HospitalInspections.org

Based on policy reviews, patient electronic medical record (EMR) reviews, observation, injectable manufacturer's guidelines review, and interviews, the critical access hospital (CAH) failed to meet the condition of participation of Provision of Services. The CAH failed to meet the requirements related to patient care policies and required CAH services. These deficient practices had the potential to affect all patients receiving services in the CAH.

Findings include:

Cross Reference C1048 - The registered nurse (RN) failed to assess patients in accordance with critical access hospital (CAH) policies and/or physician orders related to neurological (neuro) checks, vital sign assessments, effectiveness of administered medications, pain, and CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score for six (Patient (P) 1, P4, P5, P10, P14, P20) of 20 patient EMRs reviewed for RN assessment from a total sample of 23 patients.

Cross Reference C1049 - The CAH failed to ensure: 1. Medications were administered in accordance with physician orders for three (Patient (P) 3, P4, P5) of 20 patient EMRs reviewed for medication administration from a total sample of 23 EMRs and 2. Fluids placed in the warmer observed in the emergency department (ED) on 07/08/25 at 9:43 AM met the manufacturer's guidelines for storage.

Cross Reference C1050 - The CAH failed to ensure a nursing care plan was developed and kept current in accordance with the CAH's policies for three (Patient (P) 1, P2, P3) of 20 patient EMRs reviewed for a current nursing care plan from a total sample of 23 EMRs.

Cross Reference C1052 - The CAH failed to ensure physical therapy (PT) evaluations had documentation of all required content in accordance with the CAH policy for two (Patient (P) 5, P7) of two patient EMRs reviewed with physician orders for Physical Therapy evaluations from a total sample of 23 patients.

Based on review of the Governing Body Bylaws, review of the Medical Staff Bylaws and Rules and Regulations, patient electronic medical record (EMR) review, CAH policy review, and interviews, the critical access hospital (CAH) failed to ensure the governing body or individual that assumed full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that CAH policies were administered so as to provide quality health care in a safe environment had physicians write new orders when a patient was discharged from observation status and admitted as an inpatient for one (Patient (P) 7) of one patient EMR reviewed with a change from observation status to an inpatient admit from a total sample of 23 patients. This deficient practice had the potential to affect all patients who had observation status physician orders and were then admitted to the CAH as an inpatient.

Findings include:

Review of the CAH's "Third Amended and restated Bylaws [name of CAH], A Nevada Nonprofit Corporation, approved on 08/31/22, indicated the bylaws included no documentation related to the medical staff and physician orders.

Review of the CAH's "[name on the hospital] Medical Staff Bylaws," dated 2020 (no documented month and day when approved), indicated ". . . These Bylaws are adopted in recognition of the mutual accountability, interdependence and responsibility of the Medical Staff and the Governing Body of [name of hospital] in protecting the quality of medical care provided in the Hospital and monitoring the competency of the Hospital's Medical Staff . . . the Medical Staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of the Medical Staff, and to provide for the responsible governance of the Hospital. In adopting these Bylaws, the Medical Staff commits to exercise its responsibilities with diligence and good faith; and in approving these Bylaws, the Governing Body commits to allowing the Medical Staff reasonable independence in conducting the affairs of the Medical Staff. . ."

Review of the CAH's "[name of CAH] Medical Staff Rules," effective 01/01/20, indicated ". . . All entries in a medical record must be legible, complete, dated, timed, and authenticated by the member who is responsible for ordering, providing or evaluating the services provided. . ." There was no documentation in the CAH;s medical staff rules related to physician orders for patients on observation status who were then admitted as an inpatient.

Review of the CAH policy titled "Outpatient Observation," reviewed/revised May 2025, indicated ". . . Observation status is defined as the use of a bed for short-term monitoring and treatment of a patient outpatient condition to determine possible inpatient admission or discharge . . . 2. Once physician writes the order for observation, the "clock" time observation begins is
when the patient is placed into observation which should coincide with the time the physician order is written. If after one midnight, the physician has determined that the patient is not stable or safe enough for discharge, then the UR Nurse/Nursing Supervisor
will use the two midnight rule and Interqual (a system of evidence-based clinical guidelines and decision support tools used in healthcare for utilization management, particularly for determining the medical necessity of healthcare services; helps ensure that patients receive the appropriate level of care and that healthcare resources are used efficiently; used by payers (insurance companies) and providers (hospitals, doctors) to guide decisions about admissions, continued stays, and specific treatments to review inpatient criteria to assist the physician with status determination and the patient may become an inpatient, have observation time extended up to 48 hours, or be referred for secondary review). 3. Observation exceeding 48 hours are generally denied. If a particular case appears to have exceptional circumstances to justify approval, then the need is to be documented in the medical record by the physician and Director of Risk/Quality must be notified."

Review of the CAH policy titled "Admission & [and] Level of Care Review," reviewed/revised February 2025, indicated ". . . Interqual criteria is considered a screening tool and the decision to admit a patient to the hospital or place into observation is ultimately determined by the physician . . . If a patient does not meet an outpatient observation level of care per Interqual, yet is not medically stable enough for discharge from the ED and requires ongoing treatments or monitoring, then the UR representative can approve the observation status as determined by the physician. After 1[one] midnight of observation, the physician should make a decision concerning the patient's discharge or change the status to an inpatient admission pert the 2 [two] midnight rule . . . If the diagnosis, treatment, stabilization, and discharge can reasonably be expected in two midnights or more, then inpatient status should be considered. . ."

Review of P7's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P7's EMR navigated by DON, indicated P7 was admitted as an inpatient on 07/06/25 at 12:09 PM (time is 12:10 PM on the physician orders). Review of P7's H&P (located under the under the "All Notes" tab, then the "H&P" tab) indicated P7 presented with left knee pain after a fall. Review of P7's physician orders (located under the "Manage Orders" tab, then under the "Orders" tab) indicated an order on 07/04/25 at 12:50 PM by Medical Doctor 1 (MD1) to admit to "Observation - Outpatient" followed by an order by MD1 on 07/06/25 at 12:10 PM to admit "Inpatient." Review of the physician orders indicated new physician orders were not documented when P7 was changed from observation status to inpatient.

