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The Hospital was out of compliance for the Condition of Participation for Medical Staff.

Findings included:

Based on record review and interviews for one patient (Patient #1), in a total of 10 records reviewed, the Hospital failed to ensure that an accurate History and Physical Examination (H & P), to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, was completed and documented by a qualified member of the Medical Staff

Cross Reference:
482.22(c)(5)(i) Medical staff responsibilities H&p- (358)

Based on records reviewed and interviews for one (Patient #6) of 10 sampled patients, the Hospital failed to ensure Patient #6 was administered medications (Continuous Subcutaneous Insulin Infusion), in accordance with physician orders and Hospital Policy.

Cross Reference: 482.23(c): Preparation and Administration of Drugs (405).

Based on record review and interviews for one patient (Patient #1), in a total of 10 records reviewed, the Hospital failed to ensure that an accurate History and Physical Examination (H & P), to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, was completed and documented by a qualified member of the Medical Staff.

Findings included:


Review of the Hospital policy titled, "Patient Health Record Policy" undated, included the following:

-Patient health records shall be reviewed on an ongoing basis for timeliness, completeness, accuracy of information, and quality of documentation by the Health Information Management Department.

Inpatient Documentation:

A complete H&P should include the following minimum elements:

- Review of relevant systems, including a minimum review of cardiovascular and respiratory systems.

-A report of the physical examination, which must include all relevant body systems.



Review of Patient #1 ' s medical record included the following:

-Speech and Language Pathology (SLP) evaluation dated 4/2/2025, indicated Patient #1 was admitted on 4/1/2025 after a Motor Vehicle Accident (MVA). The hospital course included a workup for altered mental status. SLP consult was ordered to assess oropharyngeal swallowing function and risk of aspiration. Further review of the SLP evaluation indicated Patient #1 had poor oral/dental hygiene and many missing teeth. The evaluation indicated Patient #1 presented with mild oral dysphagia in the setting of many missing teeth. The risk of aspiration was identified as low, but a Dysphagia Soft diet with thin liquid was recommended. Further recommendations included, remaining upright as possible for all oral intake, remain upright for 30-45 minutes after meals, and small bites/sips, eat/feed slowly. Aspiration precautions were identified.

-Patient #1 ' s After Visit Summary/Instructions dated 4/3/2025, indicated dysphagia status and diet recommendation as dysphagia soft.

-Nursing note dated, 4/2/2025, indicated SLP placed patient on soft diet due to not having dentures.

-Nursing noted dated, 4/3/2025 indicated patient is being discharged home. Discharge paperwork reviewed with patient.

-Patient was readmitted on 4/8/2025 with myalgia and hyperglycemia.

-Physician order dated 4/8/2025 at 5:10 P.M., indicated Regular consistent carb 2000k/calorie diet.

- Review of History and Physical dated 4/8/2025 at 4:21 P.M. included, "History largely obtained from review of records as well as discussion with Patient ' s wife with patient providing a limited history due to baseline Lewy Body dementia with patient developing some agitation just prior to my evaluation". 10 Point Review of Systems (ROS) was negative other than the pertinent positives and negatives listed. Further review indicated a Head Eyes Ears Nose Throat (HEENT) exam was performed and did not indicate any abnormalities or missing teeth.

-Nursing flowsheets dated 4/10/2025 indicated Patient #1 needs assist and setup with feeding. Diet type documented as a diabetic/consistent carb with a fair appetite.

-Nursing assessments dated 4/8/2025, 4/9/2025, and 4/10/2025 indicate Patient #1 was forgetful, disoriented to time and short-term memory loss. HEENT assessments also indicated Patient #1 had missing teeth.

During an interview on 5/15/25 at 10:38 A.M., the Hospitalist Medical Director said the type of diet a patient is ordered depends on clinical assessment also while considering Past Medical History, problem list, and prior discharge summary. The Medical Director said Physician documentation is by exception generally noting irregularities. The Medical Director said it was presumed Patient #1 had his/her dentures on admission on 4/8/25 and if the patient had no teeth, it would have been noted. The Medical Director was unsure where it would be documented that the patient had dentures.

The admitting physician from the 4/8/25 admission was not available for an interview. Hospital staff made multiple phone calls to the involved physician and did not receive a return call back.

Further review of the medical record did not indicate Patient #1 had dentures.

