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

1. The facility failed to appropriately respond to one of 30 sampled Behavioral Health Unit (BHU,inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 30), who manifested intentions of leaving/eloping (leaving the facility without physician's permission when doing so may present an imminent threat to the person's health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility, in accordance with the facility's policy regarding patients identified as elopement risk.

This deficient practice resulted in Patient 30 eloping and putting the 5150 (temporary, involuntary psychiatric [mental health] hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled [unable to care for one's self due to mental health issues], hold is designed to provide period of professional evaluation and treatment for person in crisis) patient (Patient 30) in danger to harm himself and a potential to harm others. (Refer to A-0144)

2. The facility failed to ensure one of 30 sampled patients (Patient 19), received care in a safe setting, in accordance with the facility's policy on patient rights (a subset of human rights. Example: the right to considerate and respectful care), when a male visitor for another patient entered Patient 19's room and opened the shower curtain while Patient 19 was in the shower.

This deficient practice resulted in Patient 19 having felt violated and had the potential for Patent 19 to suffer from psychological and physical harm. (Refer to A-0144)

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

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) was met, as evidenced by:

1. The facility's Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) program failed to implement an appropriate action plan, in a timely manner, to prevent medication errors from happening, in accordance with the facility's performance improvement plan, after a Registered Nurse (RN 1) removed a wrong medication from the Pyxis (automated medication dispensing machine) tower and administered to one of 30 sampled patients (Patient 2) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department.

This deficient practice had the potential to result in the same or similar medication error happening on other nursing units and potentially causing harm to patients. (Refer to A-0286)

2. The facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight for the Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements), to address and prioritize actions needed to address patient safety issues resulting from a medication error for one of 30 sampled patients (Patient 2), to ensure there was a safe medication removal and administration process for the entire hospital units when nursing staff were retrieving medications from the Pyxis (automated medication dispensing machine) Tower.

This deficient practice had the potential to put other patients at risk for medication error. (Refer to A-0309)

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

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

1. The facility failed to ensure the Nursing staff addressed one of 30 sampled patient's (Patient 7) pain levels of 8/10 and 9/10 based on a pain scale (0-2: Mild pain, 3-4: Moderate pain, 5-6: Severe pain, 7-10: Very severe pain), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for inadequate pain control, prolonged patient suffering from pain, and psychological distress (Example: anxiety [feeling of unease]), which may lead to prolonged recovery from illness. (Refer to A-0395)

2. The facility failed to ensure Nursing staff notified the physician regarding the new onset of chest pain for one of 30 sampled patients (Patient 7), in accordance with the facility's policy regarding physician notification.

This deficient practice had the potential for delayed diagnosis and treatment which may result in worsening of Patient 7's condition and/or death. (Refer to A-0395)

3. The facility failed to ensure one of seven sampled nursing staff's (RN 14) unit-specific competencies (an integrated set of knowledge, skills, abilities, judgment, values, and professional behaviors that enable a nurse to effectively and safely provide patient care, fulfill professional obligations, and adapt to dynamic healthcare environments) was completed and validated before being released to work independently, in accordance with the facility's policy regarding staff competencies.

This deficient practice resulted in RN 14 committing a medication error (wrong dose) and administering lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025. Patient 3 received 1000 mg of lidocaine, went into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating). (Refer to A-0397)

4. The facility failed to ensure one of 30 sampled patient's (Patient 18) physician was notified of two instances wherein there was presence of blood in the tracheostomy (an opening a surgeon makes through the neck and into the patient's wind pipe to assist with breathing) dressing of Patient 18, in accordance with the facility's policy and procedure (P&P) regarding physician notification.

This deficient practice had the potential to result in a delay in the provision of care and treatment to address the tracheostomy bleed of Patient 18, which may result in patient harm. (Refer to A-0398)

5. The facility failed to ensure the nursing staff assessed the Maternal Fetal Triage (preliminary assessment to determine the urgency of the need for treatment) Index (MFTI, a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity [severity] and prioritize urgency for evaluation by a nurse and a physician) for two of three sampled patients (Patients 5 and 6), who presented to the Labor and Delivery (L&D) Triage area, in accordance with the facility's policy and procedure regarding L&D triage.

This deficient practice had the potential for the acuity level (severity of condition) of patients to be unknown and had the potential for the delay in evaluation and treatment. (Refer to A-0398)

6. The facility failed to inform two of 30 sampled patients (Patients 25 and 27) about the "Care of Patient's Belongings" Policy, which included the possibility of inspecting the patients' belongings and asking if any of the patients' belongings could be considered a contraband (prohibited items, such as weapons, sharp objects, and illicit drugs), when Patients 25 and 28 did not sign their Patient Valuables form upon admission, in acknowledgement of the facility's policy and procedure regarding Patient belongings.

This deficient practice had the potential for improper inventory of patient belongings, lost items, if not confirmed with patients upon admission, and had the potential for patients to be unaware of which items were prohibited from the hospital (such as weapons or illegal drugs). (Refer to A-0398)

7. The facility failed to ensure Nursing staff notified one of 30 sampled patient's (Patient 11) family after a code blue (the activation of the Emergency Response Team upon discovery of any individual who has suffered a sudden cessation of vital signs [temperature, blood pressure, heart rate, respiratory rate] or is in a sudden and unexpected life-threatening situation) was activated for Patient 11, in accordance with the facility's policy regarding family notification during a code blue episode.

This deficient practice had the potential to cause Patient 11's family and/or significant other, emotional distress, leading to feelings of anxiety and guilt. (Refer to A-0398)

8. The facility failed to ensure that a nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) was administered on the correct site (right knee) for one of 30 sampled patients (Patient 12), in accordance with the facility's policy regarding anesthesia time-out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site).
This deficient practice had the potential to expose the patient (Patient 12) to a greater risk of local anesthetic toxicity, mobility (ability to walk) problems post-surgery (after surgery), and increased length of stay in hospital. (Refer to A-0398)

9. The facility failed to ensure nursing staff followed safe medication administration process for three of 30 sampled patients (Patient 1, Patient 2, and Patient 3), in accordance with the facility's policy regarding medication administration when:

9.a. Registered Nurses (RN) 12 and RN 13 failed to verify the Pitocin (a form of synthetic oxytocin, medication used to induce labor in pregnant women by stimulating uterine contractions) induction (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur) order was in place, and administered to Patient 1, Pitocin 95 milliliters per hour (ml/hr, unit of rate) instead of Pitocin 2ml/hr on 5/16/2025 (wrong order).

This deficient practice resulted in Patient 1 experiencing a decreased fetal (unborn baby) heart rate and requiring medical attention and intervention to stop the contraction. (Refer to A-0405)

9.b. RN 1 gave ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection) to Patient 2 on 5/23/2025 (wrong medication).

This deficient practice resulted in Patient 2 feeling numbness to the body and blurred vision and requiring medical attention and intervention to treat the Local Anesthetic Systemic Toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels). (Refer to A-0405)

9.c. RN 14 gave lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025 (wrong dose).

This deficient practice resulted in Patient 3 receiving 1000 mg of lidocaine, going into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating).

These deficient practices also had the potential to put other patients at risk for medication errors and cause harm to patients. (Refer to A-0405)

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

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

1. The facility failed to ensure one of 30 sampled patient's (Patient 7) medical record contained copies of telemetry mounting strips (printed recording of the patient's heart electrical activity, captured continuously by the telemetry monitor important for reviewing and documenting heart rhythms over time) and copies retained from 1/27/2025 at 4:11 p.m. (the time of admission) to 1/28/2025 at 11:58 a.m., at the required intervals of every 4 hours and as needed, in accordance with the facility's policy regarding telemetry monitoring (a system that uses small, wearable devices with electrodes attached to a patient's body to wirelessly transmit their vital signs-such as heart rate, rhythm, and sometimes oxygen saturation and respiratory rate-to a central station for continuous, real-time observation by healthcare providers).

This deficient practice had the potential for Patient 7's safety to be compromised, leading to lack of monitoring, review, and assessment of the patient's (Patient 7) cardiac (heart) status, potentially delaying identification of arrhythmias (a condition in which the heart beats with an irregular or abnormal rhythm) or other critical changes. (Refer to A-0438)

2. The facility failed to ensure one of 30 sampled patient's (Patient 24), who was documented as Spanish-speaking only (both verbally and written communication), informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient) and esophagogastroduodenoscopy (EGD, a medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine), was verified by a nurse who was proficient in Spanish and certified by the facility or the process involved the use of the interpreter services (professional medical interpreter), and with documentation of interactions used to communicate with the LEP (Limited English Proficiency) person included as part of the medical record, in accordance with the facility's established policy and procedures regarding use of interpretation services and documentation.

This deficient practice had the potential to compromise Patient 24's ability to fully understand the course of treatment, procedures, or risks because the patient (Patient 24) was not properly informed in their own language thus had the potential to lead to incorrect decisions, lack of full consent, and affecting patient (Patient 24) autonomy (the capacity to be one's own person, making free and independent choices based on one's own judgment and values, rather than being controlled by external forces) and safety. (Refer to A-0438)

3. The facility failed to ensure one of 30 sampled patient's (Patient 10), language preference, was accurately documented by nursing staff, when the official record indicated that Patient 10's preferred language was English while all informed consent forms obtained during Patient 10's admission stay at the facility were in Spanish.

This deficient practice had the potential for Patient 10's actual language needs to not be properly addressed, which could impair effective communication, understanding of medical information, and informed-decision-making. (Refer to A-0438)

4. The facility failed to ensure that for one of 30 sampled patients (Patient 24), the following information was documented to justify Patient 24's progress and response to treatment plan, in accordance with the facility's policy regarding documentation, when:

4.a. Nursing staff failed to obtain and document Patient 24's daily weight in accordance with the physician's order.

This deficient practice had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment. (Refer to A-0467)


4.b. Nursing staff failed to develop, document, and maintain a personalized care plan (a formal, documented roadmap created by nurses that outlines a patient's specific health needs, goals, and planned nursing actions to achieve those goals) for monitoring fluid balance (the body's ability to maintain the proper amount of water and hydration) and nutritional status (the body's current state of nourishment, reflecting the balance between nutrient intake and the body's needs for growth, repair, and maintenance) for Patient 24.

This deficient practice had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment. (Refer to A-0467)

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

Based on observation, interview and record review, the facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure there was a safe medication removal and administration process when nursing staff were retrieving medications from three of three sampled Pyxis (an automatic medication dispensing machine) Tower (Pyxis #1), in accordance with the facility's policy regarding medication administration and with the facility's performance improvement plan.

This deficient practice resulted in Registered Nurse 2 administering a wrong medication to Patient 2 causing Patient 2 to experience numbness to the body and blurry vision, which required medical attention and intervention. This deficient practice also had the potential to have reoccurrence of similar medication errors causing harm to other patients.

Findings:

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility's Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department for antepartum (a period before labor and delivery) workup and management of fever.

During a review of Patient 2's physician order, dated 5/21/2025, the physician order indicated, to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligrams (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein).

During a review of Patient 2's physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling "numb all over her body and has blurry vision" at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2's) vision. Patient 2 overall felt very "weird." MD 1 was then notified Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin.

During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: "on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass." RN 1 also stated, "I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break." RN 1 stated she did not look at the name on the IV medication bag.

During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication).

During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on "scan removal" feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department.

During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [often described as "fainting" or "passing out"]), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically.

During a review of Patient 2's "Discharge Summaries Notes (DC Summary)," dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, "(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms."

During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia [a condition in which there are not enough red blood cells (RBCs) or hemoglobin in the blood. Hemoglobin is an iron-rich protein in RBCs that carries oxygen throughout the body]) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label).

During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication to treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial, in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient.

During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), facility's apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, "Cause Analysis Report (CAR report)," dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1) who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing.

During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), the CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. CMO further stated there should be an action plan in place to prevent it (medication error incident) from happening again.

During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system, but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, "we figured it out (Pyxis label printing function) yesterday (8/21/2025)."

During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes.

During an interview on 8/22/2025 at 3:45 p.m. with OE, OE stated the governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was responsible for patient safety and clinical quality oversight for the whole hospital. OE further stated the medication error incident was reported to GB in June.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, the P&P indicated, "To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication."

During a review of the facility's QAPI plan titled, "[the facility] Performance Improvement Plan 2025," dated 6/2025, the QAPI plan indicated, "The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient care and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... The Community Governing Board (GB) strives to assure quality patient care and customer service by requiring and supporting the establishment and maintenance of an effective hospital-wide continuous performance improvement initiative ... The overall authority for the direction of the Performance Improvement Program rests with the Community Governing Board ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization's Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee's approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized."

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

1. Appropriately respond to one of 30 sampled Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 30), who manifested intentions of leaving/eloping (leaving the facility without physician's permission when doing so may present an imminent threat to the person's health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility, in accordance with the facility's policy regarding patients identified as elopement risk.

This deficient practice resulted in Patient 30 eloping and putting the 5150 (temporary, involuntary psychiatric [mental health] hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled [unable to care for one's self due to mental health issues], hold is designed to provide period of professional evaluation and treatment for person in crisis) patient (Patient 30) in danger to harm himself and a potential to harm others.

2. Ensure one of thirty sampled patients (Patient 19), received care in a safe setting, in accordance with the facility's policy on patient rights (a subset of human rights. Example: the right to be treated with courtesy and respect), when a male visitor (MV) for another patient entered Patient 19's room and opened the shower curtain while Patient 19 was in the shower.

This deficient practice resulted in Patient 19 having felt violated and had the potential for Patent 19 to suffer from psychological and physical harm.

On 8/20/2025 at 5:29 p.m., the survey team called an immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Associate Chief Nursing Operator (ACNO), Regulatory Specialist Organization Performance (RSO), Director of Accreditation, Licensing and Regulatory (DALR), Chief Nursing Officer (CNO), Operation Executive (OE) and Administrative Director of Emergency Department (ED, provides immediate medical care to patients experiencing serious or life-threatening conditions), Intensive Care Unit and Behavioral Health Unit (ADBHU).

The facility failed to appropriately respond to a patient who manifested intentions of leaving/eloping (leaving the facility without physician's permission when doing so may present an imminent threat to the person's health or safety as they have been deemed too ill or impaired to make a reasoned decision to leave) from the facility. This most likely put the 5150 (temporary, involuntary psychiatric hold of a person who as a result of a mental disorder is a danger to themselves, danger to other or gravely disabled, hold is designed to provide period of professional evaluation and treatment for person in crisis) Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient in danger to harm himself and a potential to harm others.

A review of the facility's security footage indicated the following: on 7/29/2025, a BHU patient (Patient 30), on a 5150 got up out of bed with an intravenous (IV, into the vein) pole attached to his (Patient 30) arm, walked to the emergency department hallway and out of the facility's emergency room exit with the Patient Safety Attendant (PSA) and the Charge Nurse (CN 2) walking behind him resulting in Patient 30 eloping in the presence of several facility staff members. During an interview on 8/19/2025 at 12:59 with the Security Manager (SM), SM stated all security and nursing staff were trained to intervene in events where a patient was attempting to leave, staff were trained to de-escalate (reduce the intensity of a conflict or potentially violent situation) and if necessary, safely place hands on patient to be taken back to room or safely restrain or medicate as medically necessary.

During an interview on 8/19/2025 at 3:46 pm with the ACNO, the ACNO stated code grey (an emergency situation involving an aggressive or combative patient) was delayed and should have been called the moment Patient 30 got up out of bed and began to ambulate (to walk) in the hallway. ACNO further stated a code green was called at 12:54 a.m., and that emergency department staff made no intentions to intervene with Patient 30 from leaving facility while waiting for security to arrive. This deficient practice placed Patient 30's and others safety at risk, exposing Patient 30 to traffic, accidents, injury and/or death.

On 8/22/2025 at 2:29 p.m. the IJ was removed in the presence of the OE, DALR, CNO, and CMO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate action taken by the facility were the following: starting 8/20/2025, charge nurse and patient safety attendant involved in the incident would be re-educated on what to do if a patient attempt to elope: steps to follow during attempt to elope included call code green (emergency alert for patient elopement) via STAT (emergency) line, attempt verbal de-escalation, hands on approach (Get a patient's attention with a gentle touch on the arm or shoulder to guide them, while maintaining a calm voice and direct eye contact), use restraints (any physical device, chemical substance, or environmental factor used to restrict a patient's freedom of movement or normal body function without their consent, typically to prevent harm to themselves or others), call physician, review of behavioral health patients in the emergency department (TEAM advanced), verbal de-escalation and interventions including behavioral health emergency types, early recognition, interventions hands-on approach included team essential skills lab (skills laboratory- a controlled, simulated environment where healthcare professionals practice foundational clinical skills), safe working positions, defense and escape techniques, escort techniques and application of restraints. Immediate activation of code grey by calling STAT line 88888, the process of calling the STAT line was revised, labeling with the 88888-emergency call number for [name of Facility] campus two and 22222 for [Name of Facility] main campus.

