HospitalInspections.org

Based on interview, and record review, the facility failed to ensure patient rights for one patient (Patient 26), when an anaphylactic allergy to contrast was not discussed with the patient prior to issuing an order for a Computerized Tomography (CT) of the Abdomen/Pelvis with and without contrast (a detailed imaging test using X-rays to create cross-sectional pictures of your belly organs, blood vessels, and pelvis, taking scans before and after giving a special dye (contrast) orally or intravenously to highlight issues like tumors, inflammation, infections, or bleeding that aren't visible on the non-contrast scans).

This failure jeopardized the patient's well-being, and had the potential to delay treatment, cause an increase in stay, and further complications to the patient.

Findings:

On December 2, 2025, at 2:04 p.m., Patient 26's medical record was reviewed with the Regulatory Specialist (RS) 2.

A review of the facility document titled, "H&P [history and physical] Note," dated October 9, 2025, at 7:03 p.m., by MD 1 was conducted. The document indicated, Patient 26 was admitted to the facility on October 9, 2025, at 2:13 p.m., for Acute cholecystitis (sudden inflammation of the gallbladder) vs.[versus] choledocholithiasis (presence of gallstones in the common bile duct).

A review of the facility document titled, "CT Abdomen And Pelvis W [with] Wo [without] Con [contrast] Order," dated October 9, 2025, at 6:32 p.m., was conducted. The document indicated an order for a CT of the abdomen and pelvis with and without contrast by MD 1.

A review of the facility document titled, "Murrieta Emergency General Surgery (MEGS) Note," dated October 10, 2025, at 7:38 p.m., by MD 1 was conducted. The document indicated, "...Allergies...Contrast Dye [a special substance given during imaging tests to make specific organs, blood vessels, or tissues appear clearer and more detailed]...Reactions...Anaphylaxis [a severe, potentially life-threatening allergic reaction]...Recommendations...CT abd/pel [abdomen/pelvis] with contrast, iodine allergy protocol...Please obtain CT abdomen and pelvis with IV contrast for surgical planning..."

There was no documented evidence of a conversation with Patient 26 regarding her anaphylactic allergy to contrast and no documentation of Patient 26 verbalizing understanding or approval of the order for the CT abdomen/pelvis with and without contrast.

A review of the facility document titled, "Report Viewer," dated October 11, 2025, at 2:21 p.m., by RN 1 was conducted. The document indicated, "...Order changed for CT without contrast..."

On December 2, 2025, at 2:04 p.m., an interview was conducted with the RS 2. The RS 2 stated there was a secure chat message sent to Nurse Practitioner (NP) 1 from RN 1 stating Patient 26 was refusing the CT with contrast due to an allergy to contrast. NP 1 then discontinued the order for CT with contrast and notified MD 1. There was no reason given for discontinuation of the CT with and without contrast. The RS 2 stated, "I did not see any documentation of any communication from the physician or provider to the patient regarding the order for a CT with contrast and/or allergy to contrast.

A review of the facility P&P titled, "PATIENTS' RIGHTS AND RESPONSIBILITIES," dated, March 2021, was reviewed. The P&P indicated, "...Receive information about health status, diagnosis, prognosis, course of treatment...in terms they can understand. The patient has the right to effective communication and to participate in the development and implementation of the plan of care...Request or refuse treatment..."

Based on observation, interview, and record review, the facility failed to provide privacy for one patient, (Patient 28), while in the a hallway bed.

This failure jeopardized the patient's well-being, rights, and personal privacy.

Findings:
.
On December 3, 2025, at 2:40 p.m., a tour of the Emergency Department was conducted with the Regulatory Specialist (RS) 2, the Emergency Department Director (EDD), and the Director of Surge and Patient Care Services (DSPCS). During the tour in the radiology hallway, Patient 28 was observed in a bed in the radiology hallway, and appeared upset and crying. Patient 28 was loud and yelling at the nurse about the lack of privacy and lack of care to wounds on body. Patient 28 stated she was very upset about the lack of privacy. Patient 28 stated she has been using her blanket to provide privacy and has not been offered anything else. Patient 28 stated she had voiced her concerns to nursing and they had not done anything to address concerns. Patient 28 stated she wanted to leave against medical advice because they are not treating her wounds which is why she is admitted there.

On December 3, 2025, at 3:15 p.m., an interview was conducted with the charge nurse for surge (CNS). The CNS stated she had spoken to the nurse regarding Patient 28's complaints and notified Patient Relations regarding her complaints. The CNS stated Patient 28's concerns are because she is in the hallway and the lack of room, space, privacy, and care given by the nurse. The CNS stated they had privacy screens available.

On December 3, 2025, at 3:20 p.m., an observation was conducted with the RS 2, the EDD and the DSPCS. The nurse for Patient 28 was applying dressings to Patient 28's chest wall with tops of breast and chest wall exposed to hallway. There were no visible curtains or screens in place to provide the patient with privacy. Patient 28 had the gown lowered on the chest, exposing the skin, wound to the chest wall, and draining fluid on the wound on the chest.