During an interview on 07/09/25 at 3:00 PM, Director of Nurses (DON) confirmed new physician orders were not written when P7 was admitted as an inpatient on 07/06/25 at 12:10 PM.

During an interview on 07/10/25 at 8:45 AM, Chief Medical Officer (CMO) stated the physicians were not writing new orders when patients were admitted to inpatient from an observation bed and were using the same physician orders written when the patient was placed on observation status.

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Based on policy reviews, patient electronic medical record (EMR) reviews, and interviews, the registered nurse (RN) failed to assess patients in accordance with critical access hospital (CAH) policies and/or physician orders related to neurological (neuro) checks, vital sign assessments, effectiveness of administered medications, pain, and CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score for six (Patient (P) 1, P4, P5, P10, P14, P20) of 20 patient EMRs reviewed for RN assessment from a total sample of 23 patients. This deficient practice had the potential to affect all patients receiving services at the CAH.

Findings include:

1. Neuro checks:
Review of P1's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P1's EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the "ED Provider Note" documented on 07/05/25 at 10:28 AM (located under the "All Notes" tab, then the "ED" tab, then the "Progress Notes" tab). Review of P1's physician orders (located under the "Manage Orders" tab, then the "Orders" tab) indicated an order on 07/05/25 at 2:00 PM for neuro checks every four hours. Review of P1's nursing assessments of neuro status (located under the "Flowsheets" tab, then the "Assessment" tab) indicated P1's neuro status assessment was documented on 07/08/25 at 3:15 AM and on 07/08/25 at 8:00 AM. The 8:00 AM neuro assessment was more than four hours since the previous assessment at 3:15 AM.

During an interview on 07/08/25 at 12:34 PM, CAQ2 confirmed the neuro assessment performed on 07/08/25 at 8:00 AM was greater than four hours from the previous assessment.

2. Vital signs:
a. Review of P1's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P1's EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the "ED Provider Note" documented on 07/05/25 at 10:28 AM (located under the "All Notes" tab, then the "ED" tab, then the "Progress Notes" tab). Review of P1's physician orders (located under the "Manage Orders" tab, then the "Orders" tab) indicated an order on 07/05/25 at 1:18 PM to assess vital signs every six hours. Review of P1's nursing assessments of vital signs (located under the "Flowsheets" tab, then the "Assessment" tab) indicated P1's vital signs were assessed on 07/06/25 at 10:50 AM, then at 7:25 PM with no pulse and respiration documented, then a full set of vital signs at 10:34 PM, and then at 8:00 AM on 07/07/25 (not every six hours as ordered). Review indicated P1's vital signs were assessed on 07/07/25 at 7:11 PM then at 5:07 AM on 07/08/25 (more than six hours between vital sign assessments). Review indicated P1's vital signs were assessed at 3:30 PM on 07/08/25 then at 11:14 PM (more than six hours between vital sign assessments).

During an interview on 07/08/25 at 12:34 PM, CAQ2 confirmed P1's vital signs were not assessed every six hours as ordered by P1's physician.

b. Review of P4's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P4's EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the "General Surgery History & [and] Physical Note" documented on 07/08/25 at 8:24 AM. Review of P4's physician orders (located under the "Manage Orders" then under the "Orders" tab)) indicated an order on 07/08/25 at 10:09 AM to assess vital signs every two hours times four, then every four hours times 24 hours, and then per unit policy. Review of P4's nursing assessments of vital signs (located under the "Flowsheets" tab, then the "Assessment" tab) indicated P4's vital signs were assessed on 07/08/25 at 8:52 AM, 11:28 AM, 3:35 PM (not every two hours as ordered), 6:59 PM, 11:58 PM, and 7:45 AM on 07/09/25 (not every four hours as ordered).

During an interview on 0709/25 at 10:26 AM, DON stated P4's vital signs were not assessed as ordered by the physician.

c. Review of P5's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P5's EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5's history and physical (H&P) (located under the under the "All Notes" tab, then the "H&P" tab) indicated P5 presented with alcohol intoxication. Review of P5's physician orders (located under the "Manage Orders" then under the "Orders" tab) indicated an order 07/01/25 at 6:15 PM as follows:
If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours
If CIWA score 11-14, assess VS and CIWA every two hours
If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox
If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox
Discontinue CIWA assessments when score is less than 5 for 72 hours.
Review of P5's nursing assessments of vital signs (located under the "Flowsheets" tab, then the "Assessment" tab) indicated vital signs were not documented on 07/02/25 at the 12:35 AM assessment (CIWA score was 13) and at the 2:35 AM assessment (CIWA score at 2:30 AM was five) and then not documented again until 3:48 AM. There was no documentation of vital sign assessment at 2:33 PM when P5's CIWA score was 14.

During an interview at 12:21 PM on 07/09/25, DON confirmed P5's vital signs were not assessed as ordered in accordance with the CIWA assessments.


3. Review of the facility policy titled, "Transfusion Therapy" last revised on 08/09/24 revealed, " ...Informed consent is obtained according to organizational policy and procedure ...Start the transfusion slowly at approximately 2ml [milliliters] per minute for the first 15 minutes and remain near the patient; increase the transfusion rate, if there are no signs of reaction ...Baseline vital signs documented within one hour prior to start of transfusion. Vital signs 15 minutes after the start of the transfusion. Vital signs every hour during the transfusion. Post transfusion vital signs within one hour post transfusion. ..."

Review of P10's "Face Sheet" located in the electronic medical record (EMR) under the "Demographic" tab revealed P10 was admitted to the hospital on 07/01/25 with diagnoses of periprosthetic fracture around internal prosthetic hip joint (fracture hip).

Review of the "Physician Orders" located in the EMR under the "Manage Order" tab revealed an order dated 07/04/25 at 7:32 AM to transfuse one unit Red Blood Cells.