The IJ removal plan also included the following: Starting 8/20/2025, emergency staff charge nurses, registered nurses, emergency medical technicians, patient safety attendants, security and unit secretary received in person education on interventions and expectation when any patient on a hold attempted to leave. Security staff received education and expectations of responding to code green. The nursing director and designee would validate emergency department and behavior health unit staff understanding at both campuses (Main campus and secondary campus) including knowledge of behavioral health emergency, early recognition, interventions such as verbal de-escalation, TEAM advanced training process and care for patient on hold. Emergency manager or designee would conduct five staff interviews per day to validate knowledge on the prevention of 5150 elopement for the first week or until 100% compliance was achieved for three consecutive months. PBX (a telephone system for managing calls) manager or designee would perform five random test calls per week on the STAT line to validate functionality and confirm if the revised process was working as intended. Audit continues until 100% compliance for three consecutive months. PBX manager or designee would also conduct five daily observations of phones in patient care areas to verify Emergency Code call number stickers were in place. Audit to continue until 100% compliance was achieved for three consecutive months.

Findings:

1. During a review of Patient 30's "Emergency Physician Note," dated 7/28/2025, the note indicated Patient 30 was brought to the facility by local enforcement on 7/28/2025. Patient 30 was on a 5150 hold for being a danger to others. Patient 30 was acting erratically and making threats to kill the president. Patient 30 arrived in the Emergency Room in 4-point restraints (involves securing a patient's wrist and ankles to prevent movement used in emergency situations involving violent or self-destructive behavior) with a spit hood (disposable mesh device that fit over the head) in place.

During a review of Patient 30's "Elopement Risk Assessment Tool," dated 7/28/2025 and timed at 1830 (6:30 p.m.), the Elopement Risk Assessment Tool, indicated Patient 30's elopement score was 22 (score of 7 or higher indicated a high risk of elopement).

During an interview on 8/19/2025 at 12:40 p.m. with the Emergency Department Charge Nurse (CN 1), CN 1 stated, patients with elopement risk were assessed, and depending on the score, interventions were taken. For Patients with a score of 7 or higher or on a legal hold, the following precautions were taken: patient in green gown, patient placed away from the exit, patient safety attendant assigned, restroom in hallways: two person assisting patients and restrict ambulation to the room (no hallway ambulation).

During an interview on 8/19/2025 at 12:59 p.m. with the Security Manager (SM), SM stated, all security and nursing staff were trained to intervene in events where a patient was attempting to leave, staff were trained to de-escalate and if necessary, safely place hands on patient to be taken back to room or safely restrain or medicate as medically necessary.

During an interview on 8/19/2025 at 10:22 a.m. with the SM, the SM stated, the assigned Emergency Department's main door security guard could have moved with more sense of urgency once code green was announced overhead and via radio.

During an interview on 8/19/2025 at 2:51p.m. with Associate Chief Nursing Operator (ACNO), ACNO stated the charge nurse (CN 2) did not attempt to intervene in stopping Patient 30 from leaving because she (the charge nurse) did not want to get hurt and security guards were not sure about hands on intervention, also CN 2 verbalized her (CN 2) understanding that she (CN 2) was not to touch Patient 30.

During a concurrent observation, interview and video footage record review on 8/19/2025 at 3:24 p.m. with the Patient Safety Attendant (PSA 1), Patient 30's "Video Footage-Charge Nurse Station (A Side)," date stamped 7/29/2025 at 12:52 a.m., was reviewed. The video footage indicated, Patient 30 wearing a green gown exiting Room 9 with IV pole in right hand walking towards the emergency exit. PSA 1 and Charge Nurse 2 (CN 2) were seen walking behind Patient 30, Patient 30 continued to walk at a slow pace and exited the emergency room through the emergency exit. PSA 1, CN 2 and Emergency Medical Technician (EMT) did not follow Patient 30 out the door. The PSA1 stated she (PSA 1) did not attempt to intervene when Patient 30 got out of bed and began to walk in the hallway because the charge nurse told her (PSA 1) not to touch the patient (Patient 30).

During a concurrent observation, interview and video footage record review on 8/19/2025 at 3:34 p.m. with the SM and the ACNO, the security footage from 7/29/2025, was reviewed. The recorded events were observed and validated with the SM and the ACNO, at the indicated timestamps in the videos:

View 1 (Charge Nurse Station)
-Timed stamped:7/29/2025 at 12:52 a.m.
-Patient 30 wearing a green gown exited Room 9 with IV pole in right hand walking towards the emergency exit. PSA 1 and CN 2 were seen walking behind Patient 30, Patient 30 continued to walk at a slow pace and exited the emergency room through the emergency exit. PSA 1, CN 2 and EMT did not follow Patient 30 out the door.

View 2 (Ambulance/Emergency exit)
-Timed stamped: 7/29/2025 at 12:52 a.m., Patient 30 was seen walking towards emergency exit with PSA 1 and CN 2 following behind. EMT 1 approached Patient 30, EMT 1 reached for Patient 30's arm and Patient 30 maneuvered arm up and away from EMT 1's grasp and continued walking and exited through the door out of the video's frame.

View 3 (Exterior view of ED)
-Timed stamped: 7/29/2025 at 12:53 a.m. Patient 30 outside Emergency Room running towards Beverly Blvd. with no shoes or socks.

View 4 (ER room entrance)
-Timed stamped: 7/29/2025 at 12:54 a.m. Security guard 1 was seen standing up from his chair and slowly (no urgency) walking toward the Emergency Room door (where Patient 30 exited).

During an interview on 8/19/2025 at 3:40 p.m. with the SM, the SM stated staff members should have used the TEAM advance techniques (training techniques used to manage psychiatric patients in crisis) and taken Patient 30 back to Room 9, The SM further added that in this case (involving Patient 30) the advance training techniques were not deployed.

During an interview on 8/19/2025 at 3:46p.m. with the ACNO, ACNO stated code grey was delayed and should have been called the moment Patient 30 got up out of bed and began to ambulate in the hallway. ACNO further stated a code green was called at 12:54 a.m., and that emergency department staff made no intentions to intervene with Patient 30 from leaving facility while waiting for security to arrive.

During an interview on 8/19/2025 at 4:45 p.m. with the Unit Associate (UA), UA stated she (UA) made two attempts to reach the facility operator by dialing the stat line 88888, allowing the phone to ring about 10 times on first attempt and on second attempt was able to reach the operator to overhead page for a code green (code used to activate staff discovering a high risk patient who is missing or suspected of elopement or who witnesses the patient leave the unit).

During an interview on 8/19/2025 at 5:10 p.m. with the ACNO, ACNO stated she reviewed the stat line calls made on 7/29/2025 and that there were no calls made to operator using the emergency stat-line no. 88888. The Emergency Room (ER) unit associate probably dialed "0," the non-emergency line to operator, during the elopement incident of Patient 30. The ACNO said it was important that staff utilized emergency stat-line number "88888" for all emergency code, including code blue (a hospital term for a medical emergency, most often indicating a patient is in cardiac arrest [when the heart stops beating] or experiencing respiratory failure [when a patient stops breathing], requiring immediate medical attention and resuscitation efforts [interventions to keep the heart beating and the patient breathing]) and elopement incident, to avoid delay of interventions.

During an interview on 8/20/2025 at 11:52 a.m. with the ACNO, ACNO stated Patient 30 returned to the facility two days after eloping from facility to retrieve his (Patient 30) belongings. Patient 30 was being aggressive and making threats towards staff. Local law enforcement was called, and Patient 30 was placed on another 5150 hold. Patient 30 was admitted and transferred to the sister facility's Behavioral Health Unit.

During an interview on 8/20/2025 at 3:05 p.m. with the ACNO, ACNO stated that hospital staff can refer to the emergency operator number (example: 88888) in the phone extension list that was posted next to the phone. The hospital had no process of updating and posting of the extension list.

During an interview on 8/20/2025 at 3:50 p.m. with Charge Nurse 3 (CN 3), CN 3 stated that the phone extension list in the telemetry unit (Tower 3) did not include the operator emergency line (example: 88888) and was not posted anywhere else in the unit.

During a review of the facility's Policy and Procedure (P&P) titled, "Code Green-Patient Elopement-Missing High-Risk Patients," revised 6/18/2024, the P&P indicated "All reasonable measures will be taken to prevent the elopement of high-risks patients from the hospital." However, in the case of Patient 30, the protocol for 5150 hold patients was not implemented and this finding was validated by the ACNO.

2. During a review of Patient 19's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/10/2024, the H&P indicated Patient 19 was admitted to the facility for Uterine Contractions (uterine [ relating to womb] muscles tighten and relax to prepare for childbirth).

During an interview on 8/20/2025 at 8:53 a.m. with Charge Nurse (CN) 3, CN 3 stated security would walk around and check the unit a couple of times a day.

During a concurrent interview and record review on 8/20/2025 at 9:02 a.m. with CN 3, Patient 19's "Flowsheet -Clinical Note Nursing," dated 12/12/2024, was reviewed. CN 3 said the flowsheet indicated Patient 19 called to inform the staff that a man (a male visitor for another patient) had walked in the room looking for his (the male visitor) wife while Patient 19 was in the shower.

During the same interview on 8/20/2025 at 8:53 a.m. with Charge Nurse (CN) 3, CN 3 stated Patient 19 was showering, Patient 19 heard the shower curtain open a little bit, and it was not Patient 19's spouse. Furthermore, CN 3 stated Patient 19 was upset, did not want to talk to anybody and called the spouse (Patient 19's spouse) to be picked up.

During an interview on 8/20/2025 at 9:37 a.m. with Security Shift Supervisor (SS) 1, SS 1 stated the male visitor who entered Patient 19's room was the spouse of another patient who was in a different room. SS 1 said, the visitor mix up was explained to Patient 19, but Patient 19 stated she (Patient 19) felt violated and was upset because someone else other than her spouse entered the room and opened the shower curtain, while she (Patient 19) was in the shower.

During an interview on 8/20/2025 at 10:26 a.m. with the Director of Risk Management (DRM) 1, DRM 1 stated it was important to ensure safety and privacy of patients. Furthermore, DRM 1 stated it was expected for the staff to know who was in the unit, to ensure patient privacy was protected and ensure a healing environment, where patients can feel safe, was provided.

During a review of the facility's policy and procedure (P&P) titled, "Standard Policy: Conditions of Registration (COR)," revised in 12/6/2024, the P&P indicated, "The COR provides important information including but not limited to ...Patient Rights ...Patient Rights You have the right to: Considerate and respectful care, and to be made comfortable ...Receive care in a safe setting."

During a review of the facility's policy and procedure (P&P) titled, "Policy: Visitor Policy, Patient-Directed Visitation," revised in 6/18/2024, the P&P indicated, "In addition, [the facility's name] desires to maintain an atmosphere that is safe for patients, visitors, and staff ...Visitor: A visitor is defined as a guest of the patient."

Based on observation, interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) program failed to implement an appropriate action plan, in a timely manner, to prevent medication errors from happening, in accordance with the facility's performance improvement plan, after a Registered Nurse (RN 1) removed a wrong medication from the Pyxis (automated medication dispensing machine) tower and administered to one of 30 sampled patients (Patient 2) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department.

This deficient practice had the potential to result in the same or similar medication error happening on other nursing units and potentially causing harm to patients.

Findings:

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility's Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Department for antepartum (a period before labor and delivery) workup and management of fever.

During a review of Patient 2's physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligram (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein).

During a review of Patient 2's physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling "numb all over her body and has blurry vision" at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2's) vision. Patient 2, overall, felt very "weird." MD 1 was then notified Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin.

During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: "on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass." RN 1 also stated, "I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break." RN 1 stated she (RN 1) did not look at the name on the IV medication bag.

During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication).

During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on the "scan removal" feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in the L&D department.

During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [often described as "fainting" or "passing out"]), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically.

During a review of Patient 2's "Discharge Summaries Notes (DC Summary)," dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, "(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms."

During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, Venofer (medication to treat iron deficiency anemia [a condition in which there are not enough red blood cells (RBCs) or hemoglobin in the blood. Hemoglobin is an iron-rich protein in RBCs that carries oxygen throughout the body]) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label).

During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient.

During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), facility's apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, "Cause Analysis Report (CAR report)," dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1) who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing.

During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. CMO further stated there should be an action plan in place to prevent it (the medication error incident involving Patient 2) from happening again.

During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow, before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, "we figured it out (Pyxis label printing function) yesterday (8/21/2025)."

During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, the P&P indicated, "To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication."

During a review of the facility's QAPI plan titled, "[the facility] Performance Improvement Plan 2025," dated 6/2025, the QAPI plan indicated, "The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient car and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization's Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee's approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized."

Based on observation, interview and record review, the facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight for the Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements), to address and prioritize actions needed to address patient safety issues resulting from a medication error for one of 30 sampled patients (Patient 2), to ensure there was a safe medication removal and administration process for the entire hospital units when nursing staff were retrieving medications from the Pyxis (automated medication dispensing machine) Tower.

This deficient practice had the potential to put other patients at risk for medication error.

Findings:

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility's Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department for antepartum (a period before labor and delivery) workup and management of fever.

During a review of Patient 2's physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligrams (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein).

During a review of Patient 2's physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling "numb all over her body and has blurry vision" at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2's) vision. Patient 2 overall felt very "weird." MD 1 was then notified that Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin.

During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: "on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass." RN 1 also stated, "I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time and I was in a rush before going on break." RN 1 stated she (RN 1) did not look at the name on the IV medication bag.

During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication).

During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident, the pharmacy turned on the "scan removal" feature on the pyxis in the L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department.

During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically.

During a review of Patient 2's "Discharge Summaries Notes (DC Summary)," dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, "(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms."

During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label).

During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient.

During a concurrent interview and record review on 8/22/2025 at 3:27 p.m. with the Chief Nursing Officer (CNO), the facility's apparent cause analysis (a focused investigation used to identify the immediate causes of adverse patient safety events and develop action plan) report titled, "Cause Analysis Report (CAR report)," dated 5/23/2025, was reviewed. The CAR report indicated the medication error incident took place on 5/23/2025 involving the Primary RN (RN 1), who took the wrong medication from the Pyxis because RN (RN 1) did not pay attention to detail and did not validate the medication. The CAR report also indicated the action plan section was blank. CNO stated the CAR report was incomplete because the action plan was missing.

During an interview on 8/22/2025 at 3:28 p.m. with the Chief Medical Officer (CMO), the CMO stated cause analysis was to identify the cause so the team could put in measures to improve the system by providing education or interventions and holding people accountable. The CMO further stated there should be an action plan in place to prevent it (the medication error incident involving Patient 2) from happening again.

During an interview on 8/22/2025 at 3:30 p.m. with the Operation Executive (OE), OE stated the following: the facility was aware there was a break in the system, but it took time to work with the vendor (Pyxis) to figure out how to selectively de-activate the label printing function without interrupting another workflow before implementing the new process hospital-wide. The facility did see there was potential to have the same error happen on other units. OE also stated, "we figured it out (Pyxis label printing function) yesterday (8/21/2025)."

During an interview on 8/22/2025 at 3:38 p.m. with the CMO, CMO stated the Quality Assurance and Performance Improvement (QAPI, the facility's program for identifying problems, investigating causes and making improvements) was responsible to improve consistency of care, quality of care, patient safety and maximize patient outcomes.

During an interview on 8/22/2025 at 3:45 p.m. with OE, OE stated the governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was responsible for patient safety and clinical quality oversight for the whole hospital. OE further stated the medication error incident was reported to GB in June.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, the P&P indicated, "To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication."