An interview was conducted with the DOQ. The DOQ stated, "...curtains would impede egress if placed in the hallway....they do not have enough curtains for all the patients. They could use a screen...can utilize changing rooms for privacy..."

A review of the facility P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated March 2021, was conducted. The P&P indicated, "...[Name of facility] patient shall have the rights as stated below...Considerate and respectful care, and to be made comfortable. The patient has the right to respect for...personal values, beliefs, and preference...Have personal privacy respected...Case...examination and treatment are confidential and should be conducted discretely...Privacy curtains shall be used in semi-private rooms...Have his/her wishes considered..."

Based on interview, and record review, the facility failed to ensure a physician order for physical restraint (device that limits a patient's movement to keep them safe and prevent them from harming themselves or another person) was obtained in accordance with policy and procedures for one of 28 sampled patients (Patient 1), and assessments and monitoring were not documented as performed.

This failure had the potential to result in a potential violation of the patient's rights.

On December 2, 2025, at 2:10 p.m., a review of Patient 1's medical record was conducted with the Regulatory Specialist (RS) 1.

A facility document titled, "H&P [History and Physical]," dated November 8, 2025, at 6:07 p.m., was reviewed. The document indicated Patient 1 was admitted to the facility for cardiac arrest (the heart suddenly stops beating effectively, causing a person to collapse, lose consciousness, and stop breathing).

A facility document titled, "Frequent Charting," dated November 8, 2025, at 9:45 p.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Start..."

A facility document titled, "Restraint Non-violent or Non-self Destructive (Order)," dated November 9, 2025, at 2:30 a.m., was reviewed. The document indicated, "...Created on 11/9/25 [November 9, 2025]...0230 [2:30 a.m.]..."

A facility document titled, "Frequent Charting," dated November 9, 2025, at 7 p.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued...

A facility document titled, "Frequent Charting," dated November 9, 2025, at 4 a.m., was reviewed. The document indicated, "...I attest the patient was monitored/assessed per Patient Care Practices...[blank]..."

A facility document titled, "Frequent Charting," dated November 11, 2025, at 6 a.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued...

A facility document titled, "Frequent Charting," dated November 11, 2025, at 7:30 p.m., was reviewed. The document indicated, "...I attest the patient was monitored/assessed per Patient Care Practices...[blank]..."

On December 2, 2025, at 2:20 p.m., an interview was conducted with the RS 1. RS 1 stated, "the restraint order should have been obtained when the patient was placed in wrist restraints" on November 8, 2025. RS 1 stated there was no documented evidence that the physician was notified of Patient 1's need for restraints until November 9, 2025, at 2:30 a.m. RS 1 further stated that there was no restraint monitoring and assessment completed every two hours for the night shift on November 9, 2025, and day shift November 11, 2025. RS 1 stated the facility's policy was not followed.

A review of Policy and Procedure (P&P) titled, "RESTRAINTS AND SAFETY DEVICES," dated December 2025, was conducted. The P&P indicated, "...Initiation: Each episode of restraint or seclusion shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient, or...a qualified registered nurse if he/she determines that restraining the patient prior to receiving an order is necessary to protect the patient or others. An order from a responsible licensed independent practitioner shall be obtained as soon as clinically appropriate...Patients requiring restraints for non-violent behaviors shall be subject to ongoing monitoring and assessment. Monitoring and assessment shall occur at least every 2 [two] hours..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for 11 of 28 sampled patients (Patient 1, 2, 3, 9, 10, 13, 16, 17, 19, 20 and 26 ), when:

1. For Patient 1, restraint (device that limits a patient's movement to keep them safe and prevent them from harming themselves or another person) order was not obtained and assessments and monitoring were not documented as performed;

2. For Patients 1, 10, 13, 16, and 17, critical lab values (test result that is so far outside the expected normal range that it indicates a potentially life-threatening situation) were not documented as having been reported to the provider;

3. For Patients 2, 3, and 9, pain was not reassessed after medication administration, the provider was not notified of unrelieved pain, and pain medication orders were not followed as prescribed;

4. For Patient 9, a leaving against medical advice (AMA) form (AMA form, document a patient is asked to sign when they choose to leave a hospital or refuse a specific recommended treatment, even though their doctor believes it is unsafe for them to do so), and an electronic event report (EER, incident report, a formal document that records any unplanned or unexpected occurrence that disrupts normal operations, causes harm, or could have caused harm) were not completed;

5. For Patients 19, and 20, patients were sitting outside of the emergency department unsupervised by hospital staff with peripheral intravenous (PIV, a tiny tube in a vein to give you medication or fluids) lines in place; and

6. For Patient 26, an order for pain medication was not clarified prior to dispensing.

These failures had the potential to compromise patient safety, resulting in poor pain management, and delays in medical care and/or death.
Findings:

1. On December 3, 2025, at 2:10 p.m., a review of Patient 1's medical record was conducted with the Regulatory Specialist (RS) 1.

A facility document titled, "H&P [History and Physical]," dated November 8, 2025, at 6:07 p.m., was reviewed. The document indicated Patient 1 was admitted to the facility for cardiac arrest (the heart suddenly stops beating effectively, causing a person to collapse, lose consciousness, and stop breathing).

