.m. with Nurse Manager (NM) 4, Patient 24's Electronic Medical Record (EMR, a digital chart used by healthcare providers) document titled, "Pain Assessment," dated 3/5/2025, was reviewed. The pain assessment at 11:54 a.m. indicated Patient 24's pain was 6 out of 10 (on a scale where 0 = no pain and 10 = the worst pain imaginable). Fifty-five minutes later, at 12:49 p.m., Patient 24's pain escalated to 10 out of 10, indicating severe, uncontrolled pain. NM 4 stated that when a patient reports pain, it should be addressed promptly, and pain should not have to escalate to 10/10 before PRN (as-needed) medication was administered.

During a concurrent interview and record review on 3/6/2025 at 5:25 p.m. with Nurse Manager (NM) 4, Patient 24's "Medication Administration Record (MAR, a record that tracks all medication administrated to a patient, including dosing, timing, and route of administration)," dated, 3/5/2025, was reviewed. The MAR indicated that Patient 24 received 4 milligrams (mg, a unit of measurement) of intravenous injection (IV, administered into the vein) Morphine (a strong pain medication that works by blocking pain signals to the brain) at 12:49 p.m.
The physician's order (MD 1's order) indicated the following:

-2 mg of IV Morphine was prescribed for moderate pain (3-6 on the pain scale).
-4 mg of IV Morphine was prescribed for severe pain (7-10 on the pain scale).

During the same interview on 3/6/2025 at 5:25 p.m. with Nurse Manager (NM) 4, NM 4 confirmed that despite Patient 24 reporting a pain level of 6/10 at on 3/5/2025 at 11:54 a.m., the 2 mg dose of Morphine was not administered as ordered for moderate pain. Instead, Patient 24 had to wait nearly an hour before, at which point Patient 24's pain worsened to 10/10, requiring a higher dose of medication. NM 4 confirmed that the PRN pain medication of 2 mg Morphine should have been administered at 11:54 a.m. when the pain was first reported as 6/10, rather than delaying treatment until the pain became severe.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Timing," dated 10/23/2024, the P&P indicated, "To ensure medications are administered by authorized clinicians in a safe and timely manner to meet the needs of the patient ...Medications not eligible for scheduled dosing times: Medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, therapeutic goals, pharmacokinetics of medication, specific clinical application, or patient risk factors: Drugs prescribed on an as needed (PRN) basis ...Staff will use their professional judgement in organizing and prioritizing patient care to assure medications are delivered in a safe and timely manner. This includes: Recognition of the complex nature and variability among medications, the clinical indications for which a medication is prescribed, and the needs of the patient receiving medications. Staff administering medications have an affirmative duty to prioritize additional activities necessary to the administration of a medication, such as vital sign assessment ...to ensure safe and timely medication administration."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated, "It is the policy of (name of the facility) to recognize the patient's right to pain relief and supports a comprehensive approach to pain assessment and pain management including safe opioid use and prescribing, and use of multimodal treatment options to manage both acute and persistent pain ... The patient self-report of pain is the gold standard of assessment ... Patients shall receive treatment for any active pain issue (acute or persistent), when intensity exceeds their acceptable level in a timely manner. Treatment shall be consistent with the patient's clinical presentation ..."

4.b. During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/3/2025, the "H&P" indicated, Patient 24 had a medical history of stomach adenocarcinoma (a type of cancer that originates if the stomach) and chronic kidney disease stage 3 (CKD stage 3, a condition where the kidneys have moderate damage and are less able to filter waste from the blood). Patient 24 presented to the emergency department for severe abdominal pain.

During a concurrent interview and record review on 3/6/2025 at 4:30 p.m. with Nurse Manager (NM 4), Patient 24's Electronic Medical Record (EMR, a digital chart used by healthcare providers) document titled, "Flowsheet Blood Sugar Check," dated 3/5/2025, was reviewed. The EMR indicated that Patient 24's blood sugar was checked on 3/5/2025 at 7:54 a.m.; However, there was no documented evidence of a blood sugar check before bedtime, as indicated by the physician's (MD 2) order.

During a concurrent interview and record review on 3/6/2025 at 4:55 p.m. with Nurse Manager (NM) 4, Patient 24's EMR document titled, "Bedside Blood Glucose POC (Point of Care) ACHS (before meals and at bedtime)," order dated to start 3/3/2025, was reviewed. The order indicated that blood sugar checks were to be performed before meals and

Based on interview and record review, the facility failed to ensure timely administration of as-needed (PRN) pain medication (Morphine- a strong pain medication that works by blocking pain signals to the brain) for one of 31 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding "Medication Administration and Timing."

This deficient practice resulted in prolonged suffering and inadequate pain relief for Patient 24. Delayed pain management can lead to increased stress, decreased mobility, impaired recovery, and worsening of the patient's condition. Additionally, this deficient practice had the potential to affect other patients requiring timely pain management by failing to ensure adherence to physician orders and facility policies.

Findings:

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/3/2025, the "H&P" indicated, Patient 24 had a medical history of stomach adenocarcinoma (a type of cancer that originates if the stomach) and chronic kidney disease stage 3 (CKD stage 3, a condition where the kidneys have moderate damage and are less able to filter waste from the blood). Patient 24 presented to the emergency department for severe abdominal pain.

During a concurrent interview and record review on 3/6/2025 at 5:10 p.m. with Nurse Manager (NM) 4, Patient 24's Electronic Medical Record (EMR, a digital chart used by healthcare providers) document titled, "pain Assessment," dated 3/5/2025, was reviewed. The pain assessment at 11:54 a.m. indicated Patient 24's pain as 6 out of 10 (on a scale where 0 = no pain and 10 = the worst pain imaginable). Fifty-five minutes later, at 12:49 p.m., Patient 24's pain escalated to 10 out of 10, indicating severe, uncontrolled pain. NM 4 stated that when a patient reports pain, it should be addressed promptly, and pain should not have to escalate to 10/10 before PRN (as-needed) medication was administered.