During a review of the facility's QAPI plan titled, "[the facility] Performance Improvement Plan 2025," dated 6/2025, the QAPI plan indicated, "The purpose of the Performance Improvement Efforts at [the facility] is to ensure the delivery of safe patient car and to strive to be a benchmark for excellence in medical care and services. This is accomplished in a proactive approach by assessing patient care and other support processes in a systemic, ongoing manner in order to identify, analyze improvement opportunities and to act on those opportunities in a timely manner ... The Community Governing Board (GB) strives to assure quality patient care and customer service by requiring and supporting the establishment and maintenance of an effective hospital-wide continuous performance improvement initiative ... The overall authority for the direction of the Performance Improvement Program rests with the Community Governing Board ... Performance Improvement Methodology ... 2. Any of these performance improvement strategies may be used in response to ongoing measurement, staff suggestions, Medical Staff suggestions, Council/Committee suggestions, and from other sources. Specifically, assessment is triggered ... i. by all significant medication errors ... Proactive Analyses to Reduce Risks to Patients. 1. The organization's Patient Safety Committee is responsible for any ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients. The Committee's approach includes ... c. identify the ways in which the process could breakdown or fail to perform its desired function; d. identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects ... g. re-designing the process and/or underlying systems to minimize risk of the effects on patients; once the identification of the severity, notability, detectability and critically of the process failure has been prioritized."

Based on interview and record review, the facility's medical staff failed to demonstrate accountability for the quality of medical care provided to patients when the facility's physicians failed to perform a medical screening exam (MSE, a medical evaluation to determine if an emergency condition exits ) for two (2) of three (3) sampled patients (Patients 5 and 6) who presented to the Labor and Delivery triage area (L&D [a specialized hospital unit that provides care to pregnant individuals, from onset of labor and throughout the entire process of childbirth] where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and a physician performs a medical screening exam [MSE, an initial evaluation to determine if a patient has an emergency medical condition]), in accordance with the facility's policies and procedures regarding Patient Triage in the Labor and Delivery Department and the Medical Staff Rules and Regulations.

This deficient practice resulted in a lack of a medical screening exam performed by a physician to determine Patient 5 and 6's medical status and to determine whether an emergency medical condition existed, which may have the potential to result in patient harm.

Findings:

During an interview on 8/19/2025 at 1:16 p.m. with Registered Nurse (RN) 7, in the Emergency Department (ED, provides immediate medical care to patients experiencing serious or life-threatening conditions), RN 7 stated patients who presented to the ED, check in with him (RN 7) first. If a patient, who was over 20 weeks pregnant, presented to the ED for pregnancy related concerns, the patient was escorted to the Labor and Delivery (L&D) triage area (L&D [a specialized hospital unit that provides care to pregnant individuals, from onset of labor and throughout the entire process of childbirth] where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and a physician performs a medical screening exam [MSE, an initial evaluation to determine if a patient has an emergency medical condition]) for evaluation.

During an interview on 8/19/2025 at 1:28 p.m. with the triage intake Registered Nurse (RN 5) in L&D Triage 1 (an area where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and determines who can wait in the waiting room or who needs to be seen immediately), RN 5 stated the following: RN 5 performed a quick assessment of patients, including vital signs (temperature, blood pressure, heart rate, respiratory rate) and used a doppler ultrasound (a non-invasive test that uses sound waves to exam blood flow) to assess for a fetal (unborn baby) heart rate. The patients' acuity level (the severity, complexity, and urgency of a patient's condition, and level of care and resources required), was assessed. Then the patient will either wait in the waiting room or be taken to the adjacent Triage 2 area, where patients were placed in a bed, hooked up to a fetal monitor (a medical device used during pregnancy, labor, and delivery to track a baby's heart rate and strength or duration of uterine contractions [a shortening or uterine muscles occurring at intervals before and during childbirth) and evaluated by a physician.

During an interview on 8/19/2025 at 1:38 p.m., with RN 6, in Triage 2, RN 6 stated the following: Patients were brought to Triage 2, for fetal (baby) monitoring for a minimum of 20 minutes to determine the status of the baby and contractions. The physician will perform a medical screening exam and may conduct additional tests to determine the patients' status and course of treatment.

1. During a concurrent interview and record review on 8/20/2025 at 10:47 a.m. with RN 4, Patient 5's medical record, was reviewed. RN 4 stated the following: On 8/16/2025 at 8:20 p.m., Patient 5, who was 28 weeks pregnant, presented to L&D triage due to abdominal pain and contractions for three (3) days. On 8/16/2025 at 11:47 p.m., a physician's order was placed to admit Patient 5 to the Labor and Delivery Department. RN 4 stated Patient 5 was admitted due to antepartum high risk (increased monitoring and specialized care due to health conditions, or pregnancy complications, aiming to prevent complications for both mother and baby). RN 4 stated an order was placed for Patient 5 to be admitted to the L&D unit, however, there was no physician progress note documented in the L&D triage. RN 4 stated patients should be evaluated by a physician during L&D triage to make medical decisions, such as treatment or decision to admit patients. RN 4 verified that the facility's policy regarding L&D triage indicated that a medical screening exam would be conducted by a physician.

During a review Patient 5's L&D Triage note, dated 8/16/2025 at 8:20 p.m., the L&D Triage note indicated the following: Patient 5 presented to the L&D triage. Patient 5 was 28 weeks and 3 days pregnant and complained of abdominal pains and contractions. Patient 5 was placed on a fetal monitor, and vital signs were taken. Patient 5 had a history of anemia (blood does not have enough healthy red blood cells to carry oxygen throughout the body) and diabetes (high blood sugar).

During a review of Patient 5's Order Requisition, dated 8/16/2025 at 11:47 p.m., the Order indicated the following: Procedure: Admission Status. Admission Type: Inpatient. Level of Care: Obstetrics (medical specialty focused on childbirth and the care of mother and baby).

During a review of Patient 5's History and Physical (H&P, a comprehensive assessment of a patient's health status) dated 8/17/2025 at 2:14 a.m., the H&P indicated the following: Patient 5 presenting for abdominal pain and pressure ...Admitted to antepartum service for rule out preterm labor (labor contractions that occur before 37 weeks of gestation [pregnancy]).

During a review of the facility's policy and procedure (P&P) titled, "Patient Triage in the Labor & Delivery Unit," dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination ...Definitions:
MSE: Medical Screening Examination is the process reached to determine whether or not an emergency medical condition exists.
Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ...
Timing of initial and ongoing physician/RN assessment will be determined by the status of the mother and the fetus (unborn baby). The RN will communicate with the appropriate physician regarding the condition of the patients.
a. MSE will be performed by a physician.

During a review of the facility's "Medical Staff Rules and Regulations," approved by the Governing Body on 9/17/2024, the Medical Staff Rules and Regulations indicated the following: 7.7 - Screening Examinations. 7.7.1 - Emergency Services - Only emergency room physicians and physician assistants will perform the medical screening examination. 7.7.2 - Obstetrics - Only qualified medical persons (Physician or Resident, or labor and delivery registered nurse) will perform the medical screening exam to determine labor status.

2. During a concurrent interview and record review on 8/20/2025 at 11:26 a.m. with RN 4, Patient 6's medical record, was reviewed. RN 4 stated the following: On 8/18/2025 at 12:02 p.m., Patient 6, who was 39 weeks and 5 days pregnant, presented to the L&D triage for cramping. An order to admit Patient 6 to the L&D unit was placed on 8/18/2025 at 2:02 p.m. A history and physical examination was started on 8/18/2025 at 2:05 p.m., after Patient 6 was admitted to the L&D unit. There were no physician progress notes documented while Patient 6 was in the L&D triage. RN 4 verified that the facility's policy regarding L&D triage indicated that a medical screening exam would be conducted by a physician.

During a review Patient 6's L&D Triage note, dated 8/18/2025 at 12:02 p.m., the Triage note indicated the following: Patient 6 was 39 weeks and 5 days pregnant. Patient 6 complained of cramping.

During a review of Patient 6's Admission Order, dated 8/18/2025 at 2:04 p.m., the Admission order indicated to admit to L&D for induction of labor (using medical treatment to start labor before it begins naturally).

During a review of Patient 6's History and Physical (H&P, a comprehensive assessment of a patient's health status) dated 8/18/2025 at 2:05 a.m., the H&P indicated the following: Patient 6 presenting for contractions ...Plan: Admit to L&D for indicated induction.

During a review of the facility's policy and procedure (P&P) titled, "Patient Triage in the Labor & Delivery Unit," dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination ...Definitions:
MSE: Medical Screening Examination is the process reached to determine whether or not an emergency medical condition exists.
Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ...
Timing of initial and ongoing physician/RN assessment will be determined by the status of the mother and the fetus (unborn baby). The RN will communicate with the appropriate physician regarding the condition of the patients.
a. MSE will be performed by a physician.

During a review of the facility's "Medical Staff Rules and Regulations," approved by the Governing Body on 9/17/2024, the Medical Staff Rules and Regulations indicated the following: 7.7 - Screening Examinations. 7.7.1 - Emergency Services - Only emergency room physicians and physician assistants will perform the medical screening examination. 7.7.2 - Obstetrics - Only qualified medical persons (Physician or Resident, or labor and delivery registered nurse) will perform the medical screening exam to determine labor status.

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

1. Ensure the Nursing staff addressed one of 30 sampled patient's (Patient 7) pain levels of 8/10 and 9/10 based on a pain scale (0-2: Mild pain, 3-4: Moderate pain, 5-6: Severe pain, 7-10: Very severe pain), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for inadequate pain control, prolonged patient suffering from pain, and psychological distress (Example: anxiety [feeling of unease]), which may lead to prolonged recovery from illness.

2. Ensure Nursing staff notified the physician regarding the new onset of chest pain for one of 30 sampled patients (Patient 7), in accordance with the facility's policy regarding physician notification.

This deficient practice had the potential for delayed diagnosis and treatment which may result in worsening of Patient 7's condition and/or death.

Findings:

1. During a review of Patient 7's History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient's condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient's previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behavior). Patient 7's cardiac troponin (found only in the heart muscle and is a crucial biomarker for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit) which was significantly elevated and indicated extensive cardiac muscle injury (heart attack).

The H&P also indicated that Patient 7 was diagnosed with NSTEMI (Non-ST Segment Elevation Myocardial Infarction, a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment [an indicator for various conditions such as heart attack or lack of blood flow] on an electrocardiogram [ECG, a non-invasive medical test that records the electrical activity of the heart]) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient's body to a central location for real-time observation).

During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7's "Nursing Documentation-Flowsheet," dated 1/28/2025, was reviewed. The record indicated that on 1/28/2025 at 3:00 a.m., the primary registered nurse (Nurse 1) documented that Patient 7 had a pain level of 8/10 (on a 0-10 scale, an 8/10 pain level represents very strong to intense pain that is significantly limiting and possibly unbearable, making it hard to do anything but focus on the pain, with physical activity and even conversation severely restricted) in his back. The record also indicated that at 7:10 a.m. [on 1/28/2025], Nurse 2 documented that Patient 7 had pain level of 9/10 in the chest. The RNPSI verified that neither entry in Patient 7's record included a follow-up action (assess and reassess pain after interventions given to reduce pain, notify the physician if pain is unrelieved or if medication order may be necessary) to address Patient 7's pain. The DRM confirmed that neither nurse (Nurse 1 or Nurse 2) documented follow-up actions/interventions to address Patient 7's pain.

During an interview on 8/29/2025 at 3:06 p.m. with the Clinical Nurse Educator (CNE), the CNE said that new onset pain, especially when rated as 8 out of 10 (severe pain) or 9 out of 10 (severe pain), required a follow-up. The CNE said that both nurses (Nurse 1 and Nurse 2) should have addressed Patient 7's reported pain level of 8/10 and 9/10 on 1/28/2025, but they (Nurse 1 and Nurse 2) did not.

During a review of the facility's policy and procedure (P&P) titled, " Opioid (a class of drugs that acts on the nervous system to relieve pain) Analgesia (the absence or reduction of pain), Assessment and Monitoring," dated 1/2025, the P&P indicated that "Patients will be assessed for pain and managed per the facility's policy or online standardized procedure manual ...Screening for pain will be documented in the electronic medical records (EMR, digital version of paper chart) when completed..."

During a review of the facility's policy and procedure (P&P) titled, "OPIOID PRESCRIBING AND PAIN MANAGEMENT THERAPY," dated 11/2024, the P&P indicated that, "Patient pain treatment plan is based on evidenced-based practices and the patient's clinical condition, past medical history, and pain management goals. This may include non-pharmacologic, pharmacologic, or a combination of approaches ... When appropriate, based upon individual patient circumstances the healthcare team may consider non¿pharmacological pain treatment... If the non-pharmacological alternatives are ineffective for pain management, the attending physician will be notified... the provider may consider non-narcotic or narcotic pain treatment modalities for pain management ...Once ordered, progress with the policy..."

During a review of the facility's adopted "Patient Rights" template, dated 11/2024, the template indicated that, "The patient has the right to receive the appropriate assessment and management of the pain, information about pain, pain relief measures and participate in pain management decisions. They may request or reject the use of any or all modalities to relieve pain..."

2. During a review of Patient 7's History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient's condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient's previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behavior). Patient 7's cardiac troponin (found only in the heart muscle and is a crucial biomarker for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit) which was significantly elevated and indicated extensive cardiac muscle injury (heart attack)]. The H&P also indicated that Patient 7 was diagnosed with NSTEMI (a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment on an electrocardiogram [ECG, a non-invasive medical test that records the electrical activity of the heart]) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient's body to a central location for real-time observation).

During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7's "Nursing Documentation-Flowsheet," dated 1/28/2025, was reviewed. The DRM also confirmed that registered nurse (Nurse 2) did not notify the physician regarding Patient 7's new onset of chest pain, which was rated 9/10 (severe pain on a scale of 0-10), despite documentation indicating that a message was left for the physician regarding the chest pain. There was no follow-up made by Nurse 2 to ensure that the physician received the message and find out what the treatment course would be for Patient 7's chest pain of 9/10.

During an interview on 8/19/2025 at 2:56 p.m. with the Director of Risk Management (DRM), the DRM said that the facility had investigated this incident and reported it to the Department of Public Health (Regulatory Agency) because the patient (Patient 7) had a major heart attack a few hours after the reported chest pain of 9/10 [at 7:10 a.m. on 1/28/2025]. The DRM said the internal investigation was conducted to examine why nursing staff did not notify the physician about Patient 7's chest pain rated as 9 out of 10 on 1/28/2025 at 7:10 a.m., and why there was no follow-up action taken. The DRM said that, at that time (on 1/28/2025), although Patient 7 was admitted to the telemetry unit, the patient (Patient 7) was physically located in the Emergency Department (ED), in the area designated for patients waiting for a bed (called "holds" or holding area- admitted patients waiting for a bed in the hospital). The DRM also stated that the investigation found the nurse who documented the chest pain of 9/10 did not follow the facility's policy regarding a change of condition and did not report the new onset of chest pain to the physician.

During an interview on 8/29/2025 at 3:06 p.m. with the Clinical Nurse Educator (CNE), the CNE said that new onset chest pain, especially when rated as 9 out of 10 (severe pain), was considered a change in the patient's condition and required the nurse to notify the physician promptly. The CNE said that according to the facility's protocol for change of condition notification and escalation policy (outlines the procedures for elevating a patient's care, resources, or a problematic situation up the chain of command or to higher levels of authority until a resolution is achieved), the nurse should have called the attending physician "on call (the physician responsible for the patient's care who is available outside of regular hours)," and if the physician did not answer or call back, the nurse had to call again in 15-30 minutes. The CNE also stated that after repeated attempts, and there was still no response from the attending physician, the nurse was authorized to escalate the matter by following the chain of commands (which included contacting the charge nurse and ultimately the chair of the department).

During a review of Patient 7's "Physician Progress Note," dated 1/28/2025, the note indicated that Patient 7 was seen and examined by the resident physician on 1/28/2025. The resident physician documented that Patient 7 had complained of chest pain for the first time during the exam (on 1/28/2025 around 9:30 a.m.).The note also indicated that "About 10 minutes after the exam, patient's (Patient 7's) condition worsened significantly, and the patient (Patient 7) experienced a cardiac emergency (called Code Blue, meaning the patient's heart stopped and/or they stopped breathing) and a code STEMI (heart attack caused by a blockage of blood flow to the heart) was called ...patient (Patient 7) then was rushed to the catheterization lab (Cath lab, a specialized hospital area with advanced technology for performing minimally invasive diagnostic and therapeutic procedures on the heart and blood vessels) to get urgent help for the blocked heart artery."

During a review of Patient 7's "Death Note," dated 1/28/2025, the note indicated that Patient 7 expired on 1/28/2025 at 9:26 p.m. The note indicated the cause of death was due to STEMI and drug-induced cardiomyopathy (DICM, heart muscle disease caused by the toxic effects of a drug, resulting in weakened heart function that can lead to heart failure).