A facility document titled, "Frequent Charting," dated November 8, 2025, at 9:45 p.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Start..."

A facility document titled, "Restraint Non-violent or Non-self Destructive (Order)," dated November 9, 2025, at 2:30 a.m., was reviewed. The document indicated, "...Created on 11/9/25 [November 9, 2025]...0230 [2:30 a.m.]..."

A facility document titled, "Frequent Charting," dated November 9, 2025, at 7 p.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued..."

A facility document titled, "Frequent Charting," dated November 9, 2025, at 4 a.m., was reviewed. The document indicated, "...I attest the patient was monitored/assessed per Patient Care Practices...[blank]..."

A facility document titled, "Frequent Charting," dated November 11, 2025, at 6 a.m., was reviewed. The document indicated, "...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued..."

A facility document titled, "Frequent Charting," dated November 11, 2025, at 7:30 p.m., was reviewed. The document indicated, "...I attest the patient was monitored/assessed per Patient Care Practices...[blank]..."

On December 3, 2025, at 2:20 p.m., an interview was conducted with the RS 1. RS 1 stated, "the restraint order should have been obtained when the patient was placed in wrist restraints" on November 8, 2025. RS 1 stated there was no documented evidence the physician was notified of Patient 1's need for restraints until November 9, 2025, at 2:30 a.m. RS 1 further stated there was no restraint monitoring and assessment completed every two hours for the night shift on November 9, 2025, and day shift November 11, 2025. RS 1 stated the facility's policy was not followed.

A review of the facility's P&P titled, "RESTRAINTS AND SAFETY DEVICES," dated December 2025, was conducted. The P&P indicated, "...Initiation: Each episode of restraint or seclusion shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient, or...a qualified registered nurse if he/she determines that restraining the patient prior to receiving an order is necessary to protect the patient or others. An order from a responsible licensed independent practitioner shall be obtained as soon as clinically appropriate...Patients requiring restraints for non-violent behaviors shall be subject to ongoing monitoring and assessment. Monitoring and assessment shall occur at least every 2 [two] hours..."

2a. On December 3, 2025, at 2:10 p.m., a review of Patient 1's medical record was conducted with the Regulatory Specialist (RS) 1.

A facility document titled, "Partial Thromboplastin Time [PTT, a blood test measures how long it takes your blood to clot]: Patient Communication," dated November 10, 2025, at 9:05 p.m., was reviewed. The document indicated, "...Reference range: 25.1 - [a range of values, from one number to another] 36.5 seconds...Value 140.9!! [two punctuation marks used to show strong feeling, excitement, or urgency]...Comment...Verified by replicate analysis; Critical APTT [the result is so high it reaches a dangerous level and requires immediate attention]..."

During the review of Patient 1's medical record with the RS, there was no documented evidence the physician was notified of Patient 1's critical PTT level on November 10, 2025, at 9:05 p.m.

A facility document titled, "Hgb [hemoglobin, lab test that measures the amount of an important, iron-rich protein in your red blood cells that is responsible for carrying oxygen from your lungs to the rest of your body]: Patient Communication," dated November 13, 2025, at 10:48 a.m., was reviewed. The document indicated, "...Reference range 10.5 - 15.0 g/dL [grams / (per) deciliter, unit of measurement]...Value 6.6!!...Comment...Critical Hgb called..."

During the review of Patient 1's medical record with the RS, there was no documented evidence the physician was notified of Patient 1's critical Hgb level on November 13, 2025, at 9:05 p.m.

A facility document titled, "Na [Sodium, lab test that measures the concentration of sodium, an electrolyte in the blood to help evaluate a person's general health and fluid balance]: Patient Communication," dated November 14, 2025, at 4:57 p.m., was reviewed. The document indicated, "...Reference range 134 - 147 mMol/L [millimoles/ (per) liter, unit of measurement]...Value 161!!...Comment...Critical Na called..."

During the review of Patient 1's medical record with RS 1, there was no documented evidence the physician was notified of Patient 1's critical Na level on November 14, 2025, at 4:57 p.m.

On December 3, 2025, at 2:10 p.m., an interview was conducted with the RS 1. RS 1 stated, "the physician should have been notified of any critical lab values as soon as possible and this was not done." RS 1 stated there was no documented evidence the physician was notified of Patient 1's critical PTT, Hgb, and Na lab values. RS 1 stated the facility's policy was not followed.

2b. On December 8, 2025, at 10:45 a.m., a review of Patient 10's medical record was conducted with the Regulatory Specialist (RS) 1.

A facility document titled, "H&P [History and Physical]," dated November 8, 2025, at 3:49 a.m., was reviewed. The document indicated Patient 10 was admitted to the facility for rectal bleeding and abdominal pain.

A facility document titled, "Blood culture [a lab test that checks blood to find out if there are any germs, like bacteria or fungi, causing an infection in the bloodstream] Identification...Enterococcus faecalis [a serious medical condition that occurs when a type of bacteria normally living harmlessly in the gut enters the bloodstream] Detected," dated November 14, 2025, at 9:44 p.m., was reviewed. The document indicated, "...Reference range: Not Detected...Comment...Critical Enterococcus faecalis called..."