During a concurrent interview and record review on 3/6/2025 at 5:25 p.m. with Nurse Manager (NM) 4, Patient 24's "Medication Administration Record (MAR, a record that tracks all medication administrated to a patient, including dosing, timing, and route of administration)," was reviewed. The MAR indicated that Patient 24 received 4 milligrams (mg, a unit of measurement) of intravenous injection (IV, administered into the vein) Morphine (a strong pain medication that works by blocking pain signals to the brain) at 12:49 p.m. on 3/5/2025.
The physician's order (MD 1' order) indicated the following:

-2mg of IV Morphine was prescribed for moderate pain (3-6 on the pain scale).
-4 mg of IV Morphine was prescribed for severe pain (7-10 on the pain scale).

During the same interview on 3/6/2025 at 5:25 p.m. with Nurse Manager (NM) 4, NM 4 confirmed that despite Patient 24 reporting a pain level of 6/10 at on 3/5/2025 at 11:54 a.m., the 2 mg dose was not administered as ordered for moderate pain. Instead, Patient 24 had to wait nearly an hour before receiving pain medication, at which point their pain worsened to 10/10, requiring a higher dose of medication. NM 4 confirmed that the PRN pain medication should have been administered at 11:54 a.m. on 3/5/2025, when than pain level was first reported at 6/10, rather than delaying treatment until the pain became severe.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Timing," dated 10/23/2024, the P&P indicated, "To ensure medications are administered by authorized clinicians in a safe and timely manner to meet the needs of the patient ...Medications not eligible for scheduled dosing times: Medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, therapeutic goals, pharmacokinetics of medication, specific clinical application, or patient risk factors: Drugs prescribed on an as needed (PRN) basis ...Staff will use their professional judgement in organizing and prioritizing patient care to assure medications are delivered in a safe and timely manner. This includes: Recognition of the complex nature and variability among medications, the clinical indications for which a medication is prescribed, and the needs of the patient receiving medications. Staff administering medications have an affirmative duty to prioritize additional activities necessary to the administration of a medication, such as vital sign assessment ...to ensure safe and timely medication administration."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated, "It is the policy of (name of the facility) to recognize the patient's right to pain relief and supports a comprehensive approach to pain assessment and pain management including safe opioid use and prescribing, and use of multimodal treatment options to manage both acute and persistent pain ... The patient self-report of pain is the gold standard of assessment ... Patients shall receive treatment for any active pain issue (acute or persistent), when intensity exceeds their acceptable level in a timely manner. Treatment shall be consistent with the patient's clinical presentation ..."

Based on interview and record review, the facility failed to ensure that the medical records for three (3) of 31 sampled patients (Patient 1, Patient 4, and Patient 22) were completed and promptly filed in the patients' medical records in order to be readily available to the physician and other providers to use in making assessments of Patient 1, Patient 4, and Patient 22's condition and in making decisions on the provision of care/treatment to the patient when:

1. Patient 1 had no telemetry strips (graphical representation of a patient's heart rhythm recorded during monitoring with a telemetry system [an automated process that measures and wirelessly transmits data from remote sources to a central location for monitoring and analysis]) filed in Patient 1's electronic medical records (EMR, digital version of paper chart) for the time Patient 1 spent in the Emergency Department (ED, an area in the hospital where patients receive immediate medical care ) from 10/4/2024 to 10/5/2024, in accordance with the facility's regarding patient assessment and care planning documentation.

This deficient practice had the potential for Patient 1's heart rhythm record not to be readily available for review, assessment, and evaluation for cardiac (heart) issues or complications, potentially delaying delivery of timely care and necessary interventions.

2. Patient 4 did not have a documented care plan (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care) developed and implemented to address a diagnosis of postoperative abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 4's pain not to be managed effectively which can negatively impact patient's quality of life, emotional well-being, and recovery.

3. Patient 22 did not have a documented individualized nursing care plan (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care) to assess, manage, and monitor pain, in accordance with the facility's policy regarding care planning.

This deficient practice can lead to breakdowns in communication among healthcare providers, resulting in inconsistent pain assessment, delays in medication administration, and missed opportunities to adjust treatment based on the patient's response. Without a documented pain care plan, nurses, physicians, and other care team members may lack access to critical information regarding Patient 22's pain status, interventions performed, and the effectiveness of treatment.

Findings:

1. During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED, a hospital area that treats patients who need immediate medical care) Summary Report," dated 10/4/2024, the MR indicated that Patient 1 came to the Emergency Department (ED) on 10/4/2024 at 10:32 p.m., with a chief complaint of shortness of breath and difficulty breathing (dyspnea) and was admitted to telemetry unit (a hospital unit that can provide continuous monitoring of vital sign [VS, measurements of the body's most basic functions] that continuously transmit data, such as your heart rate, breathing, and blood pressure to monitor medical condition) on 10/5/2024 at 12:25 a.m., but continued to remain in the ED until 3:46 p.m. on 10/5/2024 when Patient 1 was eventually physically transferred to telemetry unit when the inpatient (for patients who get admitted to the hospital for treatment) bed became available.

During a concurrent interview and record review on 3/5/2025 at 2:10 p.m. with clinical informaticist (CI, one who specializes in technology and data to improve healthcare delivery, patient care, and overall health outcomes), Patient 1's electronic medical record (EMR, digital version of paper chart), dated 10/4/2024 through 10/5/2024, was reviewed. Patient 1's EMR contained no record of telemetry strips (graphical representation of a patient's heart rhythm recorded during monitoring with a telemetry system [an automated process that measures and wirelessly transmits data from remote sources to a central location for monitoring and analysis]) filed in Patient 1's electronic medical record (EMR) for the time Patient 1 spent in the Emergency Department (ED, an area in the hospital where patients receive immediate medical care ) from 10/4/2024 to 10/5/2024. CI stated that rhythm strip records were not uploaded to Patient 1's EMR (to demonstrate telemetry monitoring at four-hour intervals). CI stated that CI was not familiar with the ED policy regarding retention of telemetry monitoring rhythm strips.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Services-Standards of Care," dated 3/2024, the P&P indicated the following:
IX. Telemetry monitoring: a. Documentation of telemetry monitoring and rhythm strips will be printed and retained for uploading into the medical record:
i. Initiation of monitoring
ii. Change in condition
iii.at 4-hour intervals

2. During a review of Patient 4's History and Physical (H&P, a comprehensive assessment of a patient that includes a thorough medical history and a physical examination), dated 3/4/2025, the H&P indicated that Patient 4 was admitted with a diagnosis of postoperative abscess (a localized collection of pus that occurs in a surgical site following a surgical procedure) and right flank (refers to the side of the body of the between the rib cage and the hip) and right lower abdominal pain.