During a review of Patient 7's "Nursing Documentation Flowsheet" record, dated 1/28/2025 at 7:09 a.m., the record indicated that Nurse 2 documented that the attending physician was notified regarding "Patient (Patient 7) is having chest pain 9/10, -phone message left; follow-up required." The record contained no documented follow-up with the attending physician. This information was verified during record review on 8/19/2025 with the Program Specialist Informatics Nurse (RNPSI).

During an interview on 8/19/2025 at 4:02 p.m. with the Chief Nursing Executive (CNE), the CNE said, "We investigated the incident following an internal report indicating that the physician did not return the call regarding Patient 7's chest pain documented on 1/28/2025 at 7:10 a.m. During the review of the patient's (Patient 7) case, we found that Nurse 2 did not call the physician directly, but rather asked the emergency department secretary to page the physician and did not follow the facility's protocol for reporting a change in patient's condition-specifically, the new onset of chest pain. The physician had never been notified of the patient's (Patient 7) chest pain rated 9/10."

During a review of the facility's policy and procedure (P&P) titled, "Contacting Physician for Patient Care," dated 6/17/2025, the P&P indicated that "Effective and timely communication is critical to safe patient care. The facility is committed to ensuring hospital associates are able to contact physicians and/or their affiliated allied health providers to communicate the need for additional information, relay pertinent diagnostic test results, and/or changes in the patient's condition. Associates utilize their critical thinking skills to categorize communication as either Urgent or Routine. The physician will assume the communication is Routine unless the call-back extension entered is followed by "911" or the message left at the service as described as Urgent.
1. Escalation: all clinical issues must be resolved in a timely manner to prevent delay of treatment. If the situation cannot be resolved at the lowest possible level, the next level should be accessed. All urgent communication is expected to be followed up with a second attempt within 10 min. If no return telephone call within 30 min, associates are to escalate the issue to his/her leadership ...Documentation: Contacting a physician requires documenting date, time, name of doctor and, what was discussed. All attempts to call doctor should be documented."

Based on observation, interview and record review, the facility failed to ensure one of seven sampled nursing staff's (RN 14) unit -specific competencies (an integrated set of knowledge, skills, abilities, judgment, values, and professional behaviors that enable a nurse to effectively and safely provide patient care, fulfill professional obligations, and adapt to dynamic healthcare environments) was completed and validated before being released to work independently, in accordance with the facility's policy regarding staff competencies.

This deficient practice resulted in RN 14 committing a medication error (wrong dose) and administering lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025. Patient 3 received 1000 mg of lidocaine, went into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating).

Findings:

During a review of Patient 3's "Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)" notes, dated 7/29/2025, the procedure note indicated Patient 3 was admitted to the facility with diagnoses including but not limited to severe heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) and coronary artery disease (CAD, a condition where fats build up in the coronary arteries [major blood vessels supplying oxygen and nutrients to the heart muscle] narrowing and restricting blood flow in the heart). Patient 3 was scheduled for high-risk PCI (percutaneous coronary intervention, a minimally invasive procedure to treat narrowed or blocked coronary arteries) with Impella (a minimally invasive, catheter-based blood pump designed to temporarily support the heart's pumping function) support.

During further review of Patient 3's "Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)" notes, dated 7/29/2025, The procedure notes indicated the following: " ... patient (Patient 3) was at this point noted to have runs of VT (Ventricular tachycardia, life-threatening heart rhythm disorder that lead to inadequate blood supply to the body and potentially cardiac arrest [(sudden loss of heart function]) ... she (Patient 3) was given 50 milligrams (mg, unit of measure) lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) IV (IV, administered into a vein) for suppression (to stop) and did have normalization of the rhythm, however, subsequently was noted to have absent pulsatility (rhythmic, nature of blood flow and pressure caused by a beating heart). Unlike previous episodes during the case where patient (Patient 3) was still awake, conversant, alert during loss of pulsatility, this time patient (Patient 3) was subsequently noted to be unresponsive (does not react to sounds, touch or pain), with seizure-like/tonic-clonic (jerking) activity, and foaming at the mouth ... A Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating]) was immediately called and chest compressions were commenced (started)."

During a review of Patient 3's procedure report titled, "Hemodynamic (evaluation of physiological [function and mechanism of a living organism] parameters of cardiovascular [heart and blood vessels] systems) Procedure Report," dated 7/29/2025, the procedure report indicated, Registered Nurse (RN) 14 administered 2% lidocaine 50 milliliters (ml, unit of measure) IV to Patient 3. The procedure report also indicated, "at 18:35:32 (6:35:32 p.m.) 2% lidocaine 50 ml IV was verbally ordered with readback by [physician name] (MD 2), verified and given by [nurse name] (RN 14) per physician order."

During an interview on 8/20/2025 at 1:54 p.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated RN 14 removed ten (10) vials of 2% lidocaine (100 milligrams per 5 milliliters) from the Pyxis (automatic medication dispensing machine) machine during Patient 3's procedure on 7/29/2025.

During an interview on 8/20/2025 at 2:10 p.m. with an interventional cardiologist (MD 3, cardiologist who specialized in performing minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions), MD 3 stated a high dose of lidocaine could cause severe complication and lead to cardiac arrest.

During a concurrent observation and interview on 8/20/2025 at 2:33 p.m. with the Pharmacy Manager (PM 1) and Registered Nuse (RN) 16 at the facility's cardiac catheterization laboratory (cath lab, a hospital unit to perform minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) procedure room, PM 1 opened the Pyxis drawer and showed stocked 2% lidocaine vial. There were two (2) 2% lidocaine 100 milligrams per 5 milliliters vials stocked in the Pyxis machine. RN 16 stated the cath lab nurses (nurses who have special training in assisting the minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) had access to the Pyxis machine, to retrieve and administer medication per physician order.

During an interview on 8/20/2025 at 3:37 p.m. with the interventional cardiologist (MD 2), MD 2 stated the following: on day of procedure (7/29/2025), Patient 3 had some runs of ventricular tachycardia (VT) and he (MD 2) asked RN 14 to give 50 mg of lidocaine. RN 14 for some reason misheard and gave 50 ml which was equivalent to 1000 mg (20 times than the ordered dose). Patient 3 had seizure and lost pulsatility one to two minutes later. A Code Blue was called after. MD 2 further stated he (MD 2) would give medication dosage order in "milligrams (mg)" not in "milliliters (ml)" because "ml" was a unit of volume (amount of liquid) not a dose (amount of the medicine within the liquid).

During an interview on 8/20/2025 at 4:03 p.m. with RN 14, RN 14 stated the following: when MD 2 ordered lidocaine 50 milligrams for Patient 3's ventricular tachycardia, he (RN 14) misheard it as 50 milliliters. He (RN 14) readback "50 ml" but did not think MD 2 heard him (RN 14) clearly because he (MD 2) was busy with Patient 3. RN 14 also stated it was his (RN 14's) first time giving lidocaine and he (RN 14) was not familiar with it. RN 14 further stated, "I did not read back appropriately. It should be in milligrams."

During a concurrent interview and record review on 8/22/2025 at 11:24 a.m. with the Manager (NM 6) for Clinical Education and RN Clinical Educator (RNE 2) for Critical Care and Special Procedure, RN 14's nursing competency titled, "Initial Department/Unit Specific Orientation & Skills Competency Checklist," was reviewed. The nursing competency indicated, the medications under section "Pharmacologic Adjuncts in Cath Lab": Glucophage (medication to treat high blood sugar), Class I Antiarrhythmic - sodium channel blockers - lidocaine & procainamide (type of medication to treat abnormal heart rhythm), Class II, Class III, Class IV, and Class V antiarrhythmic medications were not checked off. NM 6 stated the following: the validator should check off the medications when he or she went over with the orientee. The clinical educator was responsible for making sure the completeness of competency validation to ensure the employee/orientee was fully competent before being released to work independently.

During a review of the facility's policy and procedure (P&P) titled, "Giving/Receiving/Authenticating Verbal Orders and Telephone Orders, Inpatient CPOE," dated 7/2022, the P&P indicated, "Verbal orders ... If a verbal order is necessary, use the following processes to ensure accuracy: a. Ordering Provider: i. to ordering provider shall dictate verbal orders slowly, clearly, and in an articulate manner to avoid confusion. b. Recipient: i. the licensed professional shall repeat back the entire verbal order to the ordering provider to ensure accuracy."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, "Administration ... the pharmacist and/or nurse should contact the prescriber to discuss concerns and issues relating to medication orders and obtain clarification as needed ... Safe Practices on Medication Administration ... C. prior to administration of medication, the licensed staff will verify 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication D. the licensed staff must know the purpose and effect of medications."

During a review of the facility's policy and procedure (P&P) titled, "Nursing Division - Overall Scope, Standards, and Structure," dated 6/2022, the P&P indicated, "Standard X - Competency. i. The patient can expect to be cared for by professional nursing staff who take responsibility for maintain current licensure and level of knowledge specific to their specialty through attendance at workshops, seminars and team conferences ... Staff Development/Competency 1. [the facility] is committed to improving the professional development staff and leadership to ensure staff is competent and well-trained to perform within the scope of their job descriptions. 2. Staff development is accomplished through: a. Providing orientation to job responsibilities/requirements of personnel. b. facilitating improved job performance and professional development of associates. This will be accomplished through assessment of learning needs, development of effective learning opportunities and evaluation of associate learning through testing, skills demonstration and on-the-job performance. c. updating nursing knowledge and clinical skills of nursing services personnel through in-services and staff development programs ... f. mechanisms utilized to validate competencies include: i. self-assessment ii. orientation skills validation iii. Annual competency review iv. Annual performance evaluation v. observation."

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

1. Ensure one of 30 sampled patient's (Patient 18) physician was notified of two instances wherein there was presence of blood in the tracheostomy (an opening a surgeon makes through the neck and into the patient's windpipe to assist with breathing) dressing of Patient 18, in accordance with the facility's policy and procedure (P&P) regarding physician notification.

This deficient practice had the potential to result in a delay in the provision of care and treatment to address the tracheostomy bleed of Patient 18, which may result in patient harm.

2. Ensure the nursing staff assessed the Maternal Fetal Triage (preliminary assessment to determine the urgency of the need for treatment) Index (MFTI, a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity [severity] and prioritize urgency for evaluation by a nurse and a physician) for two of three sampled patients (Patients 5 and 6), who presented to the Labor and Delivery (L&D) Triage area, in accordance with the facility's policy and procedure regarding L&D triage.

This deficient practice had the potential for the acuity level of patients to be unknown and had the potential for the delay in evaluation and treatment.

3. Inform two of 30 sampled patients (Patients 25 and 27) about the "Care of Patient's Belongings" Policy, which included the possibility of inspecting the patient's belongings and asking if any of the patient's belongings could be considered contraband (prohibited items, such as weapons, sharp objects, and illicit drugs), when Patients 25 and 28 did not sign their Patient Valuables form upon admission, in acknowledgement of the facility's policy and procedure regarding Patient belongings.

This deficient practice had the potential for improper inventory of patient belongings, lost items, if not confirmed with patients upon admission, and had the potential for patients to be unaware of which items were prohibited from the hospital (such as weapons or illegal drugs).

4. Ensure Nursing staff notified one of 30 sampled patient's (Patient 11) family after a code blue (the activation of the Emergency Response Team upon discovery of any individual who has suffered a sudden cessation of vital signs [temperature, blood pressure, heart rate, respiratory rate] or is in a sudden and unexpected life-threatening situation) was activated for Patient 11, in accordance with the facility's policy regarding family notification during a code blue episode.

This deficient practice had the potential to cause Patient 11's family and/or significant other, emotional distress, leading to feelings of anxiety and guilt.

5. Ensure that a nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) was administered on the correct site (right knee) for one of 30 sampled patients (Patient 12), in accordance with the facility's policy regarding anesthesia time-out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site).

This deficient practice had the potential to expose the patient (Patient 12) to a greater risk of local anesthetic toxicity, mobility (ability to walk) problems post-surgery (after surgery), and increased length of stay in the hospital.

Findings:

1. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/21/2025, the H &P indicated, Patient 18 was admitted to the facility for worsening muscle weakness and headache.

During a concurrent interview and record review on 8/20/2025 at 2:28 p.m. with Nurse Manager (NM) 1, Patient 18's "Operation/Procedure Report," dated 4/3/2025, was reviewed. NM 1 stated Patient 18 had a tracheostomy (an opening a surgeon makes through the neck and into the patient's wind pipe to assist with breathing) insertion.

During the same concurrent interview and record review on 8/20/2025 at 2:28 p.m. with Nurse Manager (NM) 1, Patient 18's "Nursing Documentation; Tracheostomy site drainage description," dated 4/4/2025 and 4/5/2025, were reviewed. NM1 stated on 4/4/2025 at 5:35 a.m. and on 4/5/2025 at 12:15 p.m., Patient 18's Tracheostomy site drainage description was documented as bloody. NM 1 stated physician should have been notified for the presence of blood in the tracheostomy dressing to check Patient 18 for any complications that needed to be addressed.

During a review of the facility's policy and procedure (P&P) titled, "Policy: Tracheostomy care, stoma (an artificial opening created through surgery) care and trach change," revised on 1/18/2022, the P&P indicated, "Policy summary/Intent: To minimize risks of infection and other complications associated with tracheostomy care and tracheostomy tube ...Report any swelling, redness, bleeding, discomfort, drainage, and/or signs of infection related to the tracheostomy to physician and document in the progress notes."

2. During an interview on 8/19/2025 at 1:28 p.m. with the Triage (preliminary assessment to determine the urgency of the need for treatment) Intake Registered Nurse (RN 5) in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Triage 1 (an area where a nurse conducts a quick assessment to identify those patients requiring immediate medical care and determines who can wait in the waiting room or who needs to be seen immediately), RN 5 stated the following regarding what happens in the L&D triage area: RN 5 performs a quick assessment of patients, including vital signs (temperature, blood pressure, heart rate, respiratory rate) and uses a doppler ultrasound (a non-invasive test that uses sound waves to exam blood flow) to assess for a fetal (unborn baby) heart rate. The patients' acuity level (the severity, complexity, and urgency of a patient's condition, and level of care and resources required), is assessed using the Maternal Fetal Triage Index (MFTI, is a five-level obstetric [concerned with childbirth and the care of women giving birth] tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity and prioritize urgency for an evaluation by the physician). The MFTI was used to determine whether the patient will wait in the waiting room or be taken to the adjacent Triage 2 area, where patients were placed in a bed, hooked up to a fetal monitor (a medical device used during pregnancy, labor, and delivery to track a baby's heart rate and strength or duration of uterine contractions [a shortening or uterine muscles occurring at intervals before and during childbirth) and evaluated by a physician.

During a concurrent interview and record review on 8/20/2025 at 10:47 a.m. with RN 4, Patient 5's medical record, was reviewed. RN 4 stated the following: On 8/16/2025 at 8:20 p.m., Patient 5, who was 28 weeks pregnant, presented to L&D triage due to abdominal pain and contractions for three (3) days. Patient 5's vital signs and the fetal heart rate (unborn baby's heart rate) were checked, however, the MFTI assessment was not documented by the Intake RN. In addition, there was no evaluation by the physician in the L&D triage area. Patient 5 was eventually admitted to the Antepartum (a period before labor and delivery) High-Risk area of the Labor and Delivery Unit on 8/17/2025 at 12:06 a.m. RN 4 verified that the facility's policy required the Triage Intake RN to assess the MFTI to prioritize which patients needed to be seen most urgently, and who can wait in the waiting room.

During a review Patient 5's L&D Triage note, dated 8/16/2025 at 8:20 p.m., the L&D Triage note indicated the following: Patient 5 presented to the L&D triage. Patient 5 was 28 weeks and 3 days pregnant and complained of abdominal pains and contractions. Patient 5 was placed on a fetal monitor, and vital signs were taken. Patient 5 had a history of anemia (blood does not have enough healthy red blood cells to carry oxygen throughout the body) and diabetes (high blood sugar). The MFTI was not documented. This was verified by RN 4.

During a concurrent interview and record review on 8/20/2025 at 11:26 a.m. with RN 4, Patient 6's medical record, was reviewed. RN 4 stated the following: On 8/18/2025 at 12:02 p.m., Patient 6, who was 39 weeks and 5 days pregnant, presented to the L&D triage for cramping. The MFTI assessment was not documented. Patient 6 was not evaluated by the physician in the L&D triage area. Patient 6 was admitted to the Labor and Delivery Unit on 8/18/2025 at 2:04 p.m. for induction of labor (using medical treatment to start labor before it begins naturally).