Review of the "Informed Consent of Refusal for Blood Transfusion" document dated 07/04/25 located in the EMR under the "Media" tab revealed, " ...I consent to have a transfusion of the following blood product ..." The area on the document did not identify the blood product the patient was consenting to receive. The area was not filled out and was left blank.

Review of the EMR under the "Flowsheets" tab revealed "Blood Transfusion Documentation" that revealed one unit PRBC (packed red blood cells) transfusion was started on 07/04/25 at 11:33 AM and stopped on 07/04/25 at 2:33 PM.

Review of the EMR under the "Assessment" tab revealed vital signs were obtained at 11:32 AM prior to the PRBC transfusion. Vital signs were next obtained on 07/04/25 at 11:47 AM (one hour 14 minutes after the start of the transfusion) and on 07/04/25 at 3:27 PM. Review of the EMR did not reveal vital signs were obtained 15 minutes after the start of the blood transfusion or every hour during the blood transfusion.

Review of P10's EMR failed to reveal the rate of administration of the PRBC received on 07/04/25 was documented.

During an interview on 07/09/25 at 11:33 AM, the Director of Nursing (DNS) stated the blood transfusion consent form should include the type of blood product the patient is consenting to receive. The DNS confirmed the area on P10's transfusion consent form did not include what blood product the patient was to receive. The DNS stated per hospital policy the rate the blood transfusion is started at and then progressed to should be documented by the nurse. The DNS stated vital signs should be obtained 15 minutes after the start of the blood transfusion and every hour thereafter until the transfusion is completed. The DNS confirmed the rate of the blood transfusion and vital signs were not obtained per hospital policy.

Review of P14's "Face Sheet" located in the EMR under the "Demographics" tab revealed P14 was admitted to the hospital on 05/26/25 with diagnoses that included hepatic encephalopathy.

Review of the "Physician Orders" located in the EMR under the "Manage Order" tab revealed an order dated 06/15/25 at 10:06 AM to transfuse one unit of Red Blood Cells.

Review of the "Informed Consent of Refusal for Blood Transfusion" document dated 06/15/25 located in the EMR under the "Media" tab revealed, " ...I consent to have a transfusion of the following blood product ..." The area on the document did not identify the blood product the patient was consenting to receive. The area was not filled out and was left blank.

Review of the EMR under the "Flowsheets" tab revealed "Blood Transfusion Documentation" that revealed one unit PRBC (packed red blood cells) transfusion was started on 06/15/25 at 12:58 PM and stopped on 06/15/25 at 3:15 PM.

Review of P14's EMR failed to reveal the rate of administration of the PRBC received on 06/15/25 was documented.

During an interview on 07/09/25 at 11:33 AM, the Director of Nursing (DNS) stated the blood transfusion consent form should include the type of blood product the patient is consenting to receive. The DNS confirmed the area on P14's transfusion consent form did not include what blood product the patient was to receive. The DNS stated per hospital policy the rate the blood transfusion is started at and then progressed to should be documented by the nurse. The DNS confirmed the rate of the blood transfusion was not documented in the medical record.




4. Review of the facility policy titled, "Medication Distribution and Administration" last revision date 05/11/25 revealed, " ...The nurse will monitor for effectiveness and adverse drug reactions of the medication administered to a patient."

Review of P20's "Flow Sheet" located in the EMR under the "Demographic" tab revealed P20 presented to the hospital emergency room on 06/09/25 at 3:29 AM and was discharged home on 06/09/25 at 4:19 AM.

Review of the "Triage Note" dated 06/09/25 at 3:34 AM located in the EMR under the "ED (Emergency Department)" tab, revealed, " ...Pt BIB [brought in by] family from home ...Patient ambulatory with steady gait. AAO x4 upon arrival. Respirations even/unlabored, No apparent distress at this time ...BP [blood pressure] 138/88, pulse (!) 104, temp 26.7 C (98.1 F) (oral), respirations 16 ...SpO2 [oxygen saturation] 98% on room air ... level four (4) acuity."

Review of the "Physician Orders" located in the EMR under the "Manage Order" tab revealed an order dated 06/09/25 at 3:47 AM for Valium 0.5mg (milligram) one dose by mouth.

Review of the "Medication Administration Record (MAR)" dated 06/09/25 at 3:50 AM located in the EMR under the "MAR" tab revealed Valium 0.5mg was administered.

Review of P20's EMR did not reveal documentation that the effectiveness of Valium administered on 06/09/25 was assessed.

During an interview on 07/10/25 at 10:45 AM, Registered Nurse (RN) 2 stated he/she did not recall P20 but did review P20's EMR prior to the interview. RN2 stated P20 presented to the emergency room with a chief complaint of anxiety and received Valium per the physician's order. RN2 stated he/she normally conducts an assessment after administering medication to treat anxiety. RN2 confirmed the EMR did not include documentation that P20 was assessed for the effectiveness of Valium after it was administered.
5 Pain assessment:
Review of the CAH policy titled "Pain Management," reviewed/revised 06/25/25, indicated ". . . Pain Management is the process of promoting the effective assessment, diagnosis and
treatment of pain . . . Pain will be assessed in all patients upon admission and a pain goal will be
chosen for effective management of pain . . . The pain management process includes pain assessment, planning and intervention, reassessment of patient responses to or outcomes of pain
management measures, education of patient and family regarding pain management, and documentation of assessments, reassessments, interventions and education provided. 4. Pain scales will be utilized . . . to assess pain that are consistent with the patients age, condition and ability to understand: numerical pain rating scale 0-10 . . . Non-Verbal Scale . . . Pain will be assessed on a regular and ongoing basis, but every four hours at a minimum by the RN. Pain will be reassessed after one hour of a patient being medicated for pain to establish the effectiveness of the medication. .

a. Review of P23's "Flow Sheet" located in the EMR under the "Demographic" tab revealed P23 presented to the hospital emergency room on 05/16/25 at 2:40 PM.