During an interview on 11/28/25 at 11:20 A.M. Patient #1 ' s family said the patient owned dentures but did not have them in the hospital during the second admission. The family then said Patient #1 only had two teeth.

Review of Patient #1 ' s discharge summary dated 4/10/25 indicated a rapid response was called at on 4/10/25 at 5:27 P.M. Patient #1 was reported to be eating dinner and started choking, Heimlich maneuver was performed, oral sweep and food was removed. Patient #1 was suctioned but was hypoxic (low oxygen level) and had a heart rate in the 30 ' s. Further attempts at suctioning/removal of food were attempted. Patient #1 was confirmed a DNR/DNI and expired at 5:39 P.M.

Based on records reviewed and interviews for one (Patient #6) of 10 sampled patients, the Hospital failed to ensure Patient #6 was administered medications (Continuous Subcutaneous Insulin Infusion), in accordance with physician orders and Hospital Policy.

Findings include:

Review of the Hospital's policy titled, Continuous Subcutaneous Insulin Infusion (CSII) (an insulin pump) Guidelines, undated, indicated that patients/family members must be trained in insulin pump therapy and be willing to take responsibility for glycemic management with the insulin pump while in hospital. The Patient/designee must demonstrate ability to manage the pump and have no contraindications for use while at the Hospital. The policy further indicated that the physician must place orders for patients using CSII while in the Hospital.

Review of Patient #6's medical record indicated he/she presented to the Emergency Department (ED) in May 2025 at approximately 12:29 P.M. and was admitted for medical management for possible aspiration pneumonia. Patient #6 had a history of cerebrovascular accident (CVA) with expressive aphasia (a language disorder that makes it difficult to speak fluently), Insulin Dependent Diabetes Mellitus, and Lewy Body Dementia.

Patient #6's Physician placed an order on 5/8/25 at 8:26 P.M., for nothing by mouth (food, drinks, or oral medication).

Review of the Hospital's Internal Investigation, dated 5/10/25, indicated that on 5/9/25 at approximately 1:00 A.M., an admitting nurse identified Patient #6 had on an insulin pump (a wearable device) and at this time he/she was found to be hypoglycemic (low blood sugar) with a blood glucose of 49 milligrams per deciliter (mg/dl) (normal fasting range is between 70 - 99 mg/dl). Patient #6 required intravenous (IV) 125 millimeters (ml) of Dextrose 10% to restore his/her blood glucose level. The Investigation further indicated the Physician's left the insulin pump on Patient #6 and ordered an Endocrinology consult.

Review of the Endocrinology Progress Note, dated 5/9/25 at 9:47 A.M., indicated Patient #6's insulin pump (CSII) was discontinued per Policy, due to Patient #6/family member being unable to independently manage the insulin pump. Patient #6's insulin pump was removed.

There was no documentation to support Patient #6 had a physician's order to use an insulin pump (CSII) at the Hospital. Patient #6 remined in the Hospital for approximately 21 hours without a physician's examination for safety and/or a physician's order for the insulin pump (CSII).

During an interview on 5/14/25 at 12:50 P.M., Physican Assistant (PA) #1 cared for Patient #6 while in the ED. He said Patient #6 was non-verbal due to a past history of a stroke. PA#1 said he spoke with Patient #6's wife but the conversation did not include Patient #6 ' s medications as the pharmacy staff typically complete the medication reconciliation details once a patient is admitted. PA#1 said he reviewed Patient #6's medications in the medical record and noted Patient #6 was on insulin; however, he was unaware Patient #6 was on an insulin pump (CSII) at the Hospital. PA #1 said he did not order insulin for Patient #6 while in the ED.

During an interview with the Medication Safety Officer on 5/14/25 at 2:40 P.M., she said that she assisted with the initial review of Patient #6's medication event on 5/9/25. The Medication Safety Officer said that upon further investigating the details of the event, she discovered that Patient #6's ED Nurse saw that Patient #6 had on some sort of pump/device (later identified as an insulin pump/CSII) but failed to notify a physician to further evaluate for safety and a potential order for continued use at the Hospital.

During an interview on 5/14/25 at 2:00 P.M., the Executive Director of Risk Management provided documentation of the Hospital's Internal Investigation and review of Patient #6's medication event on 5/9/25, however, she said there was no documentation to support the Hospital implemented system wide corrective actions in response to the event.