During a review Patient 6's L&D Triage note, dated 8/18/2025 at 12:02 p.m., the Triage note indicated the following: Patient 6 was 39 weeks and 5 days pregnancy. Patient 6 complained of cramping. The MFTI assessment was not documented. This was verified by RN 4.

During a review of the facility's policy and procedure (P&P) titled, "Patient Triage in the Labor & Delivery Unit," dated 4/19/2024, the P&P indicated the following: Policy Summary/Intent: To provide all birth persons presenting in the Labor and Delivery Triage area a nursing assessment and a medical screening examination (MSE, mandated evaluation performed by a qualified medical person to determine if a patient has an emergency medical condition)) ...Definitions:
RN: Registered Nurse
MFTI: Maternal Fetal Triage Index is a five-level obstetric tool for nurses to use when triaging a pregnant person presenting for care. It provides a standard approach to obstetric triage and is used to classify acuity and prioritize urgency for provide evaluation.
Triage: An assessment and classification of prioritization for which birthing persons will be provided with an MSE by a physician. Triage is not the equivalent of an MSE ...
Triage Intake RN: responsible for assessing and determining (MFTI)
Triage RN: Responsible for post MFTI nursing assessment in the triage area ...
Patients will arrive to the unit via Birthing Center elevator. The Triage Intake RN will complete MFTI assessment and then proceed with the registration process ...All patients will promptly be evaluated by the Triage Intake RN for:
1. Chief Complaint, or reason for coming to the L&D Unit.
2. Determination of acuity and urgency prioritization utilizing the Material Fetal Triage Index.

3.a. During an interview on 8/19/2025 at 2:21 p.m. with certified nurse assistant (CNA) 1 in the Telemetry unit, CNA 1 stated the following: When patients were admitted, usually a CNA would ask patient about which belongings were brought in. The CNA would check the patient's belongings with permission from the patient and would document the belongings in the medical record. The CNA reviews the belongings with the patient, and the patient signs the form regarding patient valuables, in acknowledgement that the patient agrees with the inventory and was informed about the policy. CNA 1 stated that patients in the Telemetry unit were not stripped searched (a physical search where a person is required to remove their clothing), only patients who were admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) were stripped or searched for any contraband.

During a concurrent interview and record review on 8/20/2025 at 1:49 p.m. with Nurse Manager (NM) 4, Patient 25's medical record, was reviewed. NM 4 stated the following: Patient 25 was admitted to the facility's Telemetry Unit (a unit dedicated to patients who require continuous cardiac [heart] monitoring) on 3/23/2025 at 12:28 a.m. Patient 25's belongings were checked on 3/23/2025 at 6:54 a.m. Patient 25's belongings included a cane, a belt, pants, shoes, socks, and a cellphone with charger. Patient 25 did not bring a backpack. NM 4 verified that the patient valuables form was not signed by Patient 25. The patient valuables form should have been signed by Patient 25 to acknowledge that Patient 25 reviewed the items, and was informed of the facility's belongings policy, which included consent to search belongings, and agreed that any items illegal in nature should be removed or disposed.

During the same interview on 8/20/2025 at 1:49 p.m. with Nurse Manager (NM) 4, NM 4 said Patient 25 was transferred to the Intensive Care Unit (a specialized hospital section providing constant monitoring and life-sustaining treatment for patients with severe, life-threatening illness or injuries) on 3/24/2025 at 11:38 a.m., due to changes in mental status, including eyes rolling back, delirium (a temporary state of mental confusion and disorientation), unintelligible speech (verbal communication that others cannot understand). NM 4 stated an unlabeled vial containing a small amount of unknown pink liquid was found in Patient 25's underwear. The vial had not been seen before, and it was unclear if Patient 25 ingested it (pink liquid). Patient 25 tested negative for methadone (a long-acting synthetic opioid medication used to treat drug addiction, and severe and chronic pain) upon admission on 3/22/2025, however, Patient 25 tested positive for methadone on 3/24/2025 at 1:20 a.m.

During an interview on 8/20/2025 at 2:45 p.m. with the Risk Manager (RM), the RM stated the amount of pink substance in the bottle found in Patient 25's underwear, was less than 5 milliliters (ml) and not enough to send to the lab for identification. Per a social worker's note, Patient 25 said the pink substance was methadone. The RM stated that patients in the telemetry units were not strip-searched, only patients who were admitted to the Behavior Health Unit were strip-searched for contraband (prohibited items, such as weapons, sharp objects, and illicit drugs).

During an interview on 8/20/2025 at 3:02 p.m. with Registered Nurse (RN) 15, RN 15 stated that RN 15 cared for Patient 25 in the Telemetry unit on 3/24/2025. An RRT (Rapid Response Team, a hospital team that intervenes for patient deterioration) was called for Patient 25 at 10:52 a.m. because he (Patient 25) looked sleepy and had tremors (shaking). During that time, Patient 25 wanted to urinate. RN 15 assisted Patient 25 with using the urinal and found a small clear container with a small amount of light pink liquid when Patient 25's underwear was pulled down. Patient 25 was transferred to the ICU for a change of condition.

During a review of Patient 25's History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient's condition), dated 3/23/2025, the H&P indicated the following: Patient 25 "was brought by paramedics from home for nausea (urge to throw up)/vomiting with blood last night ...Patient (Patient 25) had a past medical history of cirrhosis (cirrhosis of the liver, chronic liver damage from a variety of causes leading to scarring and liver failure) and alcohol abuse (a pattern of drinking that interferes with day to day activities) and was presenting with hematemesis (vomiting blood) since yesterday ...Patient denied using drugs however has positive urine drug screen for amphetamines (potent central nervous system stimulants with both medical and recreational uses) and opiates (class of natural or synthetic drugs that include both prescription and illegal drugs, such as heroin)."

During a review of Patient 25's Progress Note, dated 3/23/2025, the progress note indicated Patient 25 tested negative for Methadone (a long-acting synthetic opioid medication used to treat opioid use disorder) on 3/22/2025 at 10:50 p.m.

During a review of Patient 25's Physician Progress Note, dated 3/24/2025 at 8:25 a.m., the progress note indicated the following: "An RRT (Rapid Response Team, a hospital team that intervenes for patient deterioration) was initiated due to concerns about patient's (Patient 25) mentation ...During the assessment, the nursing staff discovered an unlabeled vial containing small amounts of a pink liquid substance in Patient 25's underwear. They were unsure of its contents and had not seen it before. It is also unclear if Patient 25 ingested this substance ...Given patient's (Patient 25) decline, the ICU team was notified for further evaluation and management ..."

During a review of Patient 25's H&P dated 3/24/2025 at 2:40 p.m., the H&P indicated the following: "Patient (Patient 25) in ICU (intensive care unit) after rapid response called secondary to AMS (altered mental status). Patient (Patient 25) may have ingested substance that contributed to presentation but was brought to ICU for further monitoring given patients' risk for decompensation. Patient (Patient 25) exhibited respiratory distress (difficulty breathing) needing emergency intubation (a tube is inserted into the airway, to keep it open and allows for the delivery of oxygen)."

During a review of Patient 25's document titled, "CM (case Management)-/ -SW (Social Work), dated 3/27/2025 at 12:17 p.m., the document indicated the following: Patient 25 explained he (Patient 25) had a history of smoking heroin (a highly addictive drug once used to treat severe pain but is now illegal to use or sell) and was now receiving methadone. Patient 25 stated the pink liquid was methadone. Patient 25 stated it was given from a clinic which provided medication-assisted treatment for opioid use disorder (drug addiction).

During a review of Patient 25's report titled, "Valuables / Medications Disposition," dated 3/24/2025 at 12:44 p.m., the report indicated the following: No medications brought from home. Valuables were reviewed on 3/23/2025 at 6:55 a.m. Valuables at bedside included: cane. Clothing at bedside included: belt, jacket, pants, shirt, shoes, socks, undershorts, hat. Electronics devices at bedside included: cell phone with charger. The report also indicated the following:
"We recommend personal belongings be sent home with family or placed in the hospital's fireproof safe. The hospital cannot assume liability for items you choose to keep at the bedside, including money ...or eyeglasses ...I agree to hospital staff inventorying my personal belongings in my presence. I agree that any items of an illegal nature should be removed and disposed of, and that such items may be provided to law enforcement for safety or if required by law." There was no documentation indicating the Patient 25 reviewed the medications, valuables, or informed or educated about the "Care of Patient's Belongings" policy. There was no signature by Patient 25's in acknowledgement of the policy. This was verified by NM 4.

During a review of the facility's policy and procedure (P&P) titled, "Care of Patient Belongings, Nursing," dated 5/24/2022, the P&P indicated the following. Because patient care units may not have a safe place to keep valuables, patients are discouraged from bringing expensive items ...Additionally, to maintain the security and patient safety, certain belongings and items are deemed contraband/prohibited or unauthorized (e.g., weapons, illegal or unauthorized drugs ...and other items that can pose a threat of physical harm to the patient ...Inventory searches may be conducted for the following reasons:

1. There is a probable cause to believe that the person has his/her possession a weapon or contraband and there is no less intrusive way of handling the situation.
2. To protect the staff and others from potential dangers.
-Procedure:
1. Inform the patients about the "Care of Patient's Belongs" Policy ...
2. Perform hand hygiene ...
3. Confirm the patient's identity ...
4. Ask the patient if s/he has any valuables or other items that could be considered prohibited (contraband).
5. Inspect the patient's belongings.

-Patient Education:
1. Inform the patient that because there are typically no locks on the doors to the patient's rooms, valuables cannot be considered safe in the room ...

-Documentation:
1. Document that the Policy on Care of Patient's Belongings was explained to the patient and the described patient's response.
2. The items being stored as well as the items remaining with the patient.
3. Document the presence of eyeglasses ...or medical devices ...
4. Note whether any of the patient's valuables ...were given to family members ...
5. If any items remain in the patient's possession, include an itemized list in the patient's medical record ...
6. Ask the patient or Representative to review and sign the form before putting valuables away ...
7. Observe items being removed, if patient permits.

3.b. During a concurrent interview and record review on 8/21/2025 at 1:18 p.m., with Nurse Manager (NM) 5, Patient 27's medical record, was reviewed. NM 5 stated the following: Patient 27 was admitted to the Telemetry unit on 8/20/2025 for epigastric (upper middle portion of the abdomen) pain. Patient 27 did not sign the Patient Valuables report. The report needed to be signed to verify the belongings were listed correctly and for Patient 27 to acknowledge having been informed of the facility's policy regarding patient belongings.

During a review of Patient 27's Face Sheet (a concise, printable document or digital view containing a patient's essential demographic, contact, insurance, and medical summary information for quick access by healthcare providers), the Face Sheet indicated Patient 27 was admitted to the facility on 8/20/2025 for abdominal pain.

During the review of Patient 27's report titled, "Valuables/Medications Disposition," dated 8/20/2025 at 4:48 p.m., the report indicated the following: "No medications brought to the hospital. Yes, brought valuables from home. Yes, patient (Patient 27) responsible for valuables. Yes, clothing discarded with patient's (Patient 27) permission. Valuables clothing at bedside included: pants, shirt, slippers (crocs). Money at bedside, $21. The wallet, cell phone and keys were at bedside." The form also indicated the following:

- "We recommend personal belongings be sent home with family or placed in the hospital's fireproof safe. The hospital cannot assume liability for items you choose to keep at the bedside, including money ...or eyeglasses ...I agree to hospital staff inventorying my personal belongings in my presence. I agree that any items of an illegal nature should be removed and disposed of, and that such items may be provided to law enforcement for safety or if required by law."

-There was no documentation indicating the Patient 27 was informed or educated about the "Care of Patient's Belongings" policy. Additionally, there was no signature by Patient 27 to indicate acknowledgement of the policy. This was verified by NM 5.

During a review of the facility's policy and procedure (P&P) titled, "Care of Patient Belongings, Nursing," dated 5/24/2022, the P&P indicated the following. Because patient care units may not have a safe place to keep valuables, patients are discouraged from bringing expensive items ...Additionally, to maintain the security and patient safety, certain belongings and items are deemed contraband/prohibited or unauthorized (e.g., weapons, illegal or unauthorized drugs ...and other items that can pose a threat of physical harm to the patient ...Inventory searches may be conducted for the following reasons:

1. There is a probable cause to believe that the person has his/her possession a weapon or contraband and there is no less intrusive way of handling the situation.
2. To protect the staff and others from potential dangers.

-Procedure:
1. Inform the patients about the "Care of Patient's Belongs" Policy ...
2. Perform hand hygiene ...
3. Confirm the patient's identity ...
4. Ask the patient if s/he has any valuables or other items that could be considered prohibited (contraband).
5. Inspect the patient's belongings.

-Patient Education:
1. Inform the patient that because there are typically no locks on the doors to the patient's rooms, valuables cannot be considered safe in the room ...

-Documentation:
1. Document that the Policy on Care of Patient's Belongings was explained to the patient and the described patient's response.
2. The items being stored as well as the items remaining with the patient.
3. Document the presence of eyeglasses ...or medical devices ...
4. Note whether any of the patient's valuables ...were given to family members ...
5. If any items remain in the patient's possession, include an itemized list in the patient's medical record ...
6. Ask the patient or Representative to review and sign the form before putting valuables away ...
7. Observe items being removed, if patient permits.


4. During a review of Patient's 11's "History and Physical (H&P)," dated 04/28/2025, the H&P indicated that Patient 11 had history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), status post (after) pacemaker (a battery-powered device implanted in the chest to regulate an abnormal heart rhythm) insertion. Patient 17 was brought to the emergency room complaining of left groin pain and left-sided chest pain. The H&P indicated that Patient 11 would be admitted to the Telemetry (a hospital level of care where patients undergo continuous cardiac [heart] monitoring) floor for further evaluation and management of chest pain.

During a concurrent interview and record review on 08/21/2025 at 2:47 p.m. with Registered Nurse (RN) 8, Patient 11's medical record titled, "Nursing Flowsheet," dated 05/2/2025, was reviewed. The Nursing Flowsheet indicated that the patient (Patient 11) was found unresponsive (does not react to sounds, touch or pain) and code blue (when someone's heart stops beating or someone stops breathing) was activated on 5/2/2025at 2:20 a.m., and at 2:54 a.m., Patient 11's spouse, granddaughter, and son were not called. RN 8 stated that it was the facility's policy and practice that family be called immediately once a code blue was activated on a patient.

During a concurrent interview and record review on 08/21/2025 at 3:22 p.m. with Registered Nurse (RN) 8, Patient 11's medical record titled, "CPR (Cardiopulmonary Resuscitation, an emergency treatment that's done when someone's breathing or heartbeat has stopped) Record," dated 05/2/2025, was reviewed. Patient 11's CPR record indicated that five (5) subsequent code blue was called on Patient 11. Code blue was activated at the following times on 5/2/2025: 2:20 a.m., 2:28 a.m., 2:38 a.m., 2:43 a.m., and at 2:49 a.m. Patient 11 expired(died) at 2:51 a.m. RN 8 stated that staffing may have been the issue why the nurses failed to notify family the first time a code blue was called on Patient 11. RN 8 further stated the nurses only called Patient 11's family at 2:54 a.m. after the Patient 11 died. There was no documentation expectation on the CPR Record Sheet that the family be notified, it only asked for the nurse to document what time the attending doctor was notified.

During a review of the facility's Policy and Procedure (P&P) titled, "Emergency Response to Adult (Code Blue) and Pediatric (Code White) Cardiac Or Respiratory," with last revised date of 07/17/2024, the document indicated the following:
In the event of a code blue, the Primary Nurse of the patient shall remain at the bedside to provide relevant history, pertinent clinical information and for notifying the attending physician and the patient's family, as appropriate.

5. During a review of Patient's 12's "History and Physical (H&P)," dated 12/16/2024, the H&P indicated that Patient 12 presented with complaint of right knee pain which had been present for approximately 3 years. Patient 12 had attempted treatment with activity modification, medication, physical therapy, and corticosteroid injection (a medical treatment that delivers potent, artificial steroid hormones to reduce inflammation and pain in a specific area of the body). Unfortunately, this treatment had not alleviated the patients' symptoms and was limited to even simple activities such as walking and going up and down the stairs. The H&P also indicated Patient 12 completed preoperative clearance (a medical evaluation that takes place before a surgical procedure) and would like to proceed with total knee arthroplasty (TKA, or total knee replacement, is a surgical procedure that replaces a damaged knee joint with artificial components made of metal and plastic) surgery.