Review of the "Nursing Assessment" located in the EMR under the "ED" tab, revealed possible stroke, history of CVA, and a pain level score of 5 out of 10. The location of the pain was listed as the head. Review of the "Nursing Assessment" revealed the next pain assessment was not conducted until 05/16/25 at 8:00 PM.

During an interview on 07/10/25 at 8:42 AM, the DNS stated per hospital policy pain assessments should be completed at a minimum every four hours. The DNS confirmed P23 did not have pain assessment conducted per the hospital policy on 05/16/25.

b. Review of P4's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P4's EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the "General Surgery History & [and] Physical Note" documented on 07/08/25 at 8:24 AM. Review of P4's physician orders (located under the "Manage Orders") indicated an order for Hydromorphone (Dilaudid) (indicated for the management of pain in patients where an opioid analgesic is appropriate) injection 0.5 mg (milligrams) every two hours as needed intravenously (IV) starting on 07/08/25 at 4:41 AM until discontinued for severe pain at level of seven to 10 and ketorolac (Toradol) injection (used for the short-term relief of moderately severe pain) 15 mg every six hours as needed IV for pain level four to six starting on 07/08/25 at 10:03 AM. Review of P4's MAR (located under the "Manage Orders" tab, then the "MAR" tab) indicated Dilaudid 0.5 mg IV was administered on 07/08/25 at 2:26 PM with no documented assessment of the pain level and at 5:28 PM with a pain level assessment of six at 5:20 PM (dose for Dilaudid was for pain level of seven to 10). Review of P4's MAR indicated Toradol 15 mg IV was administered at 10:58 AM on 07/08/25 with no pain assessment documented.

During an interview on 07/09/25 at 10:26 AM, DON stated the pain medications, Dilaudid and Toradol, were not administered in accordance with the pain assessments as ordered by the physician.

6. CIWA score assessment:
Review of P5's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P5's EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5's history and physical (H&P) (located under the under the "All Notes" tab, then the "H&P" tab) indicated P5 presented with alcohol intoxication. Review of P5's physician orders (located under the "Manage Orders" then under the "Orders" tab) indicated an order 07/01/25 at 6:15 PM as follows:
If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours
If CIWA score 11-14, assess VS and CIWA every two hours
If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox
If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox
Discontinue CIWA assessments when score is less than 5 for 72 hours.

Review of P5's nursing assessments of CIWA score (located under the "Flowsheets" tab, then the "Assessment" tab) indicated on 07/01/25 at 5:30 PM P5's CIWA score was 8, requiring the score to be reassessed in four hours. Review indicated P5's CIWA score was not reassessed until 12:00 AM on 07/02/25 (score was 7). Review indicated P5's CIWA score was assessed on 07/02/25 at 2:33 PM as a score of 14, requiring CIWA to be assessed every two hours. There was no documented assessment at 4:30 PM and 6:30 PM as required by the physician orders.

During an interview on 07/09/25 at 12:21 PM, DON stated P5's CIWA was not assessed in accordance with the physician orders based on the score obtained at the time of the assessment.

Based on policy reviews, observation, injectable manufacturer's guidelines review, patient electronic medical records (EMR) review, and interviews, the critical access hospital (CAH) failed to ensure: 1. Medications were administered in accordance with physician orders for three (Patient (P) 3, P4, P5) of 20 patient EMRs reviewed for medication administration from a total sample of 23 EMRs and 2. Fluids placed in the warmer observed in the emergency department (ED) on 07/08/25 at 9:43 AM met the manufacturer's guidelines for storage. These deficient practices had the potential to affect all patients receiving services at the CAH.

Findings include:

1. Review of the CAH policy titled "Medication Distribution and Administration," reviewed/revised 05/11/25, indicated ". . . All staff members who participate in medication management processes are responsible for maintaining and verifying patient-specific information, using paper-based or electronic charts and records . . . Drugs are administered only with the order of a physician or other individual who has been granted privileges to write such orders . . . All schedule, PRN [as needed] and STAT medications are charted on the MAR [medication administration record] immediately upon administration, including signature and title of person, and site if applicable. . indicated P4 was admitted on ."

Review of P3's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P3's EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P3 was admitted as an inpatient on 07/07/25 at 1:11 AM with a chief complaint of abdominal pain, upper abdominal pain, and nausea (located in the "ED Provider Note" documented on 07/06/25 at 6:49 PM (located under the "All Notes" tab, then the "ED" tab, then the "Progress Notes" tab). Review of P3's physician orders (located under the "Manage Orders") indicated an order on 07/07/25 at 11:45 AM to administer Zarxio (helps protect hematopoietic stem and progenitor cells (HSPCs), the source of blood cell lineages, including neutrophils, red blood cells, and platelets) injection 480 micrograms (mcg) subcutaneously SQ) once. Review of P3's medication administration record (MAR) (located under the "Manage Orders" tab, then the "MAR" tab) indicated Zarxio was not administered on 07/07/25 at 11:45 AM with documentation by Registered Nurse (RN) 1 that the reason was "missed dose." Review of the MAR indicated Zarxio was administered on 07/07/25 at 4:50 PM. There was no documentation in P3's EMR that RN1 notified P3's physician that Zarxio was not administered as ordered or that RN1 notified the pharmacist to obtain the medication at 11:45 AM.

During an interview on 07/08/25 at 3:05 PM, CAQ2 stated the Zarxio was not administered as ordered by P3's physician, and there was no documentation in P3's EMR that P3's physician or the pharmacist were notified of the dose not being available.

Review of P4's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P4's EMR navigated by Director of Nurses (DON), indicated P4 was admitted as an inpatient on 07/08/25 at 8:53 AM with a chief complaint of a small bowel obstruction (located in the "General Surgery History & [and] Physical Note" documented on 07/08/25 at 8:24 AM. Review of P4's physician orders (located under the "Manage Orders") indicated an order for Hydromorphone (Dilaudid) (indicated for the management of pain in patients where an opioid analgesic is appropriate) injection 0.5 mg (milligrams) every two hours as needed intravenously (IV) starting on 07/08/25 at 4:41 AM until discontinued for severe pain at level of seven to 10 and ketorolac (Toradol) injection (used for the short-term relief of moderately severe pain) 15 mg every six hours as needed IV for pain level four to six starting on 07/08/25 at 10:03 AM. Review of P4's MAR (located under the "Manage Orders" tab, then the "MAR" tab) indicated Dilaudid 0.5 mg IV was administered on 07/08/25 at 2:26 PM with no documented assessment of the pain level and at 5:28 PM with a pain level assessment of six at 5:20 PM (dose for Dilaudid was for pain level of seven to 10). Review of P4's MAR indicated Toradol 15 mg IV was administered at 10:58 AM on 07/08/25 with no pain assessment documented.

