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

1. The facility failed to ensure three of 35 sampled patients (Patient 16, Patient 20, Patient 21) Condition of Admission (COA - a contract between the hospital and the patient regarding treatment and payment for services by the hospital) was signed by the patient and/or patient ' s representative.

This deficient practice resulted in patient rights being violated because the patients and/or their representatives were not aware of the patient rights, treatment, billing process, payment, and services rendered by the hospital. (Refer to A-0117)

2. The facility failed to follow the facility ' s fall prevention policy for two of 35 sampled patients (Patient 25 and Patient 27). This deficient practice placed Patients 25 and 27 at risk for falls and injury. (Refer to A-0117)

3. The facility failed to ensure one of 35 sampled patients (Patient 1) received safe care by preventing an unauthorized staff from discontinuing infusion of an essential emergency medication for Patient 1 ' s survival.

This deficient practice resulted in Patient 1 undergoing a code blue to be resuscitated (to revive from apparent death) and would have likely resulted in Patient 1 ' s death. (Refer to A-0144).

4. The facility failed to ensure a radiant infant warmer (a device used to provide heat to maintain a baby ' s body temperature) had an inspection sticker that was not past due for one of 1 radiant warmers.

This deficient practice had the potential for critical medical equipment used to a vulnerable infant to not be available or might malfunction which cause physical harm to the infant. (Refer to A-0144)

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

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

1. The facility failed to ensure a medication was administered according to the doctor ' s order and if an error was committed that the medication error was documented in the electronic medical record (EMR) for one of 35 sampled patients (Patient 2) per facility policy & procedure (P&P) on medication administration.

This deficient practice had the potential to miss dosage errors and potential adverse reaction to the dosage error for Patient 2 which can lead death due to overdose.(Refer A-0398)

2. The facility failed to ensure nursing staff adhered to the hospital policies and procedures for pain assessment for two of 35 sampled patients (Patient 12 and Patient 15).

This deficient practice had the potential to result in patients ' ineffective pain management and relief. (Refer to A-0398)

3. The facility failed to ensure ketamine (a medication that sedates patients and numbs the body but can also cause hallucinations) was given according to the physician ' s orders for one of 35 sampled patients (Patient 2).

This deficient practice had the potential to harm Patient 2 and cause serious side effects. (Refer to A-0405).

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

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

1. The facility failed to ensure policies and procedures (P&P) related to the medication distribution and medication administration systems were implemented in the Emergency Department (ED). Failure by nursing and pharmacy staff to implement P&Ps specific to the removal of Ketamine (a controlled medications used for sedation (feeling calm and relaxed), immobility, and relief from pain), from the facility ' s Pyxis (ADS, an automictic dispensing system/services) machine was reviewed for medication accuracy and appropriateness, to ensure ED physician ' s order was followed and any amount greater than the ordered amount was witnessed by a second nurse and disposed of prior to ketamine administration to one of 35 sampled patients (Patient 2).

The deficient practice had the potential to affect over 200 patients seen in the ED between 11/14/2025 – 11/15/2025 who received medications from the ADS used in the ED. The failure to have a second nurse to witness controlled medication removal from the ADS and wasting of the excess dosage resulted in Patient 2 being administered 10 times the prescribed ordered dose of ketamine, resulting in Patient 2 experiencing a high respiratory rate, becoming more somnolent (drowsy or sleepy), having trouble breathing, and requiring the administration of oxygen. (Refer to A-0491)

2. The facility failed to ensure each Crash Cart/Code Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate [to bring someone back to life when their heart and breathing have stopped] a patient experiencing cardiac arrest [when the heart stops beating suddenly]) in the facility ' s Emergency Department (ED) had an inventory sheet of Crash Cart/Code Cart content attached to two out of seven Code Carts (Code Cart 3 Adults and Code Cart 3 Pediatric[Peds]). The facility's failure to implement their policy and procedure had the potential to affect over 200 patients that visit the ED daily by not responding in an emergency adequately and/or creating a delay in care. (Refer to A-0500).

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

Based on interview and record review, the facility failed to ensure three of 35 sampled patients ' (Patient 16, Patient 20, Patient 21) Condition of Admission (COA - a contract between the hospital and the patient regarding treatment and payment for services by the hospital) was signed by the patient and/or patient ' s representative.

This deficient practice resulted in patient rights being violated because the patients and/or their representatives were not aware of the patient rights, treatment, billing process, payment, and services rendered by the hospital.

Findings:

1. A review of Patient 16 ' s face sheet (a document that summarizes the patient ' s personal and demographic information), dated 4/1/2025, indicated patient was admitted with a diagnosis, which included Failure to Thrive (a syndrome characterized by a decline in health and function, often involving weight loss, decreased appetite, and inactivity).

On 4/4/2025, at 11:51 AM, during concurrent interview with assistant nurse manager (ANM 4) and record review of Patient 16 ' s conditions of admissions (COA), undated, ANM 4 stated Patient 16 did not sign the COA because of patient ' s medical condition.

Concurrently, ANM 4 stated the COA contained information including nursing care, advance directives, and patient rights.

A review of facility ' s Consents policy, dated 8/2021, indicated the following:

...2. Conditions of Admission (COA) provides permission to give basic, simple, common hospital services and medical treatment to the patient.

...4. The COA form specifies what treatment or procedure they are consenting to and by signing the form, the patient acknowledges that, if required by law, they have given their informed consent to their treating physician.

...5. The most commonly used general consent, authorization for treatment, is the one that patients sign upon admission called the conditions of admissions, which provides permission to give basic, simple, common hospital services and medical treatment, not requiring informed consent.

A review of facility ' s Patient Rights and Responsibilities policy, dated 2/2022, indicated the following:

Facility staff are expected to respect and uphold the rights and responsibilities of all individuals to whom (patient) care and services are rendered.

At the time of admission, each patient will receive a copy of the Patient Rights/Responsibilities statement.

Patient Rights included the right to make decisions regarding medical care and to receive as much information about any proposed treatment or procedure to give informed consent.

All patient rights apply to the person who has legal responsibility to make decisions regarding medical on the patient ' s behalf, as indicated in the patient right to formulate advance directives (a written statement of a person ' s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a physician)

2. A review of Patient 20 ' s face sheet, dated 3/12/2025, indicated patient was admitted with the diagnosis of acidemia (blood serum that is abnormally acidic).

On 4/4/2025, at 11:50 AM, during concurrent interview with ANM 4 and record review of patient ' s COA, undated, ANM 4 stated Patient 20 did not sign the COA due to patient ' s medical condition.

Concurrently, ANM 4 stated the COA contained information including nursing care, advance directives, and patient rights.

A review of facility ' s Consents policy, dated 8/2021, indicated the following:

...2. Conditions of Admission (COA) provides permission to give basic, simple, common hospital services and medical treatment to the patient.

...4. The COA form specifies what treatment or procedure they are consenting to and by signing the form, the patient acknowledges that, if required by law, they have given their informed consent to their treating physician.

...5. The most commonly used general consent, authorization for treatment, is the one that patients sign upon admission called the conditions of admissions, which provides permission to give basic, simple, common hospital services and medical treatment, not requiring informed consent.

A review of facility ' s Patient Rights and Responsibilities policy, dated 2/2022, indicated the following:

Facility staff are expected to respect and uphold the rights and responsibilities of all individuals to whom (patient) care and services are rendered.

At the time of admission, each patient will receive a copy of the Patient Rights/Responsibilities statement.

Patient Rights included the right to make decisions regarding medical care and to receive as much information about any proposed treatment or procedure to give informed consent.

All patient rights apply to the person who has legal responsibility to make decisions regarding medical on the patient ' s behalf, as indicated in the patient right to formulate advance directives (a written statement of a person ' s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a physician)

3. A review of Patient 21 ' s face sheet, dated 4/1/2025, indicated patient was admitted with the diagnosis of pneumonitis (lung tissue inflammation, swelling and irritation).

On 4/4/2025, at 11:50 AM, during concurrent interview with ANM 4 and review of Patient 21 ' s COA, undated, ANM 4 stated patient was unable to sign and did not know why patient did not sign the COA because no reason was indicated.

Concurrently, ANM 4 stated the COA contained information including nursing care, advance directives, and patient rights.

A review of facility ' s Consents policy, dated 8/2021, indicated the following:

...2. Conditions of Admission (COA) provides permission to give basic, simple, common hospital services and medical treatment to the patient.

...4. The COA form specifies what treatment or procedure they are consenting to and by signing the form, the patient acknowledges that, if required by law, they have given their informed consent to their treating physician.

...5. The most commonly used general consent, authorization for treatment, is the one that patients sign upon admission called the conditions of admissions, which provides permission to give basic, simple, common hospital services and medical treatment, not requiring informed consent.

A review of facility ' s Patient Rights and Responsibilities policy, dated 2/2022, indicated the following:

Facility staff are expected to respect and uphold the rights and responsibilities of all individuals to whom (patient) care and services are rendered.

At the time of admission, each patient will receive a copy of the Patient Rights/Responsibilities statement.

Patient Rights included the right to make decisions regarding medical care and to receive as much information about any proposed treatment or procedure to give informed consent.

All patient rights apply to the person who has legal responsibility to make decisions regarding medical on the patient ' s behalf, as indicated in the patient right to formulate advance directives (a written statement of a person ' s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a physician)

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

1. Ensure one of 35 sampled patients (Patient 1) received safe care by preventing the discontinuation of an essential medication for survival by an unauthorized staff member. This deficient practice resulted in Patient 1 undergoing a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating) and would have likely resulted in Patient 1 ' s death.

2. Follow the facility ' s fall prevention policy for two of 35 sampled patients (Patient 25 and Patient 27). This deficient practice placed Patients 25 and 27 at risk for falls and injury.

3. Ensure a radiant infant warmer (a device used to provide heat to maintain a baby ' s body temperature) had an inspection sticker that was not past due for one of 1 radiant warmers.

This deficient practice had the potential for critical medical equipment used to a vulnerable infant to not be available or might malfunction which cause physical harm to the infant.

On 4/2/2025, at 3:17 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements have, caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer, Chief Nursing Officer, Chief Administrative Officer, and Chief Medical Officer. 

The facility failed to ensure one of 35 sampled patients (Patient 1) received safe care by preventing an unauthorized staff from discontinuing infusion of an essential emergency medication for Patient 1 ' s survival.

The above-mentioned facility administrators were informed of the immediate jeopardy situation regarding the failure to ensure one of 35 sampled patients (Patient 1) received safe care by preventing an unauthorized staff from discontinuing infusion of an essential emergency medication for Patient 1 ' s survival.

On 4/4/2025, at 12:55 p.m., while onsite, the IJ was removed after verifying and confirming the facility's implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the following facility members: Chief Executive Officer, Chief Administrative Officer, Chief Nursing Officer, and Director of Risk Management. 

The IJ Removal Plan included the following:

1. Responsible Parties-The Chief Administration Officer and the Director of Laboratory Services are responsible for this process.

2. Policy Review- The policy "Specimen Collection and Identification" was reviewed by the Director of Laboratory Services, and no changes were identified at this time.

3. Immediate Actions with Phlebotomists- All (except PTO/LOA) phlebotomists were reeducated to the above policy and have provided an attestation of understanding,

General Staff Meeting: All (except PTO/LOA) phlebotomists were in attendance or educated on the meeting minutes which included education around the expectation of adherence to policy "Specimen Collection and Identification" when drawing labs, ensuring all staff understand pump management is outside of their scope, and only an RN can turn a pump off and back on.

Competencies- all (except PTO/LOA) phlebotomy staff will complete an annual competency regardless of when last completed.

Competency includes the understanding that phlebotomists cannot turn off or on pumps.

All phlebotomists starting with afternoon shift on 4/3/25 will be educated and sign an attestation of understanding in huddle before the start of their shift on the following:

All Phlebotomy care givers must find the bedside RN to ensure there is communication regarding any limitation that could exist regarding the blood draw. If assigned bedside RN is not immediately available, utilize escalation tree.

You can always use the call light for assistance

Ask a nearby RN for assistance

Ask Unit Coordinator where RN can be located

Escalate to charge RN

5. Future Action for Phlebotomist-

1. All new hires during onboarding will receive:

Competency completion, which includes the understanding that phlebotomists cannot turn off or on pumps.

Policy validation "Specimen Collection and Identification"

6. ICU Immediate Action-

All Nurses on shift starting 4/3/25 will be educated in huddle prior to start of shift, and sign an attestation of understanding of the following:

Do not ask or allow a phlebotomist to turn off or adjust IV pumps under any circumstances. If an IV pump alarm sounds or if you notice a device that appears to be malfunctioning, promptly assess the situation.

Collaborate with phlebotomist prior to allowing the labs to be drawn which includes but is not limited to identifying correct patient, site selection, and concerns with medications running that may interfere or affect lab result.

If unsure about appropriateness of lab draw, site selection or other concern, seek clarification from your charge RN, leadership team or through the chain of command. 

Escalate immediately if issues or safety events occur

Nursing is to manage the pumps when needed during lab draw

Lab has been educated to follow the chain of command if unable to locate the RN, and given the following recommendations

All Phlebotomy care givers must find the bedside RN to ensure there is communication regarding any limitation that could exist regarding the blood draw. If assigned bedside RN is not immediately available, utilize escalation tree.

You can always use the call light for assistance

Ask a nearby RN for assistance

Ask Unit Coordinator where RN can be located

Escalate to charge RN

Completion Date 4/4/2025.


Findings:

1. During a review of Patient 1 ' s "History & Physical" (H&P), dated 9/14/2024, at 2:22 p.m., the H&P indicated Patient 1 was admitted to the facility ' s Intensive Care Unit (ICU) for acute respiratory failure with hypoxia (a condition in which the lungs are failing to put oxygen in the blood, leading to low oxygen levels).

During a review of Patient 1 ' s "Physician Orders," dated 9/15/2024, at 12:06 p.m., the "Order" indicated MD 9 placed Patient 1 on a continuous intravenous (IV - a way of administering fluids, medications, or nutrients directly into a vein) infusion of Levophed (an emergency medication administered through the vein used to treat life-threatening low blood pressure).

During a review of Patient 1 ' s "Physician Progress Note," dated 9/18/2024, at 6:52 a.m., the "Progress Note" indicated Patient 1 was hypotensive (had low blood pressure) and was being given Levophed.

During a review of Patient 1 ' s "Nursing Progress Note," dated 9/18/2024, at 7:37 p.m., the "Progress Note" indicated, "Levophed drip running to maintain adequate blood pressure . . . At approximately 1325 [1:25 p.m.] [Registered Nurse (RN) 1] noted upon walking in [Patient 1 ' s] room, IV pumps were paused ([RN 1] did not pause drips) while phlebotomy [the licensed staff responsible for drawing blood from a patient in order to perform necessary tests] attempted to draw lines. Patient was found to have decreased heart rate, non-responsive and agonally breathing [gasping and labored breathing due to a life-threatening medical emergency]. Immediately called an RRT [Rapid Response Team, a team of health care professionals that help manage patients whose condition is deteriorating] which thereafter became a code blue. Code team at bedside and ROSC [return of spontaneous circulation - when the patient ' s heart starts beating again by itself after a code blue] was achieved."

During a review of Patient 1 ' s "Code Documentation," dated 9/18/2024 at 3:22 p.m., the "Documentation" indicated, "Code blue called as patient was found to be agonal breathing with no pulse . . . After several rounds of CPR [cardiopulmonary resuscitation - an emergency treatment that's done when someone's breathing or heartbeat has stopped consisting of chest compressions], the patient had ROSC achieved."

During an interview with the Director of Laboratory Services (DLS), on 4/2/2025, at 10:28 a.m., the DLS stated Phlebotomist 1 went to the ICU to draw a specimen from Patient 1. Phlebotomist 1 turned off the IV infusion pump to obtain the specimen because "she couldn ' t find a nurse around allegedly." The DLS stated turning off the Levophed IV infusion was out of scope of practice for the phlebotomist. The DLS further stated that the facility ' s phlebotomists know that they are supposed to talk to the patient ' s nurse to turn off the IV pumps before they obtain blood specimens.

During an interview with the Director of Critical Care (DCC), on 4/2/2025, at 10:40 a.m., the DCC stated she found out about the incident when RN 1 called for help and a code blue was called. The DCC further stated that at the time Phlebotomist 1 turned off the pump, RN 1 was in the room next door. The DCC further confirmed that the immediate effect of the Levophed infusion being turned off was the code blue.

During an interview with the Assistant Nurse Manager, ICU (ANM 2), on 4/4/2025, at 10:45 a.m., ANM 2 stated Levophed is given when a patient has "dangerously low blood pressure" and if Levophed was turned off prematurely, that patient ' s blood pressure would drop and they would "lose the pulse" (heart rate).

During a review of the hospital ' s policy & procedure (P&P) titled "Specimen Collection and Identification", dated 9/4/2024, the P&P indicated, "Phlebotomists may draw, if necessary, below the IV infusion site. Ask the RN to turn off the IV infusion for at least 2 minutes . . . When completed, ask the RN to turn the IV infusion back on. Lab [assistants] are not allowed to turn off or turn on the IV infusion."

2.a. During an observation on 4/2/2025 at 10:06 AM, signage outside Patient 25 ' s room indicated Patient 25 was on fall precautions. In the patient ' s room, Patient 25 was resting quietly with the bed in the lowest position; There was a yellow band around Patient 25 ' s right wrist denoting he was at risk for falling. Both of Patient 25 ' s lower extremities, including his feet, were cover with elastic bandages but without slip resistant coverings.

During an observation on 4/2/2025 at 10:06 AM, Patient 25 used the nurse call system (device at the patient ' s bedside enabling communication with the nurse when assistance is needed) to asked Registered Nurse (RN 7) if he could stand by the bedside to urinate. RN 7 answered Patient 25 could stand by the bedside to urinate.

During an interview on 4/2/2025 at 10:08 AM, the Nurse Manager of 5NE Medical Surgical Unit (NM5NE) stated because there was a risk for falling and potential harm, Patient 25 should have been wearing red slip resistant socks to help prevent a fall. NM5NE added slip resistant socks was impractical since Patient 25 had bandages on his lower extremities.

During a review of the flowsheet ' Morse Scale-Most Recent Current/Last Encounter ' dated 4/3/2025, indicated the fall risk score for Patient 25 was 60 at this time; This score demonstrated a high risk for falling.

During a review of the ' Fall Policy ' ID 8018451, this document indicated its purpose is to reduce incidence of preventable falls and the risk of patient injury from a fall. The policy indicated falls can be prevented through identification of patient fall risk factors and implementation of inventions targeted at those risk factors. The ' Procedure, Assessment ' section of this policy indicated patients are to be assessed using a fall risk score upon admission, when transferred, during each shift, and when the patient ' s condition changes, e.g., change in ability to ambulate, medication use, and/or recent fall. The ' Fall Policy ' indicated patients with fall score greater than 24 should: be placed on fall precautions, have a yellow fall precautions sign posted outside the patient ' s room, be wearing red nonskid footwear, be supervised during ambulation, have a ' Fall Risk ' indicator on the patient ' s ID band, use a bed alarm, be instructed to call for help when ambulating or toileting.

2.b. During an observation on 4/2/2025 at 10:35 AM, signage outside Patient 27 ' s room indicated Patient 27 was on fall precautions. In the patient ' s room, Patient 27 was resting quietly with the bed in the lowest position and wearing red slip resistant sock; However, Patient 27 was not wearing a band around either of his wrists that indicated he was at risk of falling.

During an interview on 4/2/2025 at 10:40 AM, while present outside Patient 27 ' s room, Nurse Manager 5 NE Medical Surgical Unit (NM5NE) acknowledged that Patient 27 should be wearing a yellow armband that indicated Patient 27 was risk of fall if left unattended. Subsequently, NM5NE stated patients at risk of falls should have red socks on their feet, a yellow arm band should be on their wrists, and the patient ' s bed should be in the lowest position. At this time, NM5NE was asked to provide nursing assessment for fall risk but this documentation was provided from the NM5NE.

During a review of the ' History and Physical ' dated 3/14/2025, this document indicated Patient 27 entered the emergency department (hospital department staffed and equipped to provide immediate medical care to patients with serious illness or injury) and presented with worsening right sided hemiparesis (weakness or inability to move one side of the body). This report showed Patient 27 demonstrated severe weakness of the right upper and lower extremities and slurred speech (difficulty speaking).

During a review of the patient ' s Flowsheet dated 3/14/2025 at 11:10 PM, Patient was assessed by nursing staff for Motor Response (action occurring in response to stimuli such as touch or speech). This assessment indicated Patient 27 response to stimuli to his right arm was ataxic (poor muscle control that causes clumsy movements which can affect walking and balance); the response to stimuli to Patient 27 ' s right leg was also ataxic.

During a review of the ' Fall Policy ' ID 8018451, this document indicated its purpose is to reduce incidence of preventable falls and the risk of patient injury from a fall. This policy stated falls can be prevented through identification of patient fall risk factors and implementation of inventions targeted at those risk factors. The ' Procedure, Assessment ' section of this policy indicated patients are to be assessed using a fall risk score upon admission, when transferred, during each shift, and when the patient ' s condition changes, e.g., change in ability to ambulate, medication use, and/or recent fall. The ' Fall Policy ' indicated patients with fall score greater than 24 should: be placed on fall precautions, have a yellow fall precautions sign posted outside the patient ' s room, be wearing red non skid footwear, be supervised during ambulation, have a ' Fall Risk ' indicator on the patient ' s ID band, use a bed alarm, be instructed to call for help when ambulating or toileting.

3. During a concurrent observation and interview, on 4/1/2025, at 4:04 p.m., with the Director of Emergency Services (DES), a radiant infant warmer was observed in the resuscitation room of the Emergency Department (ED). The sticker on the radiant warmer indicated "Clinical Engineering – Oct 2024." The DES stated that the date on the sticker is the date that the preventative maintenance check is due. The DES confirmed that the sticker on the warmer indicated "October 2024" and that it was past due for preventive maintenance.

During a review of the "Clinical Work Order," dated 4/1/2025, at 4:12 p.m., the "Work Order" indicated, "Baby warmer PM [preventative maintenance] sticker is expired since October 2024." The Work Order also indicated that the warmer is on a six-month preventative maintenance cycle, logged on a computerize system for monitoring of the maintenance cycles.

During a review of the hospital ' s "Medical Equipment Management Plan," not dated, the "Plan" indicated, "The hospital inspects, tests, and maintains all high-risk equipment . . . The hospital inspects, tests, and maintains non-high-risk equipment identified on the medical equipment inventory."

Based on observation, interview and record review:

1. The facility failed to ensure a medication was administered according to the doctor ' s order and if an error was committed that the medication error was documented in the electronic medical record (EMR) for one of 35 sampled patients (Patient 2) per facility policy & procedure (P&P) on medication administration.

This deficient practice had the potential to miss dosage errors and potential adverse reaction to the dosage error for Patient 2 which can lead death due to overdose.

2. The facility failed to ensure nursing staff adhered to the hospital policies and procedures for pain assessment for two of 35 sampled patients (Patient 12 and Patient 15).

This deficient practice had the potential to result in patients ' ineffective pain management and relief.


Findings:

1. During a review of Patient 2 ' s "ED (Emergency Department) Triage Note", dated 11/14/2024, at 8:44 p.m., the "Note" indicated Patient 2 came to the facility ' s ED complaining of generalized body aches (pain all over the body).

During a review of Patient 2 ' s "Physician Orders," dated 11/14/2024, at 11:35 p.m., the "Order" indicated Patient 2 ' s physician (MD 4) ordered 9.7 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of ketamine (a medication that sedates patients and numbs the body but can also cause hallucinations) to be given once intravenously (IV - a way of administering fluids, medications, or nutrients directly into a vein) to Patient 2.

During a review of Patient 2 ' s MAR, dated 11/15/2024, the MAR indicated Registered Nurse (RN2) administered 9.7 mg of ketamine at 1:12 a.m.

During a review of Patient 2 ' s "ED Encounter Note," dated 11/15/2024, at 3:09 a.m., the "Note" indicated, "Patient accidentally given 97 mg instead of 9.7 mg of ketamine -- patient monitored very closely without adverse event, reports improvement in pain. Medical error disclosed to patient." This was MD 4 ' s documentation.

During a concurrent interview and record review with the ED Assistant Nurse Manager (ANM 1), on 4/3/2025, at 12:18 p.m., Patient 2 ' s EMR was reviewed. ANM 1 stated there is no documentation by RN 2 to indicate if the correct dose of ketamine was given or that a different dose was given to the patient.

During an interview with ANM 1, on 4/3/2025, at 3:19 p.m., ANM 1 stated the nurse should document if the dose given was not what the physician ordered.

During an interview with RN 3, on 4/3/2025, at 4:12 p.m., RN 3 stated that she was the primary nurse for Patient 2 and had handed off Patient 2 to RN 2 while RN 3 went on break. RN 3 stated RN 2 gave the incorrect dose of medication while she was on break and she did not document how much ketamine Patient 2 was given because RN 2 gave the incorrect dose of medication. RN 3 did not know if RN 2 documented how much medication was given to the patient.

During a review of the hospital ' s P&P titled "Nursing Medication Administration and Documentation", effective 11/2023, the P&P indicated, "Drug administration or omission errors, including related to adverse reactions and incompatibilities issues shall be immediately reported to the attending physician, documented in the medical record, and entered as an unusual occurrence report."

2.a. A review of Patient 12 ' s face sheet (a document that summarizes the patient ' s personal and demographic information), dated 3/23/2025, indicated patient ' s diagnosis included intracranial mass (an abnormal growth within the skull).

On 4/2/2025, at 1:53 PM, during concurrent interview with quality management specialist (QM) and record review of Patient 12 ' s emergency department (ED) records, dated 3/23/2025, QM stated the following:

At 1:16 PM, Patient 12 ' s vital signs (VS – measurements of the body ' s most basic functions, including body temperature, pulse rate, rate of breathing, and blood pressure, used to monitor or to detect for medical problems) and pain score of 5 out of 10, were obtained upon arrival.

At 1:45 PM, physician ordered medication, Tylenol 1000 milligrams (mg) by mouth, for pain relief.

At 3:23 PM, registered nurse (RN)12 gave Patient 12 Tylenol 1000 mg by mouth, for pain.

Prior to administering Tylenol 1000 mg for pain, RN 12 did not check Patient 12 ' s pain score, to see if patient was still in pain or in worse pain.

After RN 12 gave Patient 12 pain medication, Tylenol 100 mg by mouth, at 3:23 PM, RN 12 did not assess patient ' s pain score, to check for the effectiveness of the pain medication.

A review of facility ' s Nursing Assessment and Documentation policy, dated 7/2023, indicated that pain score is obtained with every set of full vital signs, prior to administration of pain medication, and after administration of pain medication.

A review of facility ' s Medication Management policy, dated 1/2025, indicated each patient response to medication is monitored for any side effects and is documented in the patient ' s medical record.

A review of facility ' s Medication Range Orders policy, dated 5/2024, indicated for pain medications, the patient ' s response to pain management intervention will be assessed and re-assessed and documented for the effectiveness of pain medication.

A review of facility ' s Patient Rights and Responsibilities policy, dated 2/2022, indicated Patient Rights included the right to receive appropriate assessment and management of pain, information about pain, pain relief measures and to participate in pain management decisions.

2.b. A review of Patient 15 ' s face sheet (a document that summarizes the patient ' s personal and demographic information), dated 3/19/2025, indicated patient had a diagnosis, which included inflammation of the gallbladder (organ near the liver responsible for storing and releasing substance which helps in fat digestion from the food we eat).

On 4/4/2025, at 11:51 AM, during concurrent interview with infection preventionist (IP – a healthcare professional who is dedicated to preventing the spread of infections in healthcare settings, ensuring the safety of patients, staff and visitors by implementing and monitoring infection control practices)1 and record review of Patient 15 ' s ED records, dated 3/19/2025, IP 1 stated the following:

Upon arrival to the ED, at 3:53 PM, patient ' s VS included pain score of 6 out of 10.

Physician ordered pain medication, morphine 4 milligrams (mg – unit of measurement) by intravenous (IV – into the vein) at 4:53 PM.

Pain medication, morphine 4 mg was given to patient at 4:58 PM by IV.

Prior to administration of pain medication, morphine 4 mg IV, RN 15 did not assess patient ' s pain score.

After administration of pain medication, morphine 4 mg IV, RN 15 did not assess patient ' s pain score, for response to pain medication.

A review of facility ' s Nursing Assessment and Documentation policy, dated 7/2023, indicated that pain score is obtained with every set of full vital signs, prior to administration of pain medication, and after administration of pain medication.

A review of facility ' s Medication Management policy, dated 1/2025, indicated each patient response to medication is monitored for any side effects and is documented in the patient ' s medical record.

A review of facility ' s Medication Range Orders policy, dated 5/2024, indicated for pain medications, the patient ' s response to pain management intervention will be assessed and re-assessed and documented for the effectiveness of pain medication.

A review of facility ' s Patient Rights and Responsibilities policy, dated 2/2022, indicated Patient Rights included the right to receive appropriate assessment and management of pain, information about pain, pain relief measures and to participate in pain management decisions.

Based on interview and record review, the facility failed to ensure ketamine (a medication that sedates patients and numbs the body but can also cause hallucinations) was given according to the physician ' s orders for one of 35 sampled patients (Patient 2).

This deficient practice had the potential to harm Patient 2 and cause serious side effects.

Findings:

During a review of Patient 2 ' s "ED (Emergency Department) Triage Note", dated 11/14/2024, at 8:44 p.m., the "Note" indicated Patient 2 came to the facility ' s ED complaining of generalized body aches (pain all over the body).

During a review of Patient 2 ' s "Physician Orders," dated 11/14/2024, at 10:20 p.m., the "Order" indicated MD 4 ordered 9.7 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of ketamine to be given once intravenously (IV - a way of administering fluids, medications, or nutrients directly into a vein) to Patient 2.

During a review of Patient 2 ' s "Medication Administration Record" (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 11/14/2024, the MAR indicated RN 3 administered the first dose of ketamine at 11:07 p.m.

During a review of Patient 2 ' s "Physician Orders," dated 11/14/2024, at 11:35 p.m., the "Order" indicated MD 4 ordered a second dose of 9.7 milligrams of ketamine to be given once intravenously to Patient 2.

During a review of Patient 2 ' s MAR, dated 11/15/2024, the MAR indicated RN 2 administered the second dose of ketamine at 1:12 a.m.

During a review of Patient 2 ' s "ED Encounter Note," dated 11/15/2024, at 3:09 a.m., the "Note" indicated, "Patient accidentally given 97 mg instead of 9.7 mg of ketamine -- patient monitored very closely without adverse event, reports improvement in pain. Medical error disclosed to patient."

During an interview with the Chief Nursing Officer (CNO), on 4/3/2025, at 9:53 a.m., the CNO stated that the facility gave Patient 2 a "large dose of ketamine, larger than what was ordered to the patient."

During an interview with the Director of Pharmacy Services (DPS), on 4/3/2025, at 12:20 p.m., the DPS stated that Patient 2 was given ten times the ordered dose of ketamine per DPS review of the Pyxis log (automated medication dispensing system used in the hospitals).

During an interview with MD 4, on 4/3/2025, at 2:43 p.m., MD 4 stated Patient 2 suffered from chronic pain and "seemed to be having a flare-up," so MD 4 ordered ketamine. MD 4 stated her expectation was for the nurse to administer to the patient the correct dose of ketamine to the patient. MD 4 further stated a high dose of ketamine could have caused Patient 2 to "become so sedated or sleepy that if they were to choke on their saliva, they wouldn ' t be able to cough or protect their airway; if a patient isn ' t able to protect their airway, we would have to intubate [inserting a tube into the patient's airway to help maintain breathing if the patient is not able to breathe by themselves] them or protect their airway in other ways."

During an interview with RN 3, on 4/3/2025, at 4:12 p.m., RN 3 stated that she was the primary nurse for Patient 2 and had handed off Patient 2 to RN 2 while RN 3 went on break. Prior to going on break, Patient 2 was alert and oriented (a person is awake, aware, and can understand their surroundings, including their identity, location, and the current time) but in pain. When RN 3 returned from break, she noticed that Patient 2 was "yelling and spacing out," as well as not taking deep breaths, which was different from Patient 2 ' s behavior prior to RN 3 ' s break. Oxygen was given to Patient 2 and RN 3 asked RN 2 what happened; RN 2 informed RN 3 of the amount of ketamine she gave. RN 3 stated that is when she found out RN 2 gave Patient 2 the wrong dose of ketamine. RN 3 further stated she told RN 2 that she had given too much ketamine.

In the same interview with RN 3, on 4/3/2025, at 4:12 p.m., RN 3 stated that she gave Patient 2 9.7 mg of ketamine which is the ordered dose. She stated RN 2 gave 97 mg of ketamine; RN 2 "moved the decimal over and that ' s how we discovered she gave too much." RN 2 stated she told RN 3 that the correct dose was "lower than that, it ' s a really small amount." RN 2 further stated that a negative situation could have occurred from the medication error and that Patient 2 could have gone into respiratory distress (difficulty breathing) or become more sedated for a longer period of time.

During a review of the hospital ' s policy & procedure (P&P) titled "Nursing Medication Administration and Documentation", effective 11/2023, the P&P indicated, "Observe the 7 Rights for safe medication administration always . . . 3. Right dose . . . Staff shall confirm the following prior to each administration of medication: . . . d. Right Dose: Verify the dose matches that prescribed, and that the dose is appropriate and safe for the patient (not too high or too low)."

Based on interview and record reviews, the facility failed to ensure policies and procedures (P&P) related to the medication distribution and medication administration systems were implemented in the Emergency Department (ED). Failure by nursing and pharmacy staff to implement P&Ps specific to the removal of Ketamine (a controlled medications used for sedation (feeling calm and relaxed), immobility, and relief from pain), from the facility ' s Pyxis (ADS, an automictic dispensing system/services) machine was reviewed for medication accuracy and appropriateness, to ensure ED physician ' s order was followed and any amount greater than the ordered amount was witnessed by a second nurse and disposed of prior to ketamine administration to one of 35 sampled patients (Patient 2).

The deficient practice had the potential to affected over 200 patients seen in the ED between 11/14/2025 – 11/15/2025 who received medications from the ADS used in the ED. The failure to have a second nurse to witness controlled medication removal from the ADS and wasting of the excess dosage resulted in Patient 2 being administered 10 times the prescribed ordered dose of ketamine, resulting in Patient 2 experiencing a high respiratory rate, becoming more somnolent (drowsy or sleepy), having trouble breathing, and requiring the administration of oxygen.

Findings:

During a review of Patient 2 ' s "ED (Emergency Department) Triage Note", dated 11/14/2024, at 8:44 p.m., the "Note" indicated Patient 2 came to the facility ' s ED complaining of generalized body aches (pain all over the body).

During a review of Patient 2 ' s "Physician Orders," dated 11/14/2024, at 10:20 p.m., the "Order" indicated MD 4 ordered 9.7 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of ketamine to be given once intravenously (IV - a way of administering fluids, medications, or nutrients directly into a vein) to Patient 2.

During a review of Patient 2 ' s "Medication Administration Record" (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 11/14/2024, the MAR indicated RN 3 administered the first dose of ketamine at 11:07 p.m.

During a review of Patient 2 ' s "Physician Orders," dated 11/14/2024, at 11:35 p.m., the "Order" indicated MD 4 ordered a second dose of 9.7 milligrams of ketamine to be given once intravenously to Patient 2.

During a review of Patient 2 ' s MAR, dated 11/15/2024, the MAR indicated RN 2 administered the second dose of ketamine at 1:12 a.m.

During a review of Patient 2 ' s "ED Encounter Note," dated 11/15/2024, at 3:09 a.m., the "Note" indicated, "Patient accidentally given 97 mg instead of 9.7 mg of ketamine -- patient monitored very closely without adverse event, reports improvement in pain. Medical error disclosed to patient."

During a review of the facility ' s "ED Pyxis – All Transaction Detail," between 11/132024 to 11/17/2024, the "All Transaction Detail," indicated for Patient 2, the following transactions occurred from the ED Pyxis on:

-11/14/2025 at 10:31 p.m., removed one vial of ketamine 10 mg/ml (200 mg/20 ml) from facility ' s Pyxis by RN 3

-11/14/2025 at 10:37 p.m., wastage (destruction/disposal) of ketamine 190.3 mg out of 200 mg of the 10mg/ml (200 mg/20ml) vial, was documented in the facility ' s Pyxis by RN 3 and witnessed by RN 8

-11/15/2025 at 1:06 a.m., RN 2 accessed the facility ' s ED Pyxis to verify inventory of ketamine 10 mg/ml (200 mg/20 ml) vial

-11/15/2025 at 1:06 a.m., RN 2 accessed the facility ' s ED Pyxis a second time and removed one vial of ketamine 10 mg/ml (200 mg/20 ml) from the facility ' s Pyxis, no witness was documented

-11/15/2025 at 3:41 a.m., wastage of ketamine 103 mg out of 200 mg of the 10mg/ml (200 mg/20ml) vial, was documented in the facility ' s Pyxis by RN 2 and witnessed by RN 3, waste reason indicated, Patient 2 was supposed to receive 0.97 ml (9.7 mg) of ketamine. RN 2 accidentally gave 9.7 ml (97 mg), and wasted the remainder of the ketamine which was 10.3 ml (equals 103 mg).

During a review of Patient 2 ' s ED Encounter documentation, Patient Care Timeline indicated the following on:

-11/14/2024 at 10:42 p.m., Respiratory Rate (RR, breaths per minute [bpm], normal RR is between 12 and 20 bpm) 18 bpm

-11/14/2024 at 11:30 p.m., RR 26 bpm

-11/15/2024 at 12:00 a.m., RR 16 bpm

-11/15/2024 at 1:11 a.m., RR 45 bpm

-11/15/2024 at 1:23 a.m., ED Quick Note: MD at bedside assessing patient

-11/15/2025 at 1:31 a.m., ED Quick Note: Patient placed on cardiac monitor, NIBP monitoring, and continuous pulse oximetry

During an interview on 4/2/2025, at 1:43 p.m., with the Director of Pharmacy Services (DPS), Pharmacist of Medication Safety and Regulatory (Pharm 1), and the Pharmacy Manager (Pharm 2), Pharm 2 stated the pharmacist review reports that include, discrepancy reports and check for discrepancies between the physician orders and the medications access in the Pyxis. Pharm 2 stated the facility has about 63 Pyxis throughout the hospital with two out of three Pyxis being used in the ED.

During an interview with the Chief Nursing Officer (CNO), on 4/3/2025, at 9:53 a.m., the CNO stated that the facility gave Patient 2 a "large dose of ketamine, larger than what was ordered to the patient."

During a concurrent interview and record review on 4/3/2025, at 11:55 a.m., with the Assistant Nurse Manager, ED (ANM 1), Patient 2 ' s clinical records were reviewed. On 11/15/2024 at 1:11 a.m., ED Encounter documentation indicated Patient 2 RR was 45 bpm, ANM 1 stated a normal RR is between 12 bpm – 20 bpm. ANM 1 stated a RR of 45 is tachypneic, which is rapid breathing and requires physician notification for a high RR. ANM 1 stated there was no documentation on Patient 2 ' s Medication Administration Record to indicate that Patient 2 was administered a higher dose of ketamine than ordered. ANM 1 stated there was no documentation that RN 2 had a second nurse witnessing the wastage of the excess amount of ketamine before administering ketamine to Patient 2 on 11/15/2024 at 1:06 a.m.

On 4/3/2025, at 12:18 p.m., during a concurrent interview and review of facility ' s ED Pyxis Transaction Detail with DPS, Pharm 1, and Pharm 2, Pharm 1 stated on 11/15/2024 at 1:06 a.m., RN 2 removed from the Pyxis Ketamine 10 mg/ml (200 mg/20 ml) vial and on 11/15/2024 at 3:41 a.m., (two hours and 35 minutes later) RN 2 with RN 3 wasted at the Pyxis 103 mg out of 200 mg. Pharm 1 stated Patient 2 was administered 97 mg (9.7 ml) of ketamine and the order was for 9.7 mg (0.97 ml). Pharm 1 stated Patient 2 was administered 10 times the ordered dose of ketamine. Pharm 1 stated the wasting of ketamine should have been done at the same time the medication was pulled from the Pyxis with a witness. Pharm 2 stated the expectation is for the licensed nurses to follow the facility ' s policy that requires the licensed nurse to waste excess dose of controlled medication at the time of removal from the Pyxis with a witness inside of the medication room and not after medication administration to the patient.

During an interview on 4/3/2025, at 12:37 p.m., with DPS, Pharm 1, and Pharm 2, DPS stated removal of controlled medication, wasting in the medication room with a witness, ensures the correct dose of medication was prepared, before administration to the patient. Pharm 2 stated the process of integrated waste (wasting at the same time the medication is pulled) helps with medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) and prevent loss and diversion (when a medication is taken for use by someone other than whom it is prescribed) of controlled medications and there is a designated receptacle in the medication room to waste the controlled medication and there is not a receptacle for disposal in patients rooms.

During an interview with MD 4, on 4/3/2025, at 2:43 p.m., MD 4 stated Patient 2 suffered from chronic pain and "seemed to be having a flare-up.," so MD 4 ordered ketamine. MD 4 stated her expectation was for the nurse to administer to the patient the correct dose of ketamine to the patient. MD 4 further stated a high dose of ketamine could have caused Patient 2 to "become so sedated or sleepy that if they were to choke on their saliva, they wouldn ' t be able to cough or protect their airway; if a patient isn ' t able to protect their airway, we would have to intubate [inserting a tube into the patient's airway to help maintain breathing if the patient is not able to breathe by themselves] them or protect their airway in other ways."

During a follow-up interview on 4/3/2025, at 3:26 p.m., with DPS, Pharm 1, and Pharm 2, DPS stated the facility ' s policy requires the licensed nurse to return unused medications to the Pyxis within 30 minutes if not used. Pharm 1 stated the pharmacy do not look at timeframe, not looking at if there is a wastage during removal from the Pyxis of a controlled medication that is higher than the dose ordered. Pharm 1 stated the pharmacy became aware of the overdosage of ketamine to Patient 2 when an incident report was done.

During an interview with RN 3, on 4/3/2025, at 4:12 p.m., RN 3 stated that she was the primary nurse for Patient 2 and had handed off Patient 2 to RN 2 while RN 3 went on break. Prior to going on break, Patient 2 was alert and oriented (a person is awake, aware, and can understand their surroundings, including their identity, location, and the current time) but in pain. When RN 3 returned from break, she noticed that Patient 2 was "yelling and spacing out," as well as not taking deep breaths, which was different from Patient 2 ' s behavior prior to RN 3 ' s break. Oxygen was given to Patient 2

In the same interview with RN 3, on 4/3/2025, at 4:12 p.m., RN 3 stated that she gave Patient 2, 9.7 mg of ketamine which is the ordered dose. She stated RN 2 gave 97 mg of ketamine; RN 2 "moved the decimal over and that ' s how we discovered she gave too much." RN 3 further stated that a negative situation could have occurred from the medication error and that Patient 2 could have gone into respiratory distress (difficulty breathing) or become more sedated for a longer period.

During a review of the facility ' s policy and procedure (P&P) titled, "Inpatient Controlled Substance Management", effective 2/2023, the P&P indicated, "To establish guidelines for the procurement, receiving, storage, distribution, security, wasting and disposal of all controlled substances and reduce the potential for drug diversion ... The Department of Pharmacy solely controls access to ADS and maintains appropriate assignment of access and security levels in accordance with (the hospital) ADS policy ... WASTE & DISPOSAL OF CONTROLLED SUBSTANCES:

- Any full or partial doses of a controlled substance that is removed from the original package and not administered to the patient must be wasted at the ADS ...

- Partial doses of controlled substances should be wasted at the time of removal, not after administration.

- Wasting of controlled substances requires two persons: the person who removed the medication and a witness.

- Wasting of all controlled substances requires an independent witness performed by two licensed personnel (e.g., nurse, pharmacist or LIP) ...

- Witness that wasting occurs per policy for safe disposal and in a manner that makes the controlled substance irretrievable ...

- The unused portion of injectable or liquid controlled substance shall be drawn into a syringe and squirted into the designated controlled substance waste container ...

- Waste containers with any unusable controlled substance product are secured to prevent tampering or made otherwise non-retrievable.

- If a controlled substance is NOT administered to the patient and remains intact, it must be returned to the ADS or returned directly to the pharmacy as soon as possible, within 30 minutes from the time