During further review of Patient 4's History and Physical (H&P), the H&P indicated that Patient 4 underwent interventional radiology (IR, guided procedure involving the use of imaging techniques to assist in performing minimally invasive procedures) to drain the abscess and had placement of a drainage catheter (a flexible tube placed to drain fluid or pus from body cavities) and was admitted to telemetry monitoring unit (a unit that provides continuous monitoring of patient's vital signs, particularly heart rhythm and rate, using wireless devices that transmit data to a central monitoring system).

During a review of Patient 4's medical record (MR) titled, "Inpatient Plan of Care (a detailed, individualized plan outlining the medical, nursing, and other interventions needed during a patient's stay in a hospital or other inpatient facility, aiming to achieve specific health goals and ensure safe and effective care), dated 3/4/2025, and updated on 3/6/2025, the MR indicated that Patient 4 did not have a care plan developed to address Patient 4's pain.

During an interview on 3/5/2025 at 3:10 p.m. with charge nurse (CN) 2, CN 2 stated that if a patient was admitted with pain and had orders for pain management, a nursing care plan must be developed. The CN 2 also stated that typically a care plan contained interventions and education for pain management (specific strategies and actions to assess, manage and alleviate a patient's pain, and education provides patients with information about pain management).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Care Planning," dated 10/23/2024, the P&P indicated the following: B. Developing and Implementing a Plan of Care:

3. Once needs have been identified and prioritized, members of the healthcare team develop, implement, and evaluate the plan of care, for the patient. This is documented in the patient's medical records.
4. The plan of care should identify the following:
a. The need(s) to be addressed
b. The care goal(s) relative to the need identified
c. Interventions planned by the healthcare team to address the need and meet the care goals
d. Monitoring of the patient's progress toward achieving the care goals(s).

3. During a review of Patient 22's History and Physical (H&P, a comprehensive assessment including a patient's medical history and a physical examination), dated 3/3/2025, the H&P indicated Patient 22 was brought into the emergency department due to a trauma injury (a serious physical injury caused by an external force, such as a fall, accident, or blow to the body, that can result in damage to bones, muscles, organs, or the brain). The H&P further indicated that Patient 22 had a head injury on the right scalp, which included a head laceration (a deep cut or tear in the skin, often requiring stitches to close the wound). The head laceration measured 3 centimeters (cm, a unit of measurement) and required a surgical procedure (a medical operation performed by a doctor to treat an injury, remove damaged tissue, or repaired a wound) to close the wound with staples. The H&P also indicated that Patient 22 had a history of musculoskeletal pain (pain affecting the muscles, bones, ligaments, tendons, and nerves, which can cause chronic discomfort, stiffness, or mobility issues). For pain management, the H&P indicated the physician ordered Fentanyl (a powerful pain medication used to relieve severe pain by blocking pain signals in the brain).

During a concurrent interview and record review on 3/5/2025 at 2:27 p.m. with the Nurse Manger (NM) 4, Patient 22's Electronic Medical Record (EMR, a digital chart used by health care provider) document titled, "Inpatient Plan of Care (a detailed plan that outlines the medical, nursing, and other interventions required for a patient during their hospital stay to ensure safe and effective treatment)," was reviewed. The EMR, dated 3/5/2025 and updated on 3/5/2025, indicated that no care plan was developed to address Patient 22's pain, despite the patient's history of chronic (long-lasting or persistent) pain and the need for post-surgical pain relief. NM 4 stated it was important that a care plan for pain was developed for Patient 22.

During an interview on 3/5/2025 at 3:10 p.m. with Charge Nurse (CN) 2, CN 2 stated that if a patient was admitted with pain and had a physician's order for pain management, a nursing care plan for pain management must be developed. CN 2 further stated this care plan should include: Nursing interventions (specific actions taken by nurses to help relieve pain, such as administering prescribed medications, repositioning the patient, or applying cold or warm compresses) and Patient education (teaching the patient about their pain management options and how to report pain effectively to healthcare providers).

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Documentation Standards," dated 6/11/2020, the P&P indicated, "Documentation integrity involves the accuracy and completeness of the health record. The procedure below provides guidance to (name of the facility) workforce members to ensure compliance with Federal and State laws, rules and regulations and accrediting standards in regard to documentation requirements within the medical record... All relevant documents and entries should be entered into the medical record at the time the service is rendered. The electronic medical record (EMR) must be used for documentation in areas where its implementation has been completed. Every individual documenting in the medical record is responsible for the entire content of his/her documentation, whether the content is original, copied, pasted, recalled or reused. Those who document are responsible for the accuracy, medical necessity, and documentation requirements of each of their notes."

During a review of the facility's policy and procedure (P&P) titled, "Standard Procedures for Nursing," dated 10/19/2023, the P&P indicated, "This is an organization-wide policy. It applies to all settings and services where Standardized Procedures may be initiated ...
A. California Code of Regulations
1. Standardized Procedures are the legal mechanism for Registered Nurses (RN) and Nurse Practitioners (NP) to perform functions which would otherwise be considered the practice of medicine pursuant to California Business and Professional Code § 2725 ... (10) Specify patient record-keeping and other documentation requirements."