During an interview on 07/09/25 at 10:26 AM, DON stated the pain medications, Dilaudid and Toradol, were not administered in accordance with the pain assessments as ordered by the physician.

Review of P5's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P5's EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5's history and physical (H&P) (located under the under the "All Notes" tab, then the "H&P" tab) indicated P5 presented with alcohol intoxication. Review of P5's physician orders (located under the "Manage Orders") indicated the following orders on 07/01/25 at 6:15 PM:
If CIWA (Clinical Institute Withdrawal Assessment - Alcohol) score 5-10, assess VS (vital signs) and CIWA Q 4 hours
If CIWA score 11-14, assess VS and CIWA every two hours
If CIWA score 15-25, assess VS and CIWA Q one hour and continuous pulse ox
If CIWA score greater than 25, assess VS Q 15 minutes and continuous pulse ox
Consider transfer to ICU (intensive care unit) if CIWA score is greater than 20 for more than four hours, patient has received six mg Ativan in one hour, or a total of 15 mg of Ativan in four hours.
Discontinue CIWA assessments when score is less than 5 for 72 hours.
Ativan (medication that treats anxiety and helps the nervous system to slow down) 0.5 mg tablet every four hours as needed for CIWA 5-7; hold if respirations less than 12 per minute or sedation scale is greater than four
Ativan 1 mg tablet every four hours as needed for CIWA 8-10; hold if respirations less than 12 per minute or sedation scale is greater than four
Ativan 2 mg tablet every two hours as needed for CIWA 11-14; hold if respirations less than 12 per minute or sedation scale is greater than four
Ativan 3 mg tablet every one hour for CIWA 15-25; hold if respirations less than 12 per minute or sedation scale is greater than four
Ativan 4 mg tablet every 15 minutes for CIWA greater than 25; ; hold if respirations less than 12 per minute or sedation scale is greater than four.
Review of P5's MAR indicated Ativan was not administered with the CIWA assessment of seven on 07/02/25 at 12:00 AM (should have received Ativan 0.5 mg tablet) and with the CIWA assessment of five on 07/05/25 at 2:30 AM (should have received Ativan 0.5 mg tablet).

During an interview on 07/09/25 at 12:21 PM, DON stated P5 did not receive the Ativan 0.5 mg tablet on 07/02/25 at 12:00 AM and 2:30 AM as ordered by the physician.

2. Review of the CAH's policy titled "Fluid/ Blanket Warmer," reviewed/revised July 2025, indicated ". . . Intravenous/irrigation fluids and blankets will be stored according to the manufacturer's recommendation. . . Ensure warmer temperature does not exceed 130 degrees F. [Fahrenheit] The warming oven temperature must be controlled by a calibrated thermometer, and in order to protect from damage, the irrigating fluid containers should not come into direct contact with the heating elements. 2. Solutions will remain in their overwraps until use and will not come into direct contact with any metal components within the oven. 3. IV fluids, in their overwraps, can remain in the oven for up to 30 days unless otherwise specified by the manufacturer's recommendations. Record the expiration date on the overwrap when solution is initially placed in oven. 4. Once removed from the oven, solutions should be used within 24 hours or discarded, and not returned to stock supply. . ."

Review of the manufacturer's guidelines titled "Sodium Chloride Injection, USP" (United States Pharmacopeia), revised June 2018, indicated ". . . Sodium Chloride Injection, USP is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration . . . It is recommended the product be stored at room temperature (25 [degrees] C [Centigrade]/77 [degrees]F); brief exposure up to 40 [degrees] C/l104 [degrees] F does not adversely affect the product. . ." There was no documentation of a specific amount of time to determine what would be considered a "brief exposure."

Observation on 07/08/25 at 9:43 AM in the ED revealed two 1000 milliliters plastic bags in the overwraps of 0.9% (per cent) Sodium Chloride in the warmer that had a temperature setting of 105 degrees Fahrenheit. Observation revealed a notation of 07/06/25 written on the bag with no indication whether the date was the date the fluids were placed in the warmer or the date the bags were to be removed from the warmer as required by the CAH policy. Observation revealed documentation on the bag of Sodium Chloride injection read ". . . store at room temperature 77 degrees F. and avoid excessive heat. . ."

During an interview on 07/08/25 at 10:30 AM, ED Manager confirmed the tag on the IV fluids did not designate whether the date was the date the bags were placed in the warmer or the date the bags were to be removed from the warmer. ED Manager stated the policy allowed IV bags of solution to remain in the warmer for 30 days. ED Manager stated he/she did not know what the manufacturer guidelines stated regarding the temperature and time at which the solution could be warmed.

Based on policy review, patient electronic medical record (EMR) reviews, and interviews, the critical access hospital (CAH) failed to ensure a nursing care plan was developed and kept current in accordance with the CAH's policies for three (Patient (P) 1, P2, P3) of 20 patient EMRs reviewed for a current nursing care plan from a total sample of 23 EMRs. This deficient practice had the potential to affect all patients receiving services at the CAH.

Findings include:

Review of the CAH policy titled "Nursing Care Plans," reviewed/revised 05/15/25, indicated ". . . Nursing care plans will be individualized and evidence-based and kept current for each
hospitalized patient . . . Adding Care Plan Goals: Click the "add care plan" button to incorporate goals tailored to the patient's needs based on patient status, diagnosis and assessment findings. . . Care Plan goals may be automatically incorporated based on patient documentation; however, it is essential for nursing staff to review and modify these goals to ensure that the Care Plan is customized to meet the unique needs, preferences, and medical conditions of each individual patient . . . During each subsequent shift or change in patient status, the RN [registered nurse] will review the Care Plan and document the care plan progress on ALL active goals, and create a
progress note that includes the problem statement, the measurable goal, problem interventions, and the outcome. . ."