During a concurrent interview and record review on 08/19/2025 at 4:57 p.m. with Nurse Manager (NM 3), Patient 12's medical record titled, "Post-Anesthesia (a medical intervention that temporarily induces a loss of sensation, consciousness, and/or muscle relaxation to allow for surgical procedures or other medical interventions to be performed without pain or discomfort) Note," dated 12/16/2024, was reviewed. The Post-Anesthesia Note indicated that a discussion of wrong site nerve block (an injection of medication close to a targeted nerve to provide temporary pain relief) happened between Patient 12 and anesthesiologist (A1). The H&P also indicated that the surgery was performed on the correct side (right knee).

During the same interview on 08/19/2025 at 4:57 p.m. with Nurse Manager (NM 3), NM 3 stated that Patient 12 was scheduled for a right TKA and was mistakenly given a left side nerve block instead of a right-side nerve block. The mistake was caught right after the administration of the nerve block. The incident happened prior to Patient 12's TKA surgery. NM3 added that although an anesthesia time out (a critical safety protocol where the entire surgical team pauses before starting an invasive procedure to verify the correct patient, procedure, and site) was called, it was later identified that the circulating nurse (a nurse in the operating room who manages the overall flow and logistics of a surgical procedure by coordinating communication and ensuring safety protocols are followed) was interrupted by the surgical technician (a staff who prepares the operating room and assists the surgical team during procedures) during the anesthesia time out process. As a result, the circulating nurse was not able to observe and verify the correct site.

During a review of the facility's Policy and Procedure (P&P) titled, "Universal Protocol for Eliminating Wrong Site, Wrong Procedures, And Wrong Patient Surgery," with last revised date of 04/21/2022, the P&P indicated the following:

A Time-out is performed immediately before starting the operation/procedure
a. Anesthesia time-out is performed and documented in the EMR in the operating room and other areas where general anesthesia is administered.

i. Anesthesia time-out is performed before induction of general anesthesia or administration of sedation.
ii. The circulating nurse correctly identifies the patient by calling the name on the ID band and the medical record number while the anesthesiologist is verifying it with the patient label on the consent form.
iii. The team verifies the procedure and the surgical site.

Based on observation, interview and record review, the facility failed to ensure nursing staff followed safe medication administration process for three of 30 sampled patients (Patient 1, Patient 2, and Patient 3), in accordance with the facility's policy of medication administration when:

1. Registered Nurses (RN) 12 and RN 13 failed to verify the Pitocin (a form of synthetic oxytocin, medication used to induce labor in pregnant women by stimulating uterine contractions) induction (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur) order was in place, and administered to Patient 1, Pitocin 95 milliliters per hour (ml/hr, unit of rate) instead of Pitocin 2ml/hr on 5/16/2025 (wrong order).

This deficient practice resulted in Patient 1 experiencing a decreased fetal (unborn baby) heart rate and requiring medical attention and intervention to stop the contraction.

2. RN 1 gave ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection) to Patient 2 on 5/23/2025 (wrong medication).

This deficient practice resulted in Patient 2 feeling numbness to the body and blurred vision and requiring medical attention and intervention to treat the Local Anesthetic Systemic Toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels).

3. RN 14 gave lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) 50 milliliters (ml, unit of measure, used to indicate a volume) instead of 50 milligrams (mg, unit of measure, used in medication dosage) to Patient 3 on 7/29/2025 (wrong dose).

This deficient practice resulted in Patient 3 receiving 1000 mg of lidocaine, going into seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) and cardiac arrest (sudden loss of heart function) shortly after the medication administration and required cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating).

These deficient practices also had the potential to put other patients at risk for medication errors and cause harm to patients.

On 8/21/2025 at 4:08 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Operation Executive (OE), Director of Accreditation, Licensing and Regulatory (DALR), Program Manager Regulatory (PMR), Director of Patient Experience and Nurse Clinical Outcomes (DIR 2), and with the following attendees via conference call: Chief Nursing Officer (CNO), Associate Chief Nursing Officer (ACNO) and System Director Regulatory (SDR). The facility failed to ensure nursing staff followed safe medication administration process and failed to ensure there was a safe process to prevent nursing staff from removing the wrong medication from the Pyxis tower (an automatic medication dispensing machine). These deficient practices resulted in Patient 2 receiving a wrong medication, receiving ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (medication, a type of antibiotics to treat infection), on 5/23/2025. As a result, Patient 2 experienced numbness all over her (Patient 2) body and blurry vision and required medical attention and intervention.

On 5/23/2025, a Registered Nurse (RN 1) removed a bag of ropivacaine instead of clindamycin from the wrong pocket in the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) department Pyxis tower. The Pyxis machine printed a label sticker (pyxis label) with the information of clindamycin for RN 1. RN 1 scanned the barcode on the pyxis label instead of the barcode on the actual medication and administered ropivacaine to Patient 2. Patient 2 was later found having numbness to her (Patient 2's) body and blurry vision. On 8/20/2025, the Director (DIR 1) of Pharmacy stated the pyxis label was to serve as patient specific label (a label contains patient's name, medication name and strength) to identify the patient, not to replace the barcode on the medication. If the nurse scanned the pyxis label, the system would not be able to detect the medication error (wrong medication). DIR 1 further stated after the incident, the pharmacy turned on the "scan removal" feature on the pyxis tower in the L&D department to force the L&D nurses to scan the medication bag before closing pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department. On 8/21/2025, nursing staff (RN 2 and RN 3) from Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) and Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit were able to remove medications from pyxis tower without the need for scanning the medications before closing the pyxis door. RN 2 and RN 3 both stated it was ok to scan either the barcode on the medication or the pyxis label when giving the medication to a patient.

On 8/22/2025 at 2:30 p.m., the IJ was removed in the presence of the Chief Medical Officer (CMO), OE, DALR, and CNO, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate actions taken by the facility were as follows: on 8/21/2025 at 5:45 p.m., the pharmacy department modified the Pyxis tower configuration and disabled label printing functionality for all nursing units. A barcode verification upon medication removal was being enabled for medications not stored in lidded Pyxis pockets for all nursing units. A revised nursing Pyxis tower medication removal and administration processes were implemented. During the medication removal process, nursing staff must visually validate the correct medication was pulled and scan the manufacturer's barcode with the Pyxis to confirm the correct medication had been removed. Nursing staff would affix an IV medication label and a patient specific label onto the intravenous (IV, administered into a vein) medication bag. During the bedside medication administration process, the nursing staff would validate the six (6) rights: right (correct) patient, right drug, right dose, right route, right time and right documentation. Nursing staff would scan the manufacturer's barcode again at bedside prior to medication administration. Education of revised processes began on 8/21/2025 for night shift nursing staff working in the units with Pyxis tower by nursing managers, educators and charge nurses. Education will continue at the beginning of the shift until 100% of staff have completed their education. Pharmacy director and nursing director will be performing weekly audits to ensure Pyxis tower label printing function remained disabled and compliance with the Pyxis tower medication removal and administration processes.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/15/2025, the H&P indicated, Patient 1 was 40 weeks and 5 days pregnant and was admitted to the Labor and Delivery (L&D, hospital unit specialized in taking care of mothers and newborns before, during and after the birth) Department for induction labor (to start labor contractions [tightening and relaxing of uterus during pregnancy to move the baby into the birth canal] artificially before they would naturally occur).

During a review of Patient 1's "Obstetrics/Gynecology (OB, medical specialty that focuses on the health of women's reproductive systems, including pregnancy childbirth and related conditions) nursing flowsheet (OB nursing flowsheet)," dated 5/16/2025, the OB nursing flowsheet indicated, Patient 1 delivered a baby on 5/16/2025 at 12:08 p.m. via Cesarean section (C-section, a surgical procedure to deliver a baby by making an incision in the mother's abdomen and uterus).

During an interview on 8/19/2025 at 12:34 p.m. with a Labor & Delivery (L&D) Registered Nurse (RN) 9, RN 9 stated the following: Pitocin could be given for two (2) different indications. Titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) Pitocin infusion, given at 1milliunit per minute (milliUnit/min, unit of dosage is equivalent to 1 milliliters per hour [ml/hr, unit of rate] in 30 units (unit, unit of measure) per 500 milliliters (ml, unit of measure) concentration bag), which was used for labor induction while postpartum (after childbirth) Pitocin infusion, was given at 95 ml/hr after a bolus (a single large dose of fluid infusion) and was for postpartum to prevent postpartum hemorrhage (excessive bleeding after childbirth). Physician order would indicate the indication and dosage for each Pitocin infusion. RN 9 also stated Pitocin was a high-risk medication and required two RNs' verification (checking).

During an interview on 8/19/2025 at 12:51 p.m. with the L&D charge nurse (CN 4), CN 4 stated the following: the RN must choose the correct Pitocin infusion order in the system when associating (programming) the IV (Intravenous, administered into a vein) pump (a medical device allowing medical personnel to set the amount of fluids of medications to be delivered to a patient over a specific time frame) to deliver the correct rate. A second RN verifier was needed to confirm prior to Pitocin administration.

During a concurrent interview and record review on 8/19/2025 at 3:25 p.m. with the Clinical Educator of Perinatal (RN 6), Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated 5/16/2025, was reviewed. The MAR indicated, RN 12 administered Pitocin at rate of 95 ml/hr at 5:35 a.m. and witnessed by RN 13. RN 6 stated the dose rate was for postpartum but Patient 1 had not delivered the baby at that time. Patient 1 should have received the Pitocin induction dose. RN 6 stated RN 12 administered the wrong Pitocin dose (higher dose) because the pump was set up incorrectly.

During a concurrent interview and record review on 8/19/2025 at 3:35 p.m. with RN 6, Patient 1's physician orders (physician order 1 and 2), dated 5/15/2025 and 5/16/2025, were reviewed. The physician orders indicated the following:

-Physician order 1 was ordered on 5/15/2025 at 9:45 a.m. for oxytocin (same as Pitocin) 30 units [5.7 units/hr] with order comments, "AFTER DELIVERY OF INFANT'S SHOULDER: Program continuous infusion at dose of 5.7 units/hr (rate of 95 ml/hr)."

-Physician order 2 ordered on 5/16/2025 at 7:21 a.m. for oxytocin 30 units [2 milliUnit/min] with order comments, "START oxytocin at 2 milliUnit/min Titrate by 2 milliUnit/min at an interval no sooner than every thirty (30) minutes but within forty (40) minutes is acceptable, to maintain regular uterine contractions of moderate to strong intensity by palpation (examining the body by touch) and patient perception."

-RN 6 stated there were two (2) Pitocin orders with two (2) different indications. RN 12 chose the wrong order because the induction order (physician order 2) was not entered at time of administration. RN 6 further stated RN 13 was the second witness when RN 12 administered Pitocin for Patient 1. Both RN 12 and RN 13 did not follow the medication administration process to verify right order and right dose for Patient 1 thus resulting in the medication error.

During an interview on 8/19/2025 at 3:58 p.m. with RN 6, RN 6 stated Pitocin could cause hyperstimulation (too much stimulation) to the uterus and cause fetal heart rate to decelerate (drop).

During an interview on 8/20/2025 at 9:49 a.m. with RN 12, RN 12 stated the following: on 5/16/2025 when she (RN 12) scanned (process of scanning to prevent medication error) the Pitocin, the system selected the postpartum order, and she (RN 12) did not read the order. She (RN 12) associated the IV pump with the wrong order. She (RN 12) did not look at the IV pump to verify the rate.

During an interview on 8/20/2025 at 5:15 p.m. with RN 13, RN 13 stated the following: when she (RN 13) walked into Patient 1's room, the computer screen was on, and the pump was ready to start by RN 12. She (RN 13) entered her (RN 13's) credentials (login name and password) as second witness without reading the order then left the room. RN 13 further stated she (RN 13) was called to the room later because of the fetal heart rate deceleration. She (RN 13) noticed the rate was incorrect when she (RN 13) turned off the IV pump.

During a review of Patient 1's "Discharge Summaries Notes (DC Summary)," dated 5/21/2025, the DC Summary indicated, "(on 5/16/2025) Pitocin was started at 0540 (5:40 a.m.) and one minute after starting Pitocin, patient (Patient 1) had a prolonged deceleration of seven (7) minutes with nadir (the lowest point or slowest rate of fetal heart rate deceleration during labor) in 70s. Pitocin was immediately discontinued and patient (Patient 1) was repositioned to the right lateral decubitus position (lying on the right side) ...IUPC (Intrauterine Pressure Catheter, a thin, flexible tube inserted into the uterus during labor to monitor uterine contractions) picked up contractions two minutes apart with FHR (fetal heart heart) in 80s-90s after 5 minutes, terbutaline (medication used to stop or slow down contractions) was given. Prolonged deceleration resolved in left lateral decubitus position (lying on the left side) and Trendelenburg position (the body was flat on back on a 15-30 degrees incline with the feet elevated above the head). After the above events, it was identified that the patient (Patient 1) received the postpartum rate of Pitocin rather than the starting dose of 2 milliUnit/min."

During a review of the facility's policy and procedure (P&P) titled, "Oxytocin: Administration of Oxytocin for Induction or Augmentation of Labor (medical process of speeding up an ongoing labor)," dated 10/2024, the P&P indicated, "A physician's order if required prior to induction or augmentation of labor ... Nursing Responsibilities During Labor Induction/Augmentation: 1. Prior to the start or re-start of Oxytocin two (2) RN's must check and document the following ... infusion is started at the ordered dose 1 or 2 milliUnits/min."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, the P&P indicated, "To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 1. Medication should be administered only upon the order of a clinician who has been granted clinical privileges by the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to prescribe the medications ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label. c. Verify the medication dose with the physician order in the MAR and product label, to assure that the correct drug is administered in the prescribed dose, by the correct toute, and at the proper time ... 7. For the nursing staff ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Orders. A. A physician's order must be obtained before administration of medication ... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication."

2. During a review of Patient 2's "History and Physical (H&P)," dated 5/20/2025, the H&P indicated, Patient 2 was 28 weeks and 2 days pregnant and was admitted to the facility Labor and Delivery (L&D) Department for antepartum (a period before labor and delivery) workup and management of fever.

During a review of Patient 2's physician order, dated 5/21/2025, the physician order indicated to give clindamycin (medication, a type of antibiotics to treat infection) 900 milligram (mg, unit of measure) every eight (8) hours intravenously (IV, administered into a vein).

During a review of Patient 2's physician progress notes, dated 5/23/2025, the physician progress notes indicated, physician (MD 1) was notified that Patient 2 was feeling "numb all over her body and has blurry vision" at 0053 (12:53 a.m.) after the administration of clindamycin. The physician progress notes also indicated MD 1 assessed Patient 2. Patient 2 reported episodes of numbness and unable to make eye contact because she (Patient 2) had floaters/flashes in her (Patient 2's) vision. Patient 2 overall felt very "weird." MD 1 was then notified that Patient 2 received ropivacaine (medication used in epidural [a type of pain relief medication administered through a catheter inserted into the epidural space, the area between the spinal cord and the spinal column]) instead of clindamycin (thus wrong medication was given).

During an interview on 8/20/2025 at 10:16 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: "on 5/23/2025, I was trying to give the medication on time before I go on break. When I requested clindamycin from the Pyxis (an automatic medication dispensing machine), it prompted me which pocket to get it from, but I mistakenly went to the wrong pocket and took out ropivacaine instead of clindamycin. The pyxis printed a label sticker (pyxis label) for me to scan. I scanned the sticker (pyxis label) instead of the actual medication bag when giving the medication (to Patient 2) at bedside and the system let it pass." RN 1 also stated, "I should not trust the sticker (pyxis label). I should scan the medication. I wanted to be on time, and I was in a rush before going on break." RN 1 stated she did not look at the name on the IV medication bag.

During an interview on 8/20/2025 at 11:19 a.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated the following: the nurse (RN 2) deviated from the process, she (RN 2) scanned the Pyxis printed label (pyxis label) instead of the bar code on the actual medication. Nurses must scan the bar code on the medication bag not the pyxis label. The purpose of pyxis label was to serve as patient specific label to identify the patient, not replace the barcode on the medication. If the nurse scanned the pyxis printed label, the system would not be able to detect the medication error (wrong medication).

During an interview on 8/20/2025 at 11:25 a.m. with DIR 1, DIR 1 stated after the incident that the pharmacy turned on "scan removal" feature on the pyxis in L&D department to force the L&D nurses to scan the medication bag before closing Pyxis door. The medications with the scan removal feature were only limited to the medications used in L&D department.

During an interview on 8/21/2025 at 5:37 p.m. with physician (MD 1), MD 1 stated ropivacaine could cause seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness), lidocaine toxicity (LAST, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) and affect the heart and affect the patient neurologically.