During the review of Patient 10's medical record with RS 1, there was no documented evidence the physician was notified of Patient 10's critical blood culture result on November 14, 2025, at 9:44 p.m.

A facility document titled, "K [Potassium, a test that measures the amount of potassium, a mineral that helps your body's cells, nerves, and muscles function properly]: Patient Communication," dated November 16, 2025, at 10:45 a.m., was reviewed. The document indicated, "...Reference range 3.5 - 5.0 mMol/L ...Value 6.2!!...Comment...Critical K result called..."

During the review of Patient 10's medical record with RS 1, there was no documented evidence the physician was notified of Patient 10's critical K level on November 16, 2025, at 10:45 a.m.

On December 8, 2025, at 11:15 a.m., an interview was conducted with the RS 1. RS 1 stated, "the blood culture result and critical K should have been reported to the physician." RS 1 stated there was no documented evidence the physician was notified of Patient 10's positive blood culture and K critical lab values. RS 1 stated the facility's policy was not followed.

2c. On December 2, 2025, at 10:15 a.m., a review of Patient 13's medical record was conducted with the Regulatory Specialist (RS) 3.

A facility document titled, "H&P," dated November 28, 2025, at 2:05 p.m., was reviewed. The document indicated Patient 13 was admitted to the facility for acute hypoxemic respiratory failure (a sudden condition where the lungs can't get enough oxygen into the blood) and atrial fibrillation with rapid ventricular response (an irregular heart rhythm where the heart beats very fast).

A facility document titled, "Partial Thromboplastin Time [PTT, a blood test measures how long it takes your blood to clot]: Patient Communication," dated November 29, 2025, at 11:04 p.m., was reviewed. The document indicated, "...Reference range: 25.1 - [a range of values, from one number to another] 36.5 seconds...Value 148.3!! [two punctuation marks used to show strong feeling, excitement, or urgency]...Comment...Verified by replicate analysis; Critical APTT [the result is so high it reaches a dangerous level and requires immediate attention]..."

During the review of Patient 13's medical record with the RS, there was no documented evidence the physician was notified of Patient 13's critical PTT level on November 29, 2025, at 11:04 p.m.

On December 2, 2025, at 10:25 a.m., an interview was conducted with the RS 3. RS 3 stated, "the critical PTT should have been reported to the doctor." RS 3 stated there was no documented evidence the physician was notified of Patient 13's critical lab value. RS 3 stated the facility's policy was not followed.

2d. On December 3, 2025, at 11:16 a.m., a review of Patient 16's medical record was conducted with RS 3.

A facility document titled, "H&P," dated November 25, 2025, at 11:17 p.m., was reviewed. The document indicated Patient 16 was admitted to the facility for acute hypoxic respiratory failure and suspected septic shock (a severe, life-threatening condition where an infection causes the blood pressure to drop dangerously low, and the organs do not get enough blood).

A facility document titled, "Troponin T, High Sensitivity [hs-TnT, a blood test that can detect very small amounts of heart muscle injury] : Patient Communication," dated November 26, 2025, at 3:46 a.m., was reviewed. The document indicated, "...Reference range ng/L [nomograms/ (per) liter, a very tiny amount in a liter of blood]...Value 66!!...Comment...Critical Troponin result called..."

During the review of Patient 16's medical record with the RS there was no documented evidence the physician was notified of Patient 16's critical Troponin level on November 26, 2025, at 3:46 a.m.

On December 3, 2025, at 11:39 a.m., an interview was conducted with the RS 3. RS 3 stated, "the critical troponin should have been reported to the doctor." RS 3 stated there was no documented evidence the physician was notified of Patient 16's critical lab value. RS 3 stated the facility's policy was not followed.

2e. On December 5, 2025, at 9:40 a.m., a review of Patient 17's medical record was conducted with RS 3.

A facility document titled, "H&P," dated November 26, 2025, at 3:36 a.m., was reviewed. The document indicated Patient 17 was admitted to the facility for diabetic ketoacidosis (a condition where the body does not have enough insulin, so it breaks down fat for energy and makes acids (ketones, chemicals that body make) that build up in the blood).

A facility document titled, "Osmolality, Serum [a test that measures how concentrated the blood is]: Patient Communication," dated December 3, 2025, at 7:23 a.m., was reviewed. The document indicated, "...Reference range 277- 297 mOsm/kg [milliosmoles per kilogram, a unit of measurement how concentrated a fluid is]...Value 364!!...Comment...Critical OSMO [Osmolality] result called..."

During the review of Patient 17's medical record with the RS there was no documented evidence the physician was notified of Patient 17's critical Osmolality level on December 3, 2025, at 7:23 a.m.

On December 5, 2025, at 10:04 a.m., an interview was conducted with RS 3. RS 3 stated, "the critical result should have been reported to the doctor." RS 3 stated there was no documented evidence the physician was notified of Patient 17's critical lab value. RS 3 stated the facility's policy was not followed.