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Care Planning," dated 10/23/2024, the P&P indicated the following: B. Developing and Implementing a Plan of Care:

-Once needs have been identified and prioritized, members of the healthcare team develop, implement, and evaluate the plan of care, for the patient. This is documented in the patient's medical records.
-The plan of care is developed, when possible, in conjunction with the patient and family, as appropriate. The plan of care should identify the following:
-The need(s) to be addressed
-The care goal(s) relative to the need identified
-Interventions planned by the healthcare team to address the need and meet the care goals
-Monitoring of the patient's progress toward achieving the care goals(s).
-Once the plan of care is developed, the healthcare team implements it. Each discipline documents their interventions in the patient's medical record and the patient's response to these interventions.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated the following:

1. Pain is reassessed with new reports of pain, with procedures or activities that are expected to cause pain, and at appropriate intervals to evaluate the effectiveness of pain management interventions ...
4. The pain management treatment plan should consider the risks and benefits, and potential risk of dependency, addiction, and abuse (if applicable).
5. Involve patient/family and members of the multidisciplinary team in the pain management planning process through the following:
a. Developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain.
b. Establishing an individualized plan of care for pain management that addresses the patient's unique pain issues to include ongoing assessments and reassessments to evaluate response to interventions.
c. Establishing an acceptable pain management or comfort goal which includes a satisfactory level of pain that would allow him/her to carry out activities of daily living (ADLs) and maintain an improved quality of life (e.g., ability to take a deep breath, turn, move, or walk with improved pain control).

Based on observation, interview and record review, the facility failed to ensure there was a clear description of patient behavior documented to explain restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 31 sampled patients (Patient 16), when nursing staff did not document what was Patient 16's specific behavior regarding interfering with medical care , that warrants the use of restraints to ensure Patient 16's immediate physical safety, in accordance with the facility's policy regarding restraints use and documentation.

This deficient practice had the potential to result in incomplete medical record that does not reflect Patient 16's need for restraints, which may lead to unnecessary use of restraints and other complications such as circulatory (blood flow) and skin breakdown (when prolonged pressure or friction damages the skin and underlying tissues), etc.

Findings:

During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/25/2025, the H&P indicated, Patient 16 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), new onset atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure), alcohol use and hypertension (high blood pressure).

During a concurrent observation and interview on 3/4/2025 at 3:44 p.m. with Registered Nurse (RN) 5 in Patient 16's room, Patient 16 was observed in bed with eye closed, calm with family at bedside. Patient 16 had a nasogastric tube (NGT, a thin flexible tube inserted through the nose into the stomach for feeding and medication) and bilateral (both) wrist restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on. RN 5 confirmed Patient 16 had bilateral wrists restraints on.

During a concurrent interview and record review on 3/6/2025 at 4:56 p.m. with Registered Nurse (RN) 11, Patient 16's "Restraints, Non-Violent (restraints flowsheet)," dated from 3/4/2025 to 3/5/2025, was reviewed. The restraints flowsheet indicated, Patient 16 was placed on bilateral (both) wrist restraints on 3/4/2025 at 9 a.m. and removed at 11:05 a.m. The restraints flowsheet also indicated, Patient 16 was placed on bilateral wrist restraints on 3/4/2025 at 3:06 p.m. and removed on 3/5/2025 at 9 a.m. RN 11 confirmed that Patient 16's restraints was removed at 11:05 a.m. and restraints was applied again at 3:06 p.m. (4 hours later) on the same day (3/4/2025).

During a concurrent interview and record review on 3/6/2025 at 5:10 p.m. with Registered Nurse (RN) 11, Patient 16's physician orders, dated 3/4/2025, was reviewed. The physician order indicated the following:

-"On 3/4/2025 at 8:52 a.m.: Restraint - nonviolent with indication of interfering with essential medical care and additional information: bilateral soft wrist restraints;
-On 3/4/2025 at 3:02 p.m.: Restraint - nonviolent with indication of interfering with essential medical care."
-RN 11 stated physician order was required for each episode of restraints application.

During an interview on 3/7/2025 at 11:56 a.m. with the Nurse Manager (NM) 1 of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) and Definitive Observation Unit (DOU, hospital unit providing close monitoring care to patients), NM 1 stated soft wrists restraints would be used when patient was interfering with care with behavior like removing lines and dressing or pulling off oxygen mask that were important to the patient.

During a concurrent interview and record review on 3/7/2025 at 11:56 a.m. with Nurse Manager (NM) 1, Patient 16's "Restraints, Non-Violent (restraints flowsheet)," dated 3/4/2025, was reviewed. The restraints flowsheet indicated the following:

-"On 3/4/2025 at 9 a.m.: restraint type: bilateral soft limb/foam; non-violent reason for restraint: interfering with care, removing medical device, restraint prevent strategy: de-escalation techniques, re-orientation techniques, explain plan of care, increased observation, reduce stimuli.
-On 3/4/2025 at 11:05 a.m.: restraints removed. Restraint monitoring note: patient pulled out nasogastric tube (NGT, a thin flexible tube inserted through the nose into the stomach for feeding and medication) two times ... no longer need restraints.
-On 3/4/2025 at 3:06 p.m.: restraints type: bilateral anchored mitten; non-violent reason for restraint: interfering with care; restraint prevent strategy: limit setting, explain of plan of care, medication review, non-anchored mittens, increased observation and reduce stimuli."
-The restraint flowsheet did not indicate what type of specific patient behavior was being referred to as interfering with medical care. NM 1 stated Patient 16 pulled out NGT two times which implied Patient 16 continued to pull out the NGT hence Patient 16 required restraints. NM 1 was unable to provide any documentation describing Patient 16's behavior when restraints was applied at 3:06 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Non-Violent and Violent Restraints and Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)," dated 7/2024, the P&P indicated, "non-violent or non-self destructive restraint use: restraints used to manage behaviors which interfere with medical/surgical healing. For example, the patient may be trying to pull out lines or tubes and less-restrictive methods or alternative measures have not worked ... Restraint or seclusion use is limited to situations necessary to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time ...The use of restraint or seclusion is based on assessment of the needs of the patient ... Restraints for Non-Violent and Non-Destructive Behavior. The patient may be restrained for non-violent reasons only if the patient's behavior is interfering with essential medical care ... Documentation: all restraint or seclusion use is documented in the electronic medical record (EMR). Documentation includes ... description of patient's behavior and intervention used ... patient's condition or symptoms(s) that warranted the use of restraint or seclusion ... patient's response to intervention(s) used, including rationale for continued use of the intervention."