During a review of Patient 2's "Discharge Summaries Notes (DC Summary)," dated 5/25/2025, the DC Summary indicated, Ancef (medication, antibiotics to treat infection) and clindamycin started for presumed chorioamnionitis (bacterial infection and inflammation of the placenta [a temporary organ that forms inside the uterus during pregnancy connecting the mother and the developing baby], amniotic fluids [clear watery substance that surrounds and protects the developing baby during pregnancy], and the membranes [a thin protective layers that surround and cushion the developing baby during pregnancy]). The DC Summary also indicated, "(on 5/23/2025) overnight (Patient 2) noted to receive ropivacaine through IV instead of clindamycin due to nursing error resulting in whole body numbness and blurry vision. Patient (Patient 2) noted to have concern for LAST (Local Anesthetic Systemic Toxicity, also known as lidocaine toxicity, a rare but life-threatening complication that occurs when a local anesthetic [drug] is absorbed into the bloodstream at toxic levels) - anesthesia (physician who specialized in planning and administering anesthetic medications to manage pain and consciousness during surgical and medical procedures) called and 2 bags of lipid emulsion therapy (medical treatment to reverse the effects from local anesthetic systemic toxicity) was administered with resolution of patient (Patient 2) symptoms."

During a concurrent observation and interview on 8/21/2025 at 10:05 a.m., to demonstrate the retrieval of medication from the Pyxis, with RN 2 in the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) medication room, RN 2 put in a request of Cardene (medication to treat high blood pressure) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with twelve (12) pockets with different medications: 0.9% normal saline (type of IV fluid to treat fluid imbalance, phenylephrine (medication to treat low blood pressure) 20 mg per 250 milliliters (ml, unit of measure), vancomycin (type of antibiotics to treat infection) 1.25 grams (g, unit of measure) vial, mupirocin (antibiotic ointment to treat bacterial skin infection) ointment 2%, sevelamer carbonate (medication to treat high blood phosphate levels) oral suspension 0.8 g, potassium 10 milliequivalent (mEq, unit of measure) per 100 ml, epinephrine (medication to treat allergic reaction and to restore cardiac rhythm) 1mg/10ml, micafungin (medication to treat fungal infection) 100 mg vial, norepinephrine (medication to treat low blood pressure) 8 mg per 250 ml, Cardene 20mg/200ml, venofer (medication to treat iron deficiency anemia) 100mg/5ml, nystatin (medication to treat fungal infection) powder bottle in the same drawer. RN 2 removed a box of IV Cardene from Pyxis pocket number 10 and closed the Pyxis door without the need for scanning the medication. The Pyxis machine printed a label sticker (pyxis label) when RN 2 closed the pyxis door. RN 2 stated she (RN 2) could scan either the bar code on the medication (the medication itself) or the barcode on the pyxis label when giving the medication to a patient (The correct process is to scan the barcode on the actual medication and not the pyxis label).

During a concurrent observation and interview on 8/21/2025 at 10:32 a.m., to demonstrate the retrieval of medication from the pyxis, with RN 3 in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit medication room, RN 3 put in a request of Merrem (medication, type of antibiotics to treat infection) into Pyxis (for demonstration purpose). Then drawer number 4 door opened with seven (7) pockets with different medications: 0.9% normal saline 250 ml, 0.9% normal saline 50 ml, amiodarone (medication treat heart dysrhythmia [abnormal heart rhythm]) 360 mg/200 ml, Merrem 1 gram vial, magnesium sulfate (medication to treat low magnesium in blood) 2 gram/50 ml, PEG-3350 and electrolytes (laxative solution to clear bowel) for oral solution jar, and nafcillin 2 gram vial), in the same drawer. RN 3 removed a vial of Merrem from Pyxis pocket number 45 and closed the Pyxis door without the need for scanning the medication. RN 3 stated once the Pyxis drawer door opened, she (RN 3) had access to all the medications in the same drawer (drawer number 4). RN 3 stated she (RN 3) could scan either the bar code on the medication (the medication itself) or the pyxis printed label (the barcode) when giving the medication to a patient.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, the P&P indicated, "To ensure the safe and accurate administration of drugs to patients at [the facility] by using barcode technology ... Administration ... 6. Before administering a medication, the LIP (Licensed Independent Practitioner) should perform the following ... verify that the medication selected for administration is the correct one based on the medication order and product label ... 7. For the nursing staff ... bring meds (medications) to bedside. Scan all medications and verify. Remove the packaging of the medication at the bedside ... use 2 patient identifiers and follow 6 rights of medication administration. i. right patient (with 2 patient identifiers), ii. Right time, iii. Right drug, iv. Right dose, v. right route, vi. Right documentation... Safe Practices on Medication Administration ... Prior to administration of medication, the licensed staff will verify: 1. Use of two (2) patient identifiers 2. Name of drug 3. Route 4. Dosage 5. Frequency 6. Indication."

3. During a review of Patient 3's "Cardiology (heart) Procedure (procedure notes, completed by a physician who performed a special procedure)" notes, dated 7/29/2025, the procedure note indicated Patient 3 was admitted to the facility with diagnoses including but not limited to severe heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) and coronary artery disease (CAD, a condition where fats build up in the coronary arteries [major blood vessels supplying oxygen and nutrients to the heart muscle] narrowing and restricting blood flow in the heart). Patient 3 was scheduled for high-risk PCI (percutaneous coronary intervention, a minimally invasive procedure to treat narrowed or blocked coronary arteries) with Impella (a minimally invasive, catheter-based blood pump designed to temporarily support the heart's pumping function) support. The procedure notes further indicated the following: " ... patient (Patient 3) was at this point noted to have runs of VT (Ventricular tachycardia, life-threatening heart rhythm disorder that lead to inadequate blood supply to the body and potentially cardiac arrest [(sudden loss of heart function]) ... she (Patient 3) was given 50 milligrams (mg, unit of measure) lidocaine (medication for local anesthetic [reduce sensation of pain] and antiarrhythmic [treat or prevent abnormal heart rhythms]) IV (IV, administered into a vein) for suppression (to stop) and did have normalization of the rhythm, however, subsequently was noted to have absent pulsatility (rhythmic, nature of blood flow and pressure caused by a beating heart). Unlike previous episodes during the case where patient (Patient 3) was still awake, conversant, alert during loss of pulsatility, this time patient (Patient 3) was subsequently noted to be unresponsive (does not react to sounds, touch or pain), with seizure-like/tonic-clonic (jerking) activity, and foaming at the mouth ... A Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating]) was immediately called and chest compressions were commenced (started)."

During a review of Patient 3's procedure report titled, "Hemodynamic (evaluation of physiological [function and mechanism of a living organism] parameters of cardiovascular [heart and blood vessels] systems) Procedure Report," dated 7/29/2025, the procedure report indicated, Registered Nurse (RN) 14 administered 2% lidocaine 50 milliliters (ml, unit of measure) IV to Patient 3. The procedure report also indicated, "at 18:35:32 (6:35:32 p.m.) 2% lidocaine 50 ml IV was verbally ordered with readback by [physician name] (MD 2), verified and given by [nurse name] (RN 14) per physician order"

During an interview on 8/20/2025 at 1:54 p.m. with the Director (DIR 1) of Pharmacy, DIR 1 stated RN 14 removed ten (10) vials of 2% lidocaine (100 milligrams per 5 milliliters) from Pyxis (automatic medication dispensing machine) machine during Patient 3's procedure on 7/29/2025.

During an interview on 8/20/2025 at 2:10 p.m. with an interventional cardiologist (MD 3, cardiologist who specialized in performing minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions), MD 3 stated a high dose of lidocaine could cause severe complication and lead to cardiac arrest.

During a concurrent observation and interview on 8/20/2025 at 2:33 p.m. with the Pharmacy Manager (PM 1) and Registered Nuse (RN) 16 at the facility's cardiac catheterization laboratory (cath lab, a hospital unit to perform minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) procedure room, PM 1 opened the Pyxis draw and showed stocked 2% lidocaine vial. There were two (2) 2% lidocaine (100 milligrams per 5 milliliters) 5 ml vials stocked in the Pyxis machine. RN 16 stated the cath lab nurses (nurses who have special training in assisting the minimally invasive, catheter-based procedures to diagnose and treat heart and blood vessels conditions) had access to the Pyxis machine, to retrieve and administer medication per physician order.

During an interview on 8/20/2025 at 3:37 p.m. with the interventional cardiologist (MD 2), MD 2 stated the following: on day of procedure (7/29/2025), Patient 3 had some runs of ventricular tachycardia (VT), and he (MD 2) asked RN 14 to give 50 mg of lidocaine. RN 14 for some reason misheard and gave 50 ml which was equivalent to 1000 mg (20 times than the ordered dose). Patient 3 had seizure and lost pulsatility one to two minutes later. A Code Blue was called after. MD 2 further stated he would give medication dosage order in "milligrams (mg)" not in "milliliters (ml)" because "ml" was a unit of volume (amount of liquid) not a dose (amount of the medicine within the liquid).

During an interview on 8/20/2025 at 4:03 p.m. with RN 14, RN 14 stated the following: when MD 2 ordered lidocaine 50 milligrams for Patient 3's ventricular tachycardia, he (RN 14) misheard it as 50 milliliters. He (RN 14) readback "50 ml" but did not think MD 2 heard him (RN 14) clearly because he (MD 2) was busy with Patient 3. RN 14 also stated it was his (RN 14's) first time giving lidocaine and he (RN 14) was not familiar with it. RN 14 further stated, "I did not read back appropriately. It should be in milligrams."

During a review of the facility's policy and procedure (P&P) titled, "Giving/Receiving/Authenticating Verbal Orders and Telephone Orders, Inpatient CPOE," dated 7/2022, the P&P indicated, "Verbal orders ... If a verbal order is necessary, use the following processes to ensure accuracy: a. Ordering Provider: i. the ordering provider shall dictate verbal orders slowly, clearly, and in an articulate manner to avoid confusion. b. Recipient: i. the licensed professional shall repeat back the entire verbal order to the ordering provider to ensure accuracy."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration - Inpatient (Nursing)," dated 7/2024, "Administration ... the pharmacist and/or nurse should contact the prescriber to discuss concerns and issues relating to medication orders and obtain clarification as needed ... Safe Practices on Medication Administration ... C. prior to adminis

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

1. Ensure one of 30 sampled patient's (Patient 7) medical record contained copies of telemetry mounting strips (printed recording of the patient's heart electrical activity, captured continuously by the telemetry monitor important for reviewing and documenting heart rhythms over time) and copies retained from 1/27/2025 at 4:11 p.m. (the time of admission) to 1/28/2025 at 11:58 a.m., at the required intervals of every 4 hours and as needed, in accordance with the facility's policy regarding telemetry monitoring (a system that uses small, wearable devices with electrodes attached to a patient's body to wirelessly transmit their vital signs-such as heart rate, rhythm, and sometimes oxygen saturation and respiratory rate-to a central station for continuous, real-time observation by healthcare providers).

This deficient practice had the potential for Patient 7's safety to be compromised, leading to lack of monitoring, review, and assessment of the patient's (Patient 7) cardiac (heart) status, potentially delaying identification of arrhythmias (a condition in which the heart beats with an irregular or abnormal rhythm) or other critical changes.

2. Ensure one of 30 sampled patient's (Patient 24), who was documented as Spanish-speaking only (both verbally and written communication), informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for blood transfusion (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient) and esophagogastroduodenoscopy (EGD, a medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine), was verified by a nurse who was proficient in Spanish and certified by the facility or the process involved the use of the interpreter services (professional medical interpreter), and with documentation of interactions used to communicate with the LEP (Limited English Proficiency) person included as part of the medical record, in accordance with the facility's established policy and procedures regarding use of interpretation services and documentation.

This deficient practice had the potential to compromise Patient 24's ability to fully understand the course of treatment, procedures, or risks because the patient (Patient 24) was not properly informed in their own language thus had the potential to lead to incorrect decisions, lack of full consent, and affecting patient (Patient 24) autonomy (the capacity to be one's own person, making free and independent choices based on one's own judgment and values, rather than being controlled by external forces) and safety.

3. Ensure one of 30 sampled patient's (Patient 10), language preference, was accurately documented by nursing staff, when the official record indicated that Patient 10's preferred language was English while all informed consent forms obtained during Patient 10's admission stay at the facility were in Spanish.

This deficient practice had the potential for Patient 10's actual language needs to not be properly addressed, which could impair effective communication, understanding of medical information, and informed decision-making.

Findings:

1. During a review of Patient 7's History and Physical (H&P, a formal, comprehensive clinical evaluation by a healthcare provider to gather information about a patient's condition ), dated 1/27/2025, the H&P indicated the following: Patient 7 was admitted to the facility on 1/27/2025 due to abdominal pain, nausea (the urge to throw up), and vomiting. Patient 7 also had documented past medical history (PMH, a patient's previous medical conditions, treatments, surgeries, hospitalizations, and medications) of cardiomegaly (enlarged heart), polysubstance drug abuse (the repeated, non-prescribed use of three or more different types of drugs [or drug categories] for non-medical or recreational purposes, often resulting in harm or impairment) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behavior). The H&P further indicated that Patient 7's cardiac troponin (a measurable substance [a biomarker] found only in the heart muscle, crucial for diagnosing heart damage, including heart attacks) level was 5030 nanogram/Liter (ng/L, measuring unit which was [significantly elevated and indicated extensive cardiac muscle injury (heart attack)]. The H&P also indicated that Patient 7 was diagnosed with NSTEMI (Non ST Elevated Myocardial Infarction, a type of heart attack where there is damage to the heart muscle [myocardium] without significant elevation of the ST segment [an indicator for various conditions such as heart attack or lack of blood flow] on an electrocardiogram (ECG, a non-invasive medical test that records the electrical activity of the heart) and was admitted to telemetry unit (a hospital floor for remote cardiac monitoring, or a portable device that collects and transmits data from a patient's body to a central location for real-time observation).

During a concurrent interview and record review on 8/19/2025 at 2:15 p.m. with the Director of Risk Management (DRM) and the Program Specialist Informatics Nurse (RNPSI), Patient 7's "Nursing Documentation-Flowsheet," dated 1/28/2025, was reviewed. The record indicated that at 7:10 a.m. [on 1/28/2025], Nurse 2 documented that Patient 7 had pain level of 9/10 (on a pain scale from 0 [no pain] to 10 [worst pain ever], typically signifies severe, excruciating pain) in the chest and cardiac rhythm was documented as sinus arrhythmia (a normal, physiological variation in the heart's rhythm where the heart rate speeds up slightly during inhalation and slows down during exhalation, resulting in irregular beat-to-beat intervals).

During a review of Patient 7's electronic medical record (EMR, is a digital version of a patient's medical history, containing all relevant information about their health, treatments, and medications) uploaded telemetry strips (which are recorded images of the patient's heart rhythm stored in the electronic system) in Patient 7's EMR for the period from 1/27/2025 at 4:11 p.m. (admission time) to 1/28/2025 at 9:26 p.m. [expired time), were requested to be reviewed. The EMR indicated that there were no telemetry strips that had been uploaded into the EMR to demonstrate Patient 7's recorded electrical activity from 1/27/2025 [at 4:11] p.m. to 1/28/2025 at 11:28 a.m. This information was verified with the Program Specialist Informatics Nurse (RNPSI) on 8/19/2025 at 4:11 p.m., who confirmed that Patient 7's medical record did not contain retained copies of telemetry strips (from 1/27/2025 at 4:11 p.m. to 1/28/2025 at 11:28 a.m.).

During an interview on 8/19/2025 at 4:12 p.m. with the Telemetry Nurse Manager (NM 4), the NM 4 said that a primary nurse (a nurse responsible for the continuous management of a specific patient) was responsible for printing telemetry strips upon admission, every 4 hours, and as needed for all telemetry patients, and then placing these strips into the patients' chart, in accordance with the facility's policy regarding telemetry monitoring and retention of records.

During a review of the facility's policy and procedure (P&P) titled, "Telemetry Monitoring and Trouble Shooting," dated 3/15/2022, the P&P indicated that, "The RN (Registered Nurse) trained in basic EKG monitoring will be responsible for documentation of the measurements and interpretation on all routine and PRN [as needed] rhythm strip records. Strips are ran at the beginning of each shift, as a baseline... subsequent readings will be run and interpreted every 4 hours and as needed...the interpreted strips will be placed in the mounting sheet or will be printed.... Licensed nurse measures and interprets the patient's rhythm strip and signs in each rhythm strip.... Licensed nurse is responsible for placing mounting strips in the patients' chart."