A review of the facility's P&P titled, "REPORTING OF CRITICAL TEST RESULTS," dated July 2022, was conducted. The policy indicated, "...All critical test results shall be reported as immediately as is practicable. The length of time from discovery of the critical test result to the time the information is relayed to the physician or appropriate caregiver shall not exceed one hour...Clinical Laboratory: 10 [ten] minutes..."

3a. On December 5, 2025, at 9:45 a.m., a review of Patient 2's medical record was conducted with RS 1.

A facility document titled, "H&P," dated November 23, 2025, at 1:32 a.m., was reviewed. The document indicated Patient 2 was admitted to the facility for right foot pain from a right foot stump ulcer (an open sore or a break in the skin that develops on the remaining part of a limb after an amputation) and concerns for infection and possible osteomyelitis (a bone infection, usually caused by bacteria, that leads to inflammation, pain, swelling, and can destroy bone tissue if not treated).

A facility document titled, "Care Plan (a personalized roadmap detailing a patient's health needs, goals, and the interventions required to achieve them)," was reviewed. The document indicated, "Problem...Pain/Discomfort...Goal...Patient's pain/discomfort is manageable...Reassess pain after intervention..."

A facility document titled, "Flowsheet," dated November 25, 2025, was reviewed. The document indicated, Patient 2's pain score on November 25, 20205, at 7:35 p.m., was five (Pain intensity reference, where a pain score of 1-3 is mild/minor pain, pain score of 4-6 is moderate pain, and pain score of 7-10 is severe pain), and received pain medication at 7:40 p.m.

During the review of Patient 2's medical record with RS 1, there was no documented evidence Patient 2's pain level was reassessed following the medication administration on November 25, 2025, at 7:40 p.m.

A facility document titled, "Flowsheet," dated November 30, 2025, was reviewed. The document indicated, Patient 2's pain score on November 30, 20205, at 10 a.m., was eight, and received pain medication at 10 a.m.

During the review of Patient 2's medical record with RS 1, there was no documented evidence Patient 2's pain level was reassessed following the medication administration on November 30, 2025, at 10 a.m.

On December 5, 2025, at 10 a.m., an interview was conducted with RS 1. RS 1 stated Patient 2's pain level "should have been reassessed after one hour following pain medication administration." RS 1 stated there was no documented evidence that Patient 2's pain was reassessed, as required by Patient 2's care plan. RS 1 further stated the clinical nursing skills (the essential, evidence-based procedures and knowledge registered nurses and other healthcare professionals use to provide direct patient care in a clinical setting) were not followed.

3b. On December 5, 2025, at 11:30 a.m., a review of Patient 3's medical record was conducted with RS 1.

A facility document titled, "H&P," dated November 29, 2025, at 3:42 a.m., was reviewed. The document indicated Patient 3 was admitted for acute onset (began suddenly) of petechial rash (cluster of tiny, flat, pinpoint-sized red, purple, or brown spots on the skin caused by minor bleeding from broken, tiny blood vessels under the skin's surface). The document further indicated that Patient 3 has a history of uterine (womb) sarcoma (a rare type of cancer that begins in the muscle wall or supporting tissues of the uterus).

A facility document titled, "Care Plan," was reviewed. The document indicated, "Problem...Pain/Discomfort...Goal...Patient's pain/discomfort is manageable...Give pain meds [medications] as ordered and monitor for effectiveness..."

A facility document titled, "Flowsheet," dated December 2, 2025, was reviewed. The document indicated, Patient 3's pain score on December 2, 20205, at 3:25 p.m., was eight, and received pain medication at 3:25 p.m.

During the review of Patient 3's medical record with RS 1, there was no documented evidence that Patient 3's pain level was reassessed following the medication administration on December 2, 2025, at 3:25 p.m.

A facility document titled, "Flowsheet," dated December 3, 2025, was reviewed. The document indicated, Patient 3's pain score on December 3, 2025, at 8:16 a.m., was ten, and received pain medication at 8:16 a.m. The document further indicated Patient 3's pain score on December 3, 20205, at 9:16 a.m., was seven.

During the review of Patient 3's medical record with RS 1, there was no documented evidence the physician was notified when Patient 3's pain was not relieved following medication administration on December 3, 2025, at 8:16 p.m.

On December 5, 2025, at 11:50 a.m., an interview was conducted with RS 1. RS 1 stated Patient 3's pain level "should have been reassessed after one hour following pain medication administration." RS 1 stated there was no documented evidence that Patient 3's pain was reassessed, following pain medication administration on December 2, 2025, at 3:25 p.m. RS 1 also stated Patient 3's physician should have been notified on December 3, 2025, when Patient 3's pain level was not relieved with the ordered pain medication. RS 1 further stated the clinical nursing skills were not followed.

3c. On December 2, 2025, at 2:25 p.m., a review of Patient 9's medical record was conducted with RS 1.

A facility document titled, "H&P," dated August 16, 2025, at 5:32 a.m., was reviewed. The document indicated Patient 9 was admitted for "...worsening right leg pain with swelling, despite previous negative imaging for DVT [deep vein thrombosis, a blood clot that forms in a large vein that can break loose and travel to the lungs, causing a potentially fatal blockage] or major fracture..."