1. Review of P1's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P1's EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P1 was admitted as an inpatient on 07/05/25 at 1:35 PM with a chief complaint of P1 was getting out of the car the previous night when P1 slipped and fell on gravel resulting in a head strike with no loss of consciousness (located in the "ED Provider Note" documented on 07/05/25 at 10:28 AM (located under the "All Notes" tab, then the "ED" tab, then the "Progress Notes" tab). Review of P1's nursing care plan (located under the under the "All Notes" tab, then the "Care Plan" tab) developed on 07/05/25 at 6:12 PM indicated the following problems/goals were documented:
1. Fall risk / Patient will remain free from falls
2. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications
3. Pain / Alleviation of pain or a reduction in pain to the patient's comfort goal
4. Skin integrity / Skin integrity is maintained or improved
5. Wound/incision healing / Patient's wound,/surgical incision will decrease in size and heals properly.
There was no documentation of a means of measurement to determine when the goal was met.

During an interview on 07/08/25 at 1:02 PM, Clinical Analyst Quality 2 (CAQ2) stated P1's nursing care plan goals were not written in measurable terms to be able to determine when the goal was met.

2. Review of P2's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P2's EMR navigated by Clinical Analyst Quality 2 (CAQ2), indicated P2 was admitted as an inpatient on 07/07/25 at 7:56 PM. Review of P2's history and physical (H&P) (located under the "All Notes" tab, then under the "H&P" tab) documented on 07/07/25 at 6:08 PM indicated P2's chief complaint was shortness of breath secondary to hypoxia caused by immunotherapy. Review of P2's nursing care plan (located under the under the "All Notes" tab, then the "Care Plan" tab) developed on 07/08/25 at 4:39 AM indicated the following problems/goals were documented:
1. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications
2. Bowel elimination / Establish and maintain regular bowel function
3. Fluid volume / Fluid volume balance will be maintained
4. Mobility / Patient's capacity to carry out activities will improve
5. Respiratory / Patient will achieve/maintain optimum respiratory ventilation and gas exchange
6. Self-care / Patient will have the ability to perform ADLs independently or with assistance (bathe, groom, dress, toilet and feed)
7. Urinary elimination / Establish and maintain regular urinary output
8. Discharge planning - pneumonia / Patient will verbalize understanding of lifestyle changes and therapeutic needs post discharge.
There was no documentation of a means of measurement to determine when the goal was met.

During an interview on 07/08/25 at 2:34 PM, CAQ2 stated P2's nursing care plan goals were not written in measurable terms to be able to determine when the goal was met.

3. Review of P3's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P3's EMR navigated by CAQ2, indicated P3 was admitted as an inpatient on 07/07/25 at 1:11 AM. Review of P3's H&P (located under the "All Notes" tab, then under the "H&P" tab) documented on 07/06/25 at 11:04 PM indicated P3's chief complaint was upper abdominal pain and nausea. Review of P3's nursing care plan (located under the under the "All Notes" tab, then the "Care Plan" tab) developed on 07/07/25 at 4:01 AM indicated the following problems/goals were documented:
1. Knowledge deficit / Patient and family/care givers will demonstrate understanding of plan of care, disease process/condition, diagnostic tests and medications
2. Skin integrity / Skin integrity is maintained or improved
3. Communication / The ability to communicate needs accurately and effectively will improve
4. Bowel elimination / Establish and maintain regular bowel function
5. Gastrointestinal irritability / Nausea and vomiting will be absent or improve; diarrhea will be absent or improved.
There was no documentation of a means of measurement to determine when the goal was met.

During an interview on 07/08/25 at 4:36 PM, CAQ2 stated P3's nursing care plan goals were not written in measurable terms to be able to determine when the goal was met.

Based on observations, policy reviews, and interviews, the critical access hospital (CAH) failed to ensure a clean and sanitary environment was maintained to avoid the potential transmission of infection by having expired lab tubes available for use in the emergency department (ED) and having a trampoline cover in the rehab gym with multiple tears that prevented surface disinfection. These deficient practices had the potential to affect all patients receiving services in the ED and the rehab gym.

Findings include:

Review of the CAH policy titled "General Infection Control Practices," reviewed/revised July 2023, indicated ". . . Work surfaces should be kept clean and uncluttered, and should be cleaned periodically with surface disinfectant wipes. Staff may not have food in clinical areas or their workspace . . . Clean and sterile supplies are to be stored in such a manner as to protect them from contamination. Stock supplies must be rotated and expired supplies are to be pulled
from stock on a monthly basis. . ."

Observation in the clean supply room of the ED on 07/08/25 at 9:43 AM revealed 27 BD vacutainer yellow top 5.0 milliliter (ml) lab tubes had expired 06/30/25, and two BD vacutainer 6.0 ml pink top lab tubes had expired 01/31/25.

During an interview on 07/08/25 at 9:43 AM, ED Manager confirmed the lab tubes had expired. ED Manager stated the staff who stocks the lab tubes should check for expiration dates. ED Manager stated each nurse was supposed to check the lab tube before use for expiration date. He/She stated one ED nurse was assigned to check all supplies in the ED clean supply room twice a month.

Observation on 07/10/25 at 9:00 AM in the rehab gym revealed a small trampoline cover had multiple tears that would prevent it from being disinfected thoroughly.

During an interview on 07/10/15 at 9:00 AM, Rehab Services Manager (RSM) stated the trampoline cover with multiple tears would prevent the cover from being thoroughly disinfected after use.

Based on medical record review, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure the baseline care plans were developed to provide person-centered care for three of six sampled Swing bed (Patients (P) 11, P12, and P13 from a total sample of 23 patients. This failure had the potential to affect any patient admitted to the CAH Swing bed program for care and services.

Findings include:

Review of the facility policy titled, "Interdisciplinary Comprehensive Person-Centered Care Plan" last revision 05/23/25 revealed, " ...The IDT [Interdisciplinary Team] will develop and implement a baseline care plan that includes interventions needed to provide effective and person-centered care of the resident. The baseline care plan will be developed within 48 hours of admission to the SWING bed program. ..."

1. Review of P11's "Face Sheet" located in the electronic medical record (EMR) under the "Demographic" tab revealed P11 was admitted to the hospital Swing bed on 06/04/25.

Review of the History and Physical dated 06/04/25 located in the EMR under the "All Notes" tab revealed, " ...Assessment/Plan: Patient will need a bed on Rehabilitation service ...recurrent
Major depressive disorder, in partial remission ...pressure ulcer (present on admission) chronic pressure wounds to bilateral heels. IP [Infection Prevention] wound care consultation ...deaf (present on admission) since early childhood speaks sign language, reads lips ...urinary incontinence (present on admission) ...seizure disorder (present on admission) ....other specified anemias (present on admission) continue to trend closely, transfuse 1 unit PRBC's [packed red blood cells] for hemoglobin less than 7. ..."

Review of P11's "Baseline Care Plan" dated 06/05/25 located in the EMR under the "All Notes" tab revealed, " ...Initial goals based on admission order: Improve strength and endurance prior to discharge. Short term: Patient to participate in IV [intravenous] antibiotic therapy and initial weekly reassessment on 06/11/25. Long term: Patient to meet goals set by therapy and nursing prior to discharge anticipated on or before 06/14/25. Patient goals: Patient would like to return home, upon discharge from SWING program, with home health services. ..."

Review of the "Baseline Care Plan" did not include interventions to provide effective person-centered care.

2. Review of P12's "Face Sheet" located in the EMR under the "Demographic" tab revealed P12 was admitted to the hospital Swing bed on 07/03/25.

Review of the History and Physical dated 07/03/25 located in the EMR under the "All Notes" tab revealed, " ...Assessment/Plan: ...Neck abscess (present on admission) MRSA [group of bacteria difficult to treat] infection and bacteremia -wound care ...alcohol use disorder (present on admission) multivitamins ...Marijuana use ...depression ...seizure disorder. ..."

Review of P12's "Baseline Care Plan" dated 0704/25 located in the EMR under the "All Notes" tab revealed, " ... Initial goals based on admission order. Complete the course of IV antibiotics prior to discharge. Short Term: Patient to participate with daily IV antibiotic infusion, with initial weekly assessment on 07/09/25. Long term: Patient to meet goals set by pharmacy and nursing prior to discharge anticipated on or before 07/22/25. Patient goals: Patient would like to return home, upon discharge from the SWING program, with outpatient wound care services. ..."

Review of the "Baseline Care Plan" did not include interventions to provide effective person-centered care.

3. Review of P13's "Face Sheet" located in the EMR under the "Demographic" tab revealed P13 was admitted to the hospital Swing bed on 07/03/25.

Review of the History and Physical dated 07/03/25 located in the EMR under the "All Notes" tab revealed, " ...Assessment/Plan: ...Postoperative pain- (present on admission) hip x-ray does not show any acute fracture/dislocation- Multimodal pain control-scheduled Percocet [pain medication], as needed Tylenol and Dilaudid [pain medication] ...Chronic hypoxic [not sufficient oxygen] respiratory failure - patient uses O2 intermittently at home, resume Chronic diastolic congestive heart failure ...paroxysmal atrial fibrillation [irregular heart beat] ....BPH (benign prostatic hyperplasia) - watch for retention. ..."

Review of P13's "Baseline Care Plan" dated 0704/25 located in the EMR under the "All Notes" tab revealed, " ... Initial goals based on admission order. Improve strength and endurance prior to discharge. Short Term: Patient to participate with therapies, and to improve strength and endurance, with initial weekly reassessment on 07/09/25. Long term: Patient to meet goals set by therapies prior to discharge anticipated on or before 07/16/25. Patient goals: Patient would like to return home, upon discharge from the SWING program, with home health services."

Review of the "Baseline Care Plan" did not include interventions to provide effective person-centered care.

During an interview on 07/09/10 at 9:25 AM, Clinical Quality Analyst (CQA) 1 stated the patients baseline care plans should be person-centered and include interventions to provide the necessary care to patients. CQA 1 confirmed P11's, P12's, and P13's baseline care plans did not include person-centered interventions.

Based on medical record review, policy review, and interview, the Critical Access Hospital (CAH) failed to provide an Occupation Therapy (OT) evaluation for one of six sampled Swing (Patient (P)11 from a total sample of 23 patients. This failure had the potential to affect any patient admitted to the CAH Swing bed who requires occupational therapy services.

Findings include:

Review of the facility policy titled, "Rehabilitation Evaluations" last revision date 08/29/23 revealed, " ... Evaluations are completed in a timely fashion (24 hours) and will contain all the necessary information as outlined in the procedure section ...Upon receipt of a verbal or written physician's order for OT, PT [physical therapy], and/or SLP [speech language therapy], the licensed therapist will complete an initial evaluation within 24 hours (Mon-Fri) for inpatients. On the weekends occupational and speech therapy are on call, but PT work 7 days/week. ..."

Review of the facility policy titled, "Staffing and Assignments" last revision date 12/29/24 revealed, " ...Swing Bed therapy coverage is available six days a week for PT and five days a week for SLP and OT ...The Rehab Services Manager is ultimately responsible for supervising the therapy treatments. ..."

Review of the facility policy titled, "Rehabilitation Services Staffing" last revision date 12/29/24 revealed, " ... An appropriate staffing of therapists and supportive personnel will be scheduled to provide quality rehabilitation services. ..."

Review of P11's "Face Sheet" located in the electronic medical record (EMR) under the "Demographic" tab revealed P11 was admitted to the hospital Swing bed on 06/04/25 with diagnoses that included weakness and multiple sclerosis (MS).