2. During a review of Patient 24's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient's previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) of gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells (erythrocytes) or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body's tissues, often affecting the feet, ankles, and legs due to gravity).

During further review of Patient 24's History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called, EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink), and an order was placed upon admission to check and record Patient 24's weight every day to monitor Patient 24's fluid status and overall health (daily weight fluctuations are an early indicator of a patient's worsening condition).

During an interview on 8/20/2025 at 3:13 p.m. with the nurse manager (NM 7), the NM 7 said the following regarding verified consents and the process of obtaining them (the process of confirming that an individual has a full understanding of a medical procedure or research study before voluntarily agreeing to it, and signing a consent form as a voluntary agreement to proceed with the treatment or a medical procedure): "If the patient's primary language is Spanish, the interpreter used to translate should provide their identification number, which must be documented on the consent form. A nurse can also translate without using an interpreter if the nurse is certified through the facility. We have a list of certified nurses, which we can use to provide interpretation." The NM 7 also said that for the accuracy of documentation, patient language preferences should be respected, and the patient should fully understand what they are signing to make informed decisions about their treatment and care.

During a concurrent interview and record review on 8/21/2025 at 11:30 a.m. with the Clinical Informatics Specialist Nurse (CISN), Patient 24's verified informed consents for the EGD, dated 8/17/2025, and 2 verified informed consents for Blood Transfusions, dated 8/16/2025 and 8/18/2025, were reviewed. All three consents were verified in the presence of nursing staff, who signed the consent forms as a witness. The CISN said that not one consent form had a documentation regarding the use of interpreter services. All three informed consents were in Spanish language and sighed by the patient (Patient 24). All three nurses, who were used to interpret, were also not listed among the qualified/certified Spanish interpreters list provided by the facility's Director of Accreditation, Licensing, and Regulatory Services (DARL) on 8/21/2025 at 11:00 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Language Assistance Program-Interpretation and Hearing Impaired," dated 1/2025, the P&P indicated that, the facility "...will ensure that persons requiring language assistance services (such as oral language assistance or written translation) and who have limited English proficiency (LEP) will have meaningful access and an equal opportunity to participate and understand services, activities, programs, and other benefits involving medical conditions and treatment ...Language assistance will be provided using competent bilingual staff, providers, staff interpreters, or technology and telephonic interpretation services... Initial assessment of communication needs will be made during the admission process...Staff will identify the language and communication needs of the LEP person. In addition, the records are kept of past interactions with patients, the language used to communicate with the LEP person will be included as a part of the record ...Staff who have a limited familiarity (not deemed competent or qualified) with language interpreter skills should interpret only in emergency situation for a brief time..."

During a review of the facility's policy and procedure (P&P) titled, "Consent and Informed Consent-California," dated 5/2025, the P&P indicated that, "The consent form should include ...Name and signature of interpreter and an attestation that the consent has been translated, if applicable... If the patient cannot communicate with the practitioner because of language barrier, the practitioner, with the health care facility's assistance, should arrange for an interpreter. The interpreter's responsibilities include translating the information regarding the recommended medical treatment that the patient or the patient's legal representative needs to receive before deciding whether to give consent, as well as instructions regarding medical care..."

3. During a review of Patient 10's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/29/2024, the H&P indicated that Patient 10 was admitted due to weakness and abdominal pain. The H&P indicated that Patient 10 had past medical history (PMH, a comprehensive record of a person's health information before their current visit or illness, detailing past and present illnesses, hospitalizations, surgeries, injuries, allergies, medications, and health habits like diet, exercise, alcohol, and drug use) of End-Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis), hypertension (high blood pressure), recent (11/21/2024) placement of peritoneal catheter (a flexible tube, that is surgically implanted into the abdomen to facilitate peritoneal dialysis, a treatment for kidney failure), alcohol and substance abuse.

During a concurrent interview and record review on 8/20/2025 at 3:24 p.m. with Nurse Manager (NM 6), Patient 10's signed informed consents (the process by which an individual agrees to undergo a medical procedure, participate in a clinical study, or a specific course of action after receiving and understanding all the relevant information, including potential risks and benefits) for the following procedures were reviewed:

1. Esophagogastroduodenoscopy (EGD, medical procedure that allows a doctor to examine the lining of the upper gastrointestinal tract, including the esophagus, stomach, and first part of the small intestine) and Colonoscopy, dated 12/2/2024 e, colonoscopy- a medical procedure that involves examining the large intestine (colon) using a thin, flexible tube called a colonoscope.

2. Placement of Peritoneal Dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen [peritoneum] as a filter to remove waste products and excess fluid from the blood) Catheter, possible Laparoscopy (minimally invasive surgical procedure to insert a tube [catheter] into the abdomen, with a camera, into the abdomen), dated 11/21/2024.

3. Laparoscopic drainage possible open procedure all other indicated procedures, retrieval of peritoneal dialysis (removing peritoneal dialysis catheter using a minimally invasive, laparoscopic approach with small incisions and a camera)," dated 12/05/2024.

-All three consents were obtained in Spanish (Patient 10 reviewed and signed all three consent forms written in Spanish). The NM 6 verified that Patient 10's documented preferred language (spoken and written) at the time of admission (11/29/2024) was English. The NM 6 also said that if Patient 10's preferred language was English, then all the consents should have been obtained in English, not in Spanish. The NM 6 then said, "The reason why the consents should be obtained in the patient's preferred language is because we want the patient to fully understand what they are signing."

During a review of the facility's policy and procedure (P&P) titled, "Language Assistance Program-Interpretation and Hearing Impaired," dated 1/2025, the P&P indicated that, the facility "...Will ensure that persons requiring language assistance services (such as oral language assistance or written translation0 and who have Limited English Proficiency (LEP) will have meaningful access and an equal opportunity to participate and understand services, activities, programs, and other benefits involving medical conditions and treatment...Language assistance will be provided using competent bilingual staff, providers, staff interpreters, or technology and telephonic interpretation services... Initial assessment of communication needs will be made during the admission process...Staff will identify the language and communication needs of the LEP person. In addition, the records are kept of past interactions with patients, the language used to communicate with the LEP person will be included as a part of the record..."

During a review of the facility's policy and procedure (P&P) titled, "Consent and Informed Consent-California," dated 5/2025, the P&P indicated that, "The consent form should include...Name and signature of interpreter and an attestation that the consent has been translated, if applicable... If the patient cannot communicate with the practitioner because of language barrier, the practitioner, with the health care facility's assistance, should arrange for an interpreter. Vital documents, including consent forms, presented by the healthcare facility staff to a patient must be written in a language that the patient can understand, or translated into such a language with an appropriate qualified interpreter."

Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 24), the following information was documented to justify Patient 24's progress and response to treatment plan, in accordance with the facility's policy regarding documentation, when:

1. Nursing staff failed to obtain and document Patient 24's daily weight in accordance with the physician's order.

2. Nursing staff failed to develop, document, and maintain a personalized care plan (a formal, documented roadmap created by nurses that outlines a patient's specific health needs, goals, and planned nursing actions to achieve those goals) for monitoring fluid balance (the body's ability to maintain the proper amount of water and hydration) and nutritional status (the body's current state of nourishment, reflecting the balance between nutrient intake and the body's needs for growth, repair, and maintenance) for Patient 24.

These deficient practices had the potential to result in adverse patient outcomes for Patient 24, when complications such as fluid overload and/or dehydration goes undetected due to lack of monitoring and proper documentation, which can lead to delayed diagnosis and treatment.

Findings:

1. During a review of Patient 24's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient's previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) of gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells [erythrocytes] or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body's tissues, often affecting the feet, ankles, and legs due to gravity).

During further review of Patient 24's History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink) and an order was placed upon admission to check and record Patient 24's weight every day to monitor their (Patient 24) fluid status and overall health (daily weight fluctuations are an early indicator of a patient's worsening condition).

During a review of Patient 24's "Physician Orders" set, dated 8/16/2025, the Physician Orders indicated that Patient 24 had a standing order for "Daily Weight at 0600 (Monitoring weight every day at 6:00 a.m.), placed on 8/16/2025 at 6:32 p.m., upon Patient 24's admission to the facility.

During a concurrent interview and record review on 8/21/2025 at 11:10 a.m. with Clinical Informatics Specialist Nurse (CISN), Patient 24's "Daily Weight -Nursing Flowsheet," dated from 8/17/2025 through 8/21/2025, was reviewed. The CISN confirmed that Patient 24's medical record titled, "Daily Weight -Nursing Flowsheet," dated from 8/17/2025 through 8/21/2025, did not include documented weights at 6 a.m. [from 8/17/2025 through 8/21/2025] as ordered by physician. The CISN confirmed that the daily weight should have been obtained and documented as ordered.

During a review of the facility's policy and procedure (P&P), titled "Assessment and Reassessment Nursing Services," dated 4/2025, the P&P indicated that "Documentation-The electronic medical record (EMR) is used for clinical documentation throughout the hospital. The complete medical record is viewed as the integrated document. The EMR and the written medical record are reflections of the patient's care."

During a review of the facility's policy and procedure (P&P), titled "Clinical Record Documentation Guidelines," dated 4/2024, the P&P indicated that "The basic purpose of the clinical record is to record and communicate the following information: ...Patient condition, care, treatment and services received...Clinical record documentation is used for: ...Providing clinically relevant data...a means of communication between physicians and other healthcare team members..."

During a review of the facility's policy and procedure (P&P) titled, "NURSING ASSESSMENT, DOCUMENTATION USING POWERCHART, IVIEW, DYNAMIC CHARTING FORMS," dated 4/2024, the P&P indicated that, "Professional documentation by clinical staff is an integral part of practice to ensure safe and effective care. Documentation is a record of the care provided and reflects the judgment and critical thinking of the nurse. Documentation should reflect the patient-centered and evidence-based plan of care and indicate patient outcomes for all inpatients. Nursing care should be documented as closely as possible to the time delivered..."

2. During a review of Patient 24's History and Physical (H&P), dated 8/17/2025, the H&P indicated that Patient 24 was admitted due to dark blood coming from the rectum and weakness. The H&P also indicated that Patient 24 had past medical history (PMH, the record of a patient's previous health conditions, illness, surgeries and medical issues that have occurred before the current health concern) gastrointestinal (GI, the digestive system, encompassing all the organs involved in digestion, from the mouth to the anus) bleeding with blood transfusions (a medical procedure where blood or blood components from a donor are transferred into the bloodstream of a recipient), anemia (a condition characterized by a low level of red blood cells [erythrocytes] or hemoglobin in the blood), and edema (swelling caused by an abnormal accumulation of fluid in the body's tissues, often affecting the feet, ankles, and legs due to gravity).

During further review of Patient 24's History and Physical (H&P), dated 8/17/2024, the H&P indicated that Patient 24 required a consultation with gastroenterologist (GI, stomach and intestine doctor) and a possible test called EGD (esophagogastroduodenoscopy, a procedure to look inside the digestive system and identify any issues such as the source of bleeding) and was made NPO (nothing by mouth, meaning not allowed to eat or drink) and an order was placed upon admission to check and record Patient 24's weight every day to monitor Patient 24's fluid status and overall health (daily weight fluctuations are an early indicator of a patient's worsening condition).

During a concurrent interview and record review on 8/21/2025 at 11:02 a.m. with the Clinical Informatics Specialist Nurse (CISN), Patient 24's care plans (nursing care plan outline a patient's individualized care goals and nursing actions needed to meet those goals), dated 8/21/2025, was reviewed. The nursing care plan did not reflect a care plan developed or documented to guide nurses to maintain proper fluid and electrolyte balance (the body's process of maintaining stable levels of both water and charged minerals [electrolytes like sodium [salt], potassium [for blood pressure control], calcium [strengthen bones], and magnesium- essential for nerve and muscle function] within specific concentrations to ensure proper body's function, and preventing complications such as fluid overload and retention) and nutritional status. The CISN said that a built-in nutritional care plan was available for the nurses to initiate; however, it was marked inactive.

During a review of the facility's policy and procedure (P&P) titled, Nursing Division-Overall Scope, Standards, and Structure," dated 4/2025, the P&P indicated that:
"c. Standard Ill - Plan of Care
i. A registered nurse will analyze the admission assessment data and establish a plan of nursing care. v. The plan of care will be individualized and based on the nursing assessment, diagnostic results, and the patient's goals. The nurse will collaborate with the interdisciplinary team, the patient, patient's family, and significant others to help establish the plan of care and goals based on patient's needs."
During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Nursing Services," dated 4/2025, the P&P indicated that,
"B. A registered nurse will implement the individualized plan of care...The RN retains the responsibility for interpreting the data and identifying patient needs.
C. Documentation-The electronic medical record (EMR) is used for clinical documentation throughout the hospital. The complete medical record is viewed as the integrated document. The EMR and the written medical record are reflections of the patient's care..."

During a review of the facility's policy and procedure (P&P) titled, "Clinical Record Documentation Guidelines," dated 4/2024, the P&P indicated that "The basic purpose of the clinical record is to record and communicate the following information: ...Patient condition, care, treatment and services received...Clinical record documentation is used for: ...Providing clinically relevant data...a means of communication between physicians and other healthcare team members..."

Based on interview and record review, the facility failed to ensure proper completion of a pre procedure checklist (a tool used by surgical teams to improve patient safety by ensuring essential steps, tasks and assessment are completed before surgery) for one of 30 sampled patients (Patient 14), in accordance with the facility's policy regarding pre-operative operation.

This deficient practice had the potential to create serious risks, including surgical errors, complications, and/or death. In addition, it can also potentially lead to medical errors, inefficient use of resources, and costly delays or cancellations that can cause significant patient anxiety and inconvenience for Patient 14 and other patients undergoing surgery.

Findings:

During a review of Patient's 14's "Orthopedic (a branch of medicine that focuses on the musculoskeletal system, including bones, joints, muscles, tendons, and ligaments) SOAP (standardized, four-part progress note [Subjective, Objective, Assessment, Plan] used by healthcare providers to document a patient's condition and treatment during their hospitalization) Note," dated 08/12/2025, the record indicated that Patient 14 sustained a right hand injury on 8/4/2025. Patient 14 reported he (Patient 14) was walking his dogs outside when he (Patient 14) slipped and fell. Radiographs (X-ray imagery) of the right hand showed evidence of fourth and fifth metacarpal (any of the five long bones that form the palm of the hand) fractures (a break in the bone). The note indicated a Plan to schedule Patient 14 for a Closed Reduction Percutaneous Pinning (CRPP, a surgical procedure for bone fractures where the bone is manipulated back into alignment and then held in place with internal pins or screws) versus Open reduction and internal fixation (ORIF, a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware) for Patient 14's right fourth and fifth metacarpal fractures.

During a concurrent interview and record review on 08/22/2025 at 3:00 p.m. with Registered Nurse Educator (RNE), Patient 14's medical record titled, "Pre Procedure Checklist (a tool used by surgical teams to improve patient safety by ensuring essential steps, tasks and assessment are completed before surgery)," dated 8/20/2025 at 6:47 a.m., was reviewed. Patient 14's pre procedure checklist indicated "Holding" for the following questions: Consult note needed, H&P (History and Physical, a formal and complete assessment of the patient and the problem) available, H&P interval update, informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment), pre-anesthesia (a medical intervention that temporarily induces a loss of sensation, consciousness, and/or muscle relaxation to allow for surgical procedures or other medical interventions to be performed without pain or discomfort) evaluation documented, surgical site marked by MD (Medical Doctor), and surgical site verified by patient.

During the same interview on 08/22/2025 at 3:00 p.m. with Registered Nurse Educator (RNE), RNE stated that the pre procedure checklist was considered incomplete. RNE said that the only acceptable answer was either Yes or Not Applicable (NA). RNE added that he (RNE) was not sure what "Holding" meant based on what was documented, but RNE stated "it seems to suggest that the nurse in the Holding Unit (a hospital area where patients are prepared for surgery before being taken to the operating room) will do a follow up and complete the pre-procedure checklist." RNE further stated it was important for nurses to complete the pre-procedure checklist correctly to make sure that patient was safe and prepared for surgery.

During a review of the facility's Policy and Procedure (P&P) titled, "Surgery - Pre-Operative Preparation," with last review date of 03/18/2025, the P&P indicated the following:

Responsibility of RN (registered Nurse)
Review the pre-operative checklist to see that preparation is complete. Check if the patient is wearing an identification band.
Key Points: Complete the pre-operative checklist. Ensure consent signed, lab work done, valid history and physical in chart, etc. Document in nursing note's exact location of patient's valuables.