Based on interview and record review, the facility failed to demonstrate that Precedex (dexmedetomidine is a drug used to manage pain and sedation in the Intensive Care Unit [ICU, a specialized hospital ward that provides treatment and monitoring for people who are very ill)] and in the operating room [where surgical procedures are done]) order set was safe to be used on patients outside of the intensive care setting, in accordance with current Food and Drug Administration (FDA, the regulatory agency responsible for overseeing the safety and efficacy of mediation and medical devices) guidelines. In addition, the facility failed to demonstrate how the use of Precedex for an extended period (exceeding 24 hours recommended by the FDA period), when used for off-label indications (medications for an indication, or using a dosage or dosage form, that has not been approved by the FDA) was consistent with indications and usage for Precedex as outlined in nationally recognized and evidence-based (a decision-making approach that integrates the best available research evidence with clinical expertise and patient values to improve healthcare outcomes) guidelines.

This deficient practice had the potential to compromise patient safety, placing patients at risk for potential side effects and complications associated with prolonged use of Precedex when the Precedex order set was not administered in a controlled ICU environment where patients were closely monitored.

Findings:

During a review of the facility's current Precedex (medication indicated for sedation of initially intubated and mechanically ventilated adult patients during treatment in an intensive care setting) order set, which provides guidelines for the administration of Precedex titration drip (a continuous intravenous [given directly into a vein] infusion of Precedex that allows for controlled sedation levels), the following was reviewed in the protocol set:

Protocol... Titrate every 10 minutes to achieve RASS (Richmond Agitation -Sedation Scale, a scale used to assess a patient's level of sedation or agitation) 0 to -2 ( RASS 0 Patient is alert and awake, RASS - 1 indicates patient is drowsy, but can be awakened with verbal stimuli; RASS -2 indicates that the patient is more sedated, is not fully alert, and cannot be aroused easily with physical touch).
...After infusing in the ICU (Intensive Care Unit, a specialized department in a hospital designed for the continuous monitoring and treatment of critically ill patients) for 12 hours, the infusion may continue in the DOU (Direct Observation Unit, a unit where patients require close monitoring, but do not need the intensive care provided in the ICU).
Once in DOU status: Monitor RASS , MAP (Mean Arterial Pressure, an important measure of blood pressure that reflects the perfusion (blood supply) pressure seen by organs), and HR (heart rate, the number of heart beats per minute) at every titration ( a process of adjusting the amount of a drug at varying doses, monitoring the patient's response, and adjusting the dosage based on clinical outcomes, guidelines, or specific protocols).
In ICU status: Monitor RASS, MAP, and HR at every titration and hourly.

During an interview on 3/6/2025 at 8:51 a.m. with Pharmacy Manager (Pharm 1) regarding the Precedex Intravenous (IV) administration guidelines, Pharm 1 stated the following: "We refer to the package insert (a document provided by the manufacturer that includes essential information about the drug, including dosing, administration guidelines, contraindications, and potential side effects) which tell us about the titration (the administration of a pharmaceutical solution (medication or drug) over time through an intravenous (IV) mode using a drip system). Precedex has black and white dosing and titration rates. As to indication for use, we also look at studies for off-label use (the use of a medication for a purpose not specifically approved by regulatory agencies). Precedex is used for sedation and agitation associated with intubation according to the package insert in accordance with FDA (Food and Drug Administration, the regulatory agency responsible for overseeing the safety and efficacy (the ability of an intervention to produce the desired beneficial effect) of medications)." Pharm 1 then also stated that Precedex has no defined maximum duration for how long it can be used on a patient, in accordance with FDA recommendations and package insert.

During the same interview on 3/6/2025 at 9:05 a.m. with Pharmacy Manager (Pharm 1) regarding the facility's typical use of Precedex, Pharm 1 stated that Precedex was typically used for sedation of agitated patients, and for CIWA (Clinical Institute Withdrawal Assessment protocol -a standardized assessment tool used to evaluate the severity of alcohol withdrawal symptoms in patients, guiding the management and treatment withdrawal). Pharm 1 then stated that the facility only allows administration of Precedex for CIWA in the Intensive Care Unit (ICU), but Precedex for sedation can be administered in the Direct Observation Unit (DOU, a specialized area where patients are closely monitored, often following procedures or requiring short term observation). Pharm 1 said that the reason patients must remain in the ICU while on the CIWA protocol was not due to the administration of Precedex but because of the alcohol withdrawal process (may range from a mild and uncomfortable disorder to a serious, life-threatening condition) or the CIWA score that was driving the patient to be in an ICU status (the determination for a patient to be admitted to the Intensive Care Unit [ICU] is based on the CIWA scores, that require close observation and immediate medical intervention due to the potential complications associated with severe alcohol withdrawal).

During the same interview on 3/6/2025 at 9:07 a.m. with Pharmacy Manager (Pharm 1), Pharm 1 said the following: "When titrating Precedex, patients should be monitored for low blood pressure and slow heart rate (bradycardia). Bradycardia usually occurs with loading doses, but we don't practice administering loading doses, we titrate slowly [in accordance with the drug's guidelines]. However, the heart rate and blood pressure should still be monitored, because we are changing hemodynamics (the dynamics of blood flow and circulation) in a patient, placing the patient at risk for low blood pressure."

During an interview on 3/6/2025 at 9:15 a.m. with Pharmacy Manager (Pharm 1), Pharm 1 said the following: "The frequency of monitoring vital signs (VS) is less in the Direct Observation Unit (DOU) because nurses do not initiate the titration in DOU, but rather have the patient on a maintenance dose. The new Precedex protocol order set indicates that for the first 12 hours of Precedex titration and administration, patients remain at the ICU level of care but can be then transitioned to DOU level of care [this means that after 12 hours of administration of Precedex, during which the patient is closely monitored in the ICU to ensure their safety, the patient can be then moved to DOU for continued care. The DOU allows for less intensive monitoring while still providing a level of observation for patient who do not require the full resources and supervision of the ICU. The transition reflects an assessment that the patient is stable enough to be safely monitored in a less intensive setting]."

During the same interview on 3/6/2025 at 9:15 a.m. with Pharmacy Manager (Pharm 1), Pharm 1 stated that once Precedex continues at a DOU level of care, vital signs (VS) can be taken every 4 hours, as opposed to every 1 hour in accordance with the ICU scope of practice and (the nursing staffing ratio can be increased to 1 nurse per 3 patients in the DOU staffing model, as opposed to a 1 nurse to 2 patients ratio in the ICU staffing model) .

During a concurrent interview and record review on 3/6/2025 at 9:21 a.m. with Pharmacy Manager (Pharm 1), FDA label for Precedex that the facility referenced to justify administration of Precedex to patients in a DOU setting, was reviewed. The FDA label indicated the following:

1. Indication and Usage
1.1. Precedex is indicated for sedation of initially intubated and mechanically ventilated adult patients during treatment in an intensive care unit setting. It should be administered by continuous infusion and not to exceed 24 hours.
1.2. Precedex is also indicated for sedation of non-intubated adult patients prior to abd/or during surgical and other procedures.
1.3. Additionally, it is indicated for sedation of non-intubated pediatric patients aged 1 month to less than 18 years prior to and during non-invasive procedures.

During the same interview on 3/6/2025 at 9:21 a.m. with Pharmacy Manager (Pharm) 1, Pharm 1 stated the following: "Precedex order set has been recently approved, in January this year [2025] by the Pharmacy and Therapeutics Committee (P&T Committee, a multidisciplinary group within a healthcare organization, usually compromising pharmacists, physicians, nurses and other healthcare professionals, responsible for overseeing the appropriate use of medications within the institution, including the evaluation, selection, and management of drugs in the formulary) after nursing input was obtained. There are many medications that can be used off-label, such as Reglan (a medication commonly used to treat nausea) and it has not been approved by the FDA for the treatment of [non-chemotherapy related] nausea, while very commonly used in acute care settings. For instance, Precedex is a very light sedation drug and is used to keep patients sleepy and arousable (a state when a person can be awakened). Our facility has more conservative approach compared to other facilities... It is also not standard for the facility to inform patients about off-label use of medications..."

During an interview on 3/6/2025 at 9:39 p.m. with nurse manager of DOU and ICU (NM 1), NM 1 stated that the physician typically will have conversation with patient/family about the Precedex use but there is no written informed consent that is required. NM 1 also said that it is not a requirement to document the conversation regarding Precedex in physician's progress notes.

The facility did not provide current medical literature that supports the use of Precedex in a non-intensive care setting.

The facility does not have a protocol with clear clinical guidelines for the use of Precedex in the DOU to ensure the guidelines align with current clinical evidence and national guidelines.

A review of the FDA label for Precedex, dated 2024 indicated that patients receiving Precedex require continuous monitoring while receiving Precedex with the following indication and usage: 1.1. Intensive Care Unit sedation....

Based on interview and record review, the facility failed to ensure that the medical records for three of 31 sampled patients (Patient 10, Patient 21, and Patient 22) contained the pertinent medical information documented and filed in the patients' medical charts so that the health care staff involved in the patients' care could access and retrieve the information in order to monitor the patients' condition when:

1.a. Patient 10 had no copies of transfer documents retained and uploaded in Patient 10's electronic medical record (EMR, digital version of paper chart) to demonstrate that specific consistent information was forwarded to the receiving providers to ensure continuity of care and services when Patient 10 was transferred to another facility, in accordance with the facility's policy regarding patient transfers.

This deficient practice had the potential for Patient 10's essential medical information not to be communicated effectively, potentially leading to gaps in Patient 10's care, medication errors, and delays in necessary interventions.

1.b. Patient 10 had no timely discharge summary (a comprehensive medical document that summarizes a patient's hospitalization, outlining their diagnosis, treatment, progress, and recommendations for ongoing care, ensuring a smooth transition to the next level of care) filed prior to Patient 10's discharge and transfer to another facility, in accordance with the facility's policy regarding patient transfers.

This deficient practice had the potential for Patient 10's important medical information contained in the discharge summary to be missing from the patient's (Patient 10's) medical records potentially compromising continuity of care increasing Patient 10's risks to adverse health outcomes.

2. Patient 21's vital sign assessment was incomplete, did not include respiration rate (the number of breaths a person takes per minute) in accordance with the facility's policy and procedure regarding "Vital Signs" and Medical Record Documentation Standards.

This deficient practice resulted in missed opportunities to detect potential respiratory distress (when breathing becomes difficult or labored), delayed interventions, and incomplete medical records for Patient 21. Inconsistent vital sign documentation can lead to poor clinical decision-making, lack of timely treatment adjustments, and increased risk of undetected complications such as respiratory failure, hypoxia (low oxygen levels in the blood), or worsening of the patient's underlying medical condition.

3. Patient 22's pain assessment was not performed consistently and documented as a complete pain assessment, including pain level, location duration, and description of the pain, in accordance with the facility's policy and procedure regarding "Pain Management."

This deficient practice resulted in incomplete clinical records, missed opportunities for appropriate pain management interventions, and potential delays in treatment. Inadequate pain assessment can lead to increased suffering, impaired mobility, delayed healing, and ineffective pain relief, which can negatively impact Patient 22's overall recovery.

Findings:

1.a. During a review of Patient 10's History and Physical (H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings), dated 3/4/2025, the H&P indicated that Patient 10 was admitted to the facility on 3/4/2025 due to a fall (an unintentional descent to the floor or another lower level, regardless of whether an injury occurs) while trying to get onto the bed. The H&P further indicated that Patient 10 was unable to ambulate (walk), had left hip pain, and was admitted to trauma service (trauma services are designed to handle the most critical and complex cases of injury, focusing on immediate resuscitation, stabilization, and definitive care for patients with severe trauma) and medical-surgical unit (provide care for patients with a wide range of medical and surgical conditions).

During further review of Patient 10's medical record (MR) titled, "Consultation,' dated 3/4/2025, the MR indicated that a trauma surgeon was consulted to evaluate Patient 10's left hip injury. The MR further indicated that Patient 10 sustained a fracture of the left femur (thigh bone), but was stable and did not require a surgical intervention.

During a review of Patient 10's medical record (MR) titled, "Progress Note-Trauma Services," dated 3/5/2025, the MR indicated that Patient 10 was stable from trauma standpoint (In the context of an injury, a stable patient that does not require an immediate emergency intervention) for transfer to the same level facility (due to insurance purposes, based on the coverage and benefits provided by the insurance plan).

During a follow-up interview on 3/6/2025 at 5:25 p.m. with charge nurse (CN) 2, CN 2 stated that all pertinent medical information related to the patient's visit or stay such as H&P form, discharge summary, physician progress notes, consulting physician's notes, labs (lab results are the outcomes of medical laboratory tests, which involve analyzing samples [like blood, urine, or tissue] to determine the presence, absence, or levels of specific substances or conditions), and even CDs (Compact Disc, a digital storage medium that holds data such as images) if any, should be included in the transfer packet and transferred along with the patient to the accepting facility. CN 2 also stated that there should be a Transfer form (the form includes details such as the patient's medical history, current condition, medications, the reason for transfer, and etcetera) that typically contains the patient's health status prior to transfer, vital signs (VS, measurements of the body's most basic functions) prior to transport, and the accepting physician's information) and it should be scanned into patient's medical records.

During a concurrent interview and record review on 3/6/2025 at 5:40 p.m. with clinical informaticist (CI), Patient 10's electronic medical record (EMR, digital version of paper chart) was reviewed. CI was not able to locate the transfer documents such as retained Transfer Medication Reconciliation Form (ensures accurate medication lists during patient transfers), Transfer Summary (provides essential patient information), Patient Transfer Form (documents the transfer itself), Physician Certification for Ambulance Services (confirms the patient's stability and suitability for transport).

During an interview on 3/7/2025 at 2:49 p.m. with case manager (CM) 1, CM 1 stated that transfers to [Organization] facilities was slightly different from transfers to other hospitals because the entire transfer was set up by the facility's case management. CM 1 also stated that the case manager should fax the patient's preliminary information to the [Organization] and arrange for the transfer acceptance. The [Organization] then fax the checklist to the unit, detailing the documents that were required to be sent along with the patient. The checklist stays with the packet that was sent along with the patient to the accepting facility. The case manager stated that they (CM 1) were unaware if a copy of the checklist was retained in the patient's records.

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning and Transfer," dated 9/30/2024, the P&P indicated that the facility requires that specific, consistent information be forwarded to care providers to ensure continuity of care and services. The patient will be provided the following information when transferred: 1. Transfer SBAR (Situation, Background, Assessment and Recommendation- used to facilitate clear and concise information exchange, especially in healthcare, to improve patient safety and teamwork). 2. Belongings Records 3. Transfer Medication Reconciliation form 4. Med summary (eMAR, electronic Medication Administration Record), 5. Case Management Information Packet 6. Transfer Summary (E Forms), 7. Patient Transfer form (E Form), 8. Physician Certification for Ambulance Services (E forms), 9. Copies of portions of the Medical Record according to each facility's request.

1.b. During a review of Patient 10's History and Physical (H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings), dated 3/4/2025, the H&P indicated that Patient 13 was admitted to the facility on 3/4/2025 due to a fall while trying to get onto the bed. The H&P further indicated that Patient 13 was unable to ambulate (walk), had left hip pain, and was admitted to trauma service (trauma services are designed to handle the most critical and complex cases of injury, focusing on immediate resuscitation, stabilization, and definitive care for patients with severe trauma) and medical-surgical unit (provide care for patients with a wide range of medical and surgical conditions).

During further review of Patient 10's medical record (MR) titled, "Consultation,' dated 3/4/2025, the MR indicated that a trauma surgeon was consulted to evaluate Patient 10's left hip injury. The MR further indicated that Patient 13 sustained a fracture of the left femur (thigh bone), but was stable and did not require a surgical intervention.

During a review of Patient 13's medical record (MR) titled, "Progress Note-Trauma Services," dated 3/5/2025, the MR indicated that Patient 10 was stable from trauma standpoint (In the context of an injury, a stable patient that does not require an immediate emergency intervention) for transfer to the same level facility (due to insurance purposes, based on the coverage and benefits provided by the insurance plan).

During a follow-up interview on 3/6/2025 at 5:25 p.m. with charge nurse (CN) 2, CN 2 stated that all pertinent medical information related to the patient's visit or stay such as H&P form, discharge summary, physician progress notes, consulting physician's notes, labs (lab results are the outcomes of medical laboratory tests, which involve analyzing samples [like blood, urine, or tissue] to determine the presence, absence, or levels of specific substances or conditions), and even CDs (Compact Disc, a digital storage medium that holds data such as images) if any, should be included in the transfer packet and transferred along with the patient to the accepting facility.

During a review of Patient 10's medical record (MR) titled, "Nurse Notes," dated 3/5/2025, the MR indicated that Patient 10 was discharged to the [Organization- receiving facility] on 3/5/2025 at 6:01 p.m.

During a concurrent interview and record review on 3/6/2025 at 5:45 p.m. with clinical informaticist (CI), Patient 10's electronic medical record (EMR) was reviewed. Patient 10's Discharge Summary (a comprehensive document summarizing a patient's hospital stay, including diagnoses, treatments, progress, and recommendations for ongoing care) was not located in the EMR. CI verified that Discharge Summary was not found in Patient 10's electronic medical records (EMR).

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning and Transfer," dated 9/30/2024, the P&P indicated that the facility requires that specific, consistent information be forwarded to are providers to ensure continuity of care and services. The patient will be provided the following information when transferred to a higher level of care (in healthcare, "higher level of care" means a more intensive and specialized form of treatment or support than what's typically provided, often involving more frequent or longer-term interventions, and potentially a higher level of staff to patient ratio) or the same level of care ...the patient will be provided the following information when discharged from the facility 3. Discharge Summary

2. During a review of Patient 21's "ED Physician Documentation" note, dated 1/16/2025, the ED Physician note indicated that Patient 21 had reported experiencing swollen hands and was lightheaded (sensation of dizziness or feeling faint) over the past three days. The note further indicated Patient 1 had a medical history of hypertension (high blood pressure) and dyslipidemia (a medical condition where there are abnormal levels of lipids [fats] in the blood increasing the risk of heart disease).

During a concurrent interview and record review on 3/6/2025 at 11:35 a.m. with Registered Nurse (RN) 11, Patient 21's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) document titled, "Vital Signs," dated from 1/24/2025 through 1/28/2025, was reviewed. RN 11 stated Patient 21 had telemetry status which required vital signs to be checked every four hours. However, the EMR showed multiple gaps in documentation where the respiration rate was not recorded:

-On 1/24/2025 at 11:30 p.m., no respiration rate was documented.
-On 1/25/2025 at 11:38 a.m., no respiration rate was documented.
- On 1/25/2025 at 3:46 p.m.., no respiration rate was documented.
-On 1/25/2025 at 7:47 p.m., no respiration rate was documented.
-On 1/27/2025 at 11:07 p.m., no respiration rate was documented.

During the same interview on 3/6/2025 at 11:35 a.m. with Registered Nurse (RN) 11, RN 11 confirmed that respiration rate should have been recorded during every vital sign assessment and that these gaps indicate incomplete documentation, which could lead to missed signs of respiratory distress or worsening health conditions.

During an interview with on 3/7/2025 at 11:00 a.m. with the Charge Nurse (CN) 7, CN 7 stated, "Respiration is part of the vital signs assessment and must be documented."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs," dated 3/13/2024, the P&P indicated, "Vital signs include; blood pressure, heart rate, respiratory rate, temperature, oxygen saturation and pain ...All patients will have vital signs assessed in accordance with their specific condition, care needs and standard for the area where they are being cared for, or as importantly, the circumstances under which they are being cared for at the time. Patient vital signs will be assessed, collected, documented and communicated."

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Documentation Standards," dated 6/11/2020, the P&P indicated, "Documentation integrity involves the accuracy and completeness of the health record. The procedure below provides guidance to (name of the facility) workforce members to ensure compliance with Federal and State laws, rules and regulations and accrediting standards in regard to documentation requirements within the medical record... All relevant documents and entries should be entered into the medical record at the time the service is rendered. The electronic medical record (EMR) must be used for documentation in areas where its implementation has been completed. Every individual documenting in the medical record is responsible for the entire content of his/her documentation, whether the content is original, copied, pasted, recalled or reused. Those who document are responsible for the accuracy, medical necessity, and documentation requirements of each of their notes."

During a review of the facility's policy and procedure (P&P) titled, "Standard Procedures for Nursing," dated 10/19/2023, the P&P indicated, "This is an organization-wide policy. It applies to all settings and services where Standardized Procedures may be initiated ...
A. California Code of Regulations
1. Standardized Procedures are the legal mechanism for Registered Nurses (RN) and Nurse Practitioners (NP) to perform functions which would otherwise be considered the practice of medicine pursuant to California Business and Professional Code § 2725 ...
(10) Specify patient record-keeping and other documentation requirements."

3. During a review of Patient 22's History and Physical (H&P, a comprehensive assessment including a patient's medical history and a physical examination), dated 3/3/2025, the H&P indicated Patient 22 was brought into the emergency department due to a trauma injury (a serious physical injury caused by an external force, such as a fall, accident, or blow to the body, that can result in damage to bones, muscles, organs, or the brain). The H&P further indicated that Patient 22 had a head injury on the right scalp, which included a head laceration (a deep cut or tear in the skin, often requiring stitches to close the wound). The head laceration measured 3 centimeters (cm, a unit of measurement) and required a surgical procedure (a medical operation performed by a doctor to treat an injury, remove damaged tissue, or repaired a wound) to close the wound with staples. The H&P also indicated that Patient 22 had a history of musculoskeletal pain (pain affecting the muscles, bones, ligaments, tendons, and nerves, which can cause chronic discomfort, stiffness, or mobility issues). For pain management, the H&P indicated the physician ordered Fentanyl (a powerful pain medication used to relieve severe pain by blocking pain signals in the brain).

During a concurrent interview and record review on 3/5/2025 at 2:27 p.m. with Nurse Manger (MN) 4, Patient 22's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) document titled, "Pain Assessment," dated 3/4/2025, was reviewed. The EMR indicated for 3/4/2025 at 12:03 a.m. and at 4:03 a.m., "Current pain: Yes, and at right hip;" However, the pain location, duration, and description were left blank.

During concurrent interview and record review on 3/5/2025 at 2:35 p.m. with Nurse Manager (NM) 4, Patient 22's EMR document titled, "Medication Administration Record (MAR)," dated 3/4/2025, was reviewed. The MAR indicated that no pain medication was administered within 12:03 a.m. and at 4:03 a.m. on 3/4/2025. NM 4 was unable to determine from the documentation why there were blanks in the pain assessment during this period.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/18/2024, the P&P indicated, "It is the policy of (name of the facility) to recognize the patient's right to pain relief and supports a comprehensive approach to pain assessment and pain management ... Comprehensive Pain Assessment: An assessment process that includes an evaluation of, but is not limited to: the reported origin or cause of pain, signs and symptoms, aggravating and alleviating factors, onset, duration, location/site, intensity, quality, and response to prior treatment."

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Documentation Standards," dated 6/11/2020, the P&P indicated, "Documentation integrity involves the accuracy and completeness of the health record. The procedure below provides guidance to (name of the facility) workforce members to ensure compliance with Federal and State laws, rules and regulations and accrediting standards in regard to documentation requirements within the medical record... All relevant documents and entries should be entered into the medical record at the time the service is rendered. The electronic medical record (EMR) must be used for documentation in areas where its implementation has been completed. Every individual documenting in the medical record is responsible for the entire content of his/her documentation, whether the content is original, copied, pasted, recalled or reused. Those who document are responsible for the accuracy, medical necessity, and documentation requirements of each of their notes."

During a review of the facility's policy and procedure (P&P), titled "Standard Procedures for Nursing" dated 10/19/2023, the P&P indicated, "This is an organization-wide policy. It applies to all settings and services where Standardized Procedures may be initiated ...
A. California Code of Regulations
1. Standardized Procedures are the legal mechanism for Registered Nurses (RN) and Nurse Practitioners (NP) to perform functions which would otherwise be considered the practice of medicine pursuant to California Business and Professional Code § 2725 ... (10) Specify patient record-keeping and other documentation requirements."