A facility document titled, "Care Plan," was reviewed. The document indicated, "Problem...Pain/Discomfort...Goal...Patient's pain/discomfort is manageable...Assess pain every 4 [four] hours, medicate per order, provide non pharmacological pain methods [ways to ease pain without using medicine], reassess pain 30-60 [thirty to sixty] minutes after treatment..."

A facility document titled, "Order Summary," was reviewed. The document indicated, "...Start Date/Time...8/16/25 [August 16, 2025] 0429 [4:29 a.m.]...HYDROmorphone [a strong pain medication used to treat severe pain]...0.2 [two tenths] mg [milligram, unit of measurement]...Intravenous [administered in the vein]...Every 4 [four] hours PRN [as needed] for Severe Pain 7-10 [seven to 10 pain level on a pain scale from 0-10]..."

A facility document titled, "Order Summary," was reviewed. The document indicated, "...Start Date/Time...8/16/25 [August 16, 2025] 0429 [4:29 a.m.]...HYDROcodone-aceteminophen [a pain medication used to treat moderate to severe pain]...1 [one] tablet...Every 6 [six] hours PRN for Moderate Pain 4-6 [four to six pain level on a pain scale from 0-10]..."

A facility document titled, "Flowsheet," dated August 15, 2025, was reviewed. The document indicated, Patient 9's pain score on August 15, 2025, at 8:38 p.m., was ten and the non pharmacological intervention of rest was implemented.

During the review of Patient 9's medical record with RS 1, there was no documented evidence Patient 9's pain level was reassessed until August 16, 2025, at 3:26 a.m., and the pain score was seven. Additionally, the review found no documented evidence of any pain intervention provided at the time of the 3:26 a.m. assessment.

A facility document titled, "Flowsheet," dated August 16, 2025, was reviewed. The document indicated, Patient 9's pain score on August 16, 2025, at 4:37 a.m., was six, and received pain medication at 4:47 a.m.

During the review of Patient 9's medical record with RS 1, there was no documented evidence that Patient 9's pain level was reassessed following the medication administration on August 16, 2025, at 4:37 a.m.

A facility document titled, "Flowsheet," dated August 16, 2025, was reviewed. The document indicated, Patient 9's pain score on August 16, 2025, at 11:53 a.m., was eight, and received pain medication at 11:53 a.m. The document further indicated that Patient 9's pain score on August 16, 2025, at 12:53 p.m. was five.

A facility document titled, "Flowsheet," dated August 16, 2025, was reviewed. The document indicated, Patient 9's pain score on August 16, 2025, at 7:44 p.m., was ten, and received pain medication at 7:44 p.m. The document further indicated that Patient 9's pain score on August 16, 2025, at 8:44 p.m. was four.

A facility document titled, "Medication Administration Report," was reviewed. The document indicated, Patient 9 received Hydrocodone-acetaminophen on August 16, 2025, at 11:53 a.m., when the pain score was eight. The document also indicated, Patient 9 received Hydrocodone-acetaminophen on August 16, 2025, at 7:44 p.m., when the pain score was ten.

On December 2, 2025, at 3 p.m., an interview was conducted with RS 1. RS 1 stated Patient 9's pain level should have been reassessed after non-pharmacological methods or after the administration of pain medication. RS 1 stated there was no documented evidence that Patient 9's pain was reassessed following the non-pharmacological intervention of rest on August 15, 2025, at 8:38 p.m., or after the administration of pain medication on August 16, 2025, at 4:47 a.m. RS 1 further stated that Patient 9 should have received Hydromorphone on August 16, 2025, at 11:53 a.m., when the pain score was eight, and again at 7:44 p.m., when the pain score was ten, in accordance with the physician's order for severe pain, instead of the Hydrocodone-acetaminophen, or if Patient 9 requested the lower dose of medication, then this have been documented in the medical record. RS 1 also stated that the physician should have been notified when Patient 9's pain level was not relieved with the ordered pain medication. RS 1 stated the clinical nursing skills were not followed.

A review of the facility's P&P titled, "MEDICATION ADMINISTRATION AND ERRORS," dated February 2025, was conducted. The P&P indicated "...Medications that are ordered with a dosage range shall either be administered according to specified parameters (e.g. [example] level of pain, anxiety/agitation)...Per patient request, the nurse may administer the following while awaiting contact with provider for adjustments to PRN pain management medication orders...A lower DOSE of PRN pain medication (same medication) than ordered...A PRN pain MEDICATION which has been ordered for the patient but indicated for a PAIN SCALE lower than that reported by the patient...The nurse shall document the reason for the lower dose/medication, and the provider contact..."

A review of the facility's untitled document, dated July, 2021, was conducted. The document indicated, "...Assess the patient's pain using an organization-approved pain scale...Assess the patient's response to previous pharmacologic interventions...If nonpharmacologic intervention are unsuccessful and if analgesics are ineffective or none have been ordered, consult the practitioner regarding an order...Administer analgesics [pain medication] as ordered...Reassess the patient's pain status...Assess, treat, and reassess pain...Clinical nursing skills & [and] techniques..."

4. On December 2, 2025, at 2:25 p.m., a review of Patient 9's medical record was conducted with RS 1.

A facility document titled, "Multidisciplinary Progress Note," dated August 19, 2025, at 4:43 p.m. was reviewed. The document indicated, "...1422 [2:22 p.m.] NP [nurse practitioner] made aware patient's family at the bedside requesting to go home today because the pain on right lower leg has not been control [sic] while in the hospital and her primary doctor already ordered medication that will help her with the pain...1515 [3:15 p.m.] Charge nurse made aware and will follow up with NP...1635 [4:35 p.m.] Per charge nurse, NP order MRI [Magnetic Resonance Imaging, a medical test that uses a strong magnet and radio waves to take detailed pictures of the body] of right leg and no agree with d/c [discharge] order. Family made aware and patient daughter still wants to leave..."

A facility document titled, "Discharge Summary," dated August 19, 2025, at 5:20 p.m. was reviewed. The document indicated, "...Discharge...Left Against Medical Advice..."

During the review of Patient 9's medical record with RS 1, there was no documented evidence that Patient 9 or Patient 9's family was provided with information regarding why continued hospitalization was recommended, what the risks and potential consequences of leaving were, and that alternatives were available, so the patient could make an informed decision.

On December 3, 2025, at 10:30 a.m., an interview was conducted with RS 1. RS 1 stated "the physician should have attempted to provide the patient with information regarding risk of leaving the hospital AMA." RS 1 further stated an AMA form should have been signed by the patient, and a EER should have been completed, but neither was done. RS 1 stated the policy was not followed.

On December 3, 2025, at 11 a.m., an interview was conducted with the Quality and Patient Safety Specialist (QPSS). The QPSS stated both the Registered Nurse (RN) and physician should have documented that Patient 9 wanted to leave AMA and recommendations on why to stay and this was not done.

On December 5, 2025, at 10:50 a.m., an interview was conducted with RN 1. RN 1 stated she cared for Patient 9 on August 19, 2025 on the day she left AMA. RN 1 stated Patient 9 wanted to leave AMA because the leg pain was not being controlled. RN 1 further stated a AMA form should have been completed and this was not done.

A review of the facility's P&P titled, "PATIENTS LEAVING AGAINST MEDICAL ADVICE," dated August 2024, was conducted. The P&P indicated "...If the patient or his or her legal representative makes the decision to be discharged prior to completion of treatment or contrary to medical advice, the physician should first attempt to provide the patient or the legal representative with information regarding why continued hospitalization is recommended, what the risk and potential consequences of leaving are, and what alternative are available, so the patient or legal representative can make an informed decision...Clinical Nurse/Charge Nurse...Requests that the patient or legal representative sign the 'AMA' form...Completes an Electronic Event Report (EER)..."

5a. On December 3, 2025, at 1:55 p.m., a tour of the Emergency Département (ED) was conducted with the Regulatory Specialist (RS) 2, RS 3, the Emergency Department Director (EDD), the Flow Charge (FC), and the Director of Surge (DS). During the tour, Patients 19 and 20 were observed sitting outside in front of the Emergency Department (ED) entrance with peripheral intravenous (IV) lines in place. The patients were unsupervised by hospital staff at the time of the observation. No staff members were present to monitor the safety and integrity of the IV sites. At the entrance of the ED there was a sign posted that stated, "Attention: Please notify staff if you choose to wait outside. Patients with an IV in place are not permitted to wait outside. Thank you."

On December 5, 2025, at 9:40 a.m., a review of Patient 19's medical record was conducted with the Regulatory Specialist (RS) 3.

A facility document titled, "Emergency Department Notes," dated December 3, 2025, at 11:49 a.m., was reviewed. The document indicated Patient 19 was seen in the ED for chief complaint of cough and shortness of breath.

A facility document titled, "Patient Care Timeline," dated December 3, 2025, at 12:46 p.m., was reviewed. The document indicated, "...Peripheral IV [intravenous]...Placement Date/Time ...December 3, 2025, 12:46 [p.m.] Size (Guage) 20 G...Left Location: Antecubital [the bend of the arm]..."

On December 3, 2025, at 2:07 p.m., an interview was conducted with Patient 19. Patient 19 stated, "I was not told I could not wait outside. They put in my IV and then put me out here." Patient 19 stated she was not informed by any staff members that she was not permitted to wait outside with an IV in place.

5b. On December 5, 2025, at 10:20 a.m., a review of Patient 20's medical record was conducted with the RS 3.

A facility document titled, "Emergency Department Notes," dated December 3, 2025, at 11:51 a.m., was reviewed. The document indicated Patient 20 was seen in the ED for chief complaint of abdominal pain and headache.

A facility document titled, "Patient Care Timeline," dated December 3, 2025, at 12:48 p.m., was reviewed. The document indicated, "...Peripheral IV...Placement Date/Time...December 3, 2025, 12:48 [p.m.] Size [Guage] 20 G Length: 1 inch [unit of length]...Left Location: Antecubital..."