Review of the History and Physical dated 06/04/25 located in the EMR under the "All Notes" tab revealed, " ...Justification for Admission Status- Patient will need a bed on the Rehabilitation service. ..."

Review of the "Physician Orders" dated 06/06/25 located in the EMR under the "Manage Orders" tab revealed an order for "OT Eval [evaluation] and Treat."

Review of the "Occupational Therapy Contact Note" dated 06/12/25 located in the EMR under the "Assessment" tab revealed an OT evaluation was attempted but the patient was outside at 11:45 AM and with the dietitian at 4:40 PM.

Review of the "Occupational Therapy Contact Note" dated 06/13/25 located in the EMR under the "Assessment" tab revealed an OT evaluation was attempted but the patient at 2:40 PM but the patient was not feeling well so the evaluation was not completed.

Review of P11's EMR failed to reveal that an OT evaluation was attempted prior to 06/12/15.

Review of the "Occupational Therapy Initial Evaluation" dated 06/16/25 located in the EMR under the "Assessment" tab revealed, " ...admitted to SWING bed program for antibiotics and therapy ...Plan OT 3-5x/week. ..."

During an interview on 07/09/25 at 1:00 PM, Occupational Therapist Registered Licensed (OTRL) 1 stated P11 had an order written on 06/06/25 for an OT evaluation. OTRL stated he/she was not working from 06/03/25 through 06/10/25. When he/she returned to work, attempts were made to complete the OT evaluation on 06/12/25 and 06/13/25 but the patient was not available. OTRL 1 stated the evaluation was not completed by the other hospital OT staff member because that staff was out sick.

During an interview on 07/09/25 at 1:15 PM, the Rehabilitation Services Manager (RSM) stated there are only two OT staff in house to complete OT evaluations. RSM stated one OT staff was out sick and the other OT staff was on vacation when the OT evaluation was ordered. RSM state he/she was aware there was no OT coverage from 06/05/25 to 06/10/25. RSM stated the Chief Operating Officer (COO) was made aware of the need for additional OT staff during their one on one every other week meetings. RSM confirmed P11's OT evaluation was not completed per facility policy.

During an interview on 07/09/25 at 3:30 PM, COO stated he/she was not aware the hospital did not have OT coverage between 06/05/25 and 06/10/25.

Based on observation, policy review, and interview, the critical access hospital (CAH) failed to ensure EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in areas where patients waited for treatment. This deficient practice had the potential to affect all patients presenting for examination of an emergency medical condition.

Findings include:

Review of the CAH policy titled "EMTALA," effective 08/01/24, indicated ". . . The hospital will post conspicuously signs explaining individuals' rights to the Emergency Department and other areas where individuals are likely to wait for examination or treatment . . . The hospital will post conspicuously information indicating whether the hospital participates in Medicaid. . ."

Observation on 07/08/25 at 9:43 AM in the waiting area (lobby) of the emergency department (ED) revealed the required EMTALA signage posted in English and Spanish on the wall adjacent to the reception window where patients presented to register. Observation revealed the sign was printed on a standard sheet of paper (8.5 x 11 inches) with the required wording of "This hospital participates in Medicaid" in fine print, making it difficult to be seen by the surveyor. Observation revealed EMTALA signage was not posted in the ambulance bay, within the ED where the nursing station and examination rooms were located, and within the examination rooms. There was no posting of the EMTALA signage that could be seen by patients who were brought to the CAH by ambulance and placed in an examination room.

During an interview on 07/08/25 at 9:43 AM, ED Manager confirmed the EMTALA signage was not posted in a conspicuous place that could be seen by patients who were brought to the CAH by ambulance and placed in an examination room.

Based on policy review, patient electronic medical records (EMR), and interviews, the critical access hospital (CAH) failed to ensure physical therapy (PT) evaluations had documentation of all required content in accordance with the CAH policy for two (Patient (P) 5, P7) of two patient EMRs reviewed with physician orders for PT evaluations from a total sample of 23 patients. This deficient practice had the potential to affect all inpatients receiving PT services when admitted to the CAH.

Findings include:

Review of the CAH policy titled "Rehabilitation Evaluations," reviewed/revised 08/29/23, indicated ". . . Upon receipt of a verbal or written physician's order for OT [occupational therapy], PT, and/or SLP [speech and language pathology], the licensed therapist
will complete an initial evaluation within 24 hours (Mo-Fri) [Monday through Friday] for inpatients . . . Evaluations must contain the following information: a. Rehabilitation potential . . .
h. Therapy plan, including frequency and duration . . ."

1. Review of P5's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P5's EMR navigated by Director of Nurses (DON), indicated P5 was admitted as an inpatient on 07/01/25 at 5:17 PM. Review of P5's history and physical (H&P) (located under the under the "All Notes" tab, then the "H&P" tab) indicated P5 presented with alcohol intoxication. Review of P5's "Physical Therapy Initial Evaluation" (located under the "All Notes" tab, then under the "Progress Notes" tab) documented on 07/02/25 at 4:45 PM by PT DPT1 (Physical Therapist Doctorate of Physical Therapy) indicated no documentation of the rehab potential and the frequency and duration of PT visits.

2. Review of P7's "Event Log" (located under the "Summary" tab, then the "Overview" tab), with P7's EMR navigated by DON, indicated P7 was admitted as an inpatient on 07/06/25 at 12:09 PM. Review of P7's H&P (located under the under the "All Notes" tab, then the "H&P" tab) indicated P7 presented with left knee pain after a fall. Review of P7's "Physical Therapy Initial Evaluation" (located under the "All Notes" tab, then under the "Progress Notes" tab) documented on 07/05/25 at 9:12 AM indicated no documentation of the rehab potential and the frequency and duration of PT visits.

During an interview on 07/09/25 at 3:32 PM with Rehab Services Manager (RSM) and PT DPT2 present, PT DPT2 confirmed P5's and P7's PT evaluations did not include each patient's rehab potential and frequency and duration of PT visits as required by the CAH policy.