On December 3, 2025, at 2:07 p.m., an interview was conducted with Patient 20's father. Patient 20's father stated, "We were not told he [Patient 20] could not wait outside. They put in his [Patient 20's] IV and sent us [Patient 20 and his father] to the waiting room and we [Patient 20 and his father] decided to wait outside due to crowd and no available seats."

On December 3, 2025, at 2:48 p.m., an interview was conducted with the Quick View Nurse (QVN) 1. QVN 1 stated, typically we [nurses] have everyone stay inside. We [nurses] cannot force them [patients] to stay inside.

On December 3, 2025, at 2:51 p.m., an interview was conducted with the QVN 2. QVN 2 stated, we [staff] were not aware patients [Patient 19 and 20] were outside with IVs.

On December 5, 2025, at 11:17 a.m., an interview and record review was conducted with RS 3. RS 3 stated, "I do not see any documentation in the Electronic Medical Record [EMR] indicating Patient 19 and 20 were instructed to remain to the waiting room."

On December 9, 2025, at 3:30 p.m., an interview was conducted with QVN 3. QVN 3 stated the primary role is to monitor patients in the waiting room. QVN 3 further stated it is not standard practice for patients to go outside with IVs because we cannot monitor them for safety.

A facility undated document titled, "JOB DESCRIPTION...Job Title: Clinical Nurse B-ED," was reviewed. The document indicated, "...Identifies and reports processes or systems and risks that could potentially lead to errors or adverse events. Participate s in the design of safe systems and processes as requested...Minimizes the existence of unsafe conditions in the work environment and clinical practice as follows: embraces and incorporates a culture of safety; demonstrates knowledge of and implements emergency management procedures as appropriate..."

A review of the facility's P&P titled, "Plan For Providing Care," dated November 2, 2019, was conducted. The policy indicated, "...The Emergency Department is committed to compliance, performance improvement, risk management, safe environment care, commitment to health information management, and service excell

Based on interview, and record review, the facility failed to complete a vascular duplex ultrasound (a non-invasive, test that uses high-frequency sound waves to see how blood is moving through the arteries and veins) timely for one of 28 sampled patients (Patient 9), when a radiology order was discontinued without a provider order.

This failure had the potential to compromise care and result in delays in medical care.

Findings:

On December 2, 2025, at 2:25 p.m., a review of Patient 9's medical record was conducted with the Regulatory Specialist (RS) 1.

A facility document titled, "H&P," dated August 16, 2025, at 5:32 a.m., was reviewed. The document indicated Patient 9 was admitted for "...worsening right leg pain with swelling, despite previous negative imaging for DVT [deep vein thrombosis, a blood clot that forms in a large vein that can break loose and travel to the lungs, causing a potentially fatal blockage] or major fracture [break]..."

A facility document titled, "Vas [vascular] Duplex Lower Ext [extremity] Vein Bilat [bilateral] Order," was reviewed. The document indicated the order was placed on August 16, 2025, at 8:08 a.m. The document further indicated, "...This Order Has Been Canceled...Order Status Canceled...Reason Other: Recent negative venous ultrasound, documented in notes. Duplicate order...Discontinued mode Radiology Protocol...Entered by [Name of Vascular Sonographer (VS)]...On August 16, 2025 1318 [1:18 p.m.]..."

During the review of Patient 9's medical record with RS 1, there was no vascular duplex ultrasound of the lower extremities result located in the record.

On December 3, 2025, at 1 p.m., an interview was conducted with the VS. VS stated she canceled the vascular duplex lower extremity bilateral because the H&P (History and Physical) indicated Patient 9 had the test performed at another facility and it was negative for DVT. VS further stated this would be considered a duplicate test and did not speak to the physician who ordered the test prior to discontinuing the test. VS stated she used secure chat (a way of communicating digitally where messages are protected so only the person sending and receiving the message can read them), but did not receive a response back from the provider.

On December 3, 2025, at 1:40 p.m., an interview was conducted with RS 1. RS 1 stated Patient 9 did not have a vascular duplex ultrasound of the lower extremities completed at the facility at the time of the order on August 16, 2025, at 8:08 a.m., and therefore would not be considered a duplicate order. RS 1 further stated that a physician telephone order was required to discontinue an existing order and that radiology protocol should not be used for this purpose.

On December 3, 2025, at 3:45 p.m., an interview was conducted with the Director of Quality (DOQ). The DOQ stated VS should "speak to the provider and enter a telephone order to cancel or change the order," and Patient 9 did not have a vascular duplex ultrasound of the lower extremities completed at the facility; therefore, the order would not be considered a duplicate. The DOQ further stated orders are not accepted via secure chat and the policy was not followed.

A review of the facility's P&P titled, "DIAGNOSTIC, THERAPEUTIC AND STANDING ORDERS," dated July, 2025, was conducted. The P&P indicated, "...Orders shall not be transmitted/accepted via electric device (e.g. [example] texting, email)...The provider shall be notified if the order cannot be carried out...Verbal or Telephone Orders: Use of verbal/telephone orders (VO/TO) shall be minimized...Shall be read back to the authorized practitioner after they are written/entered to confirm the orders before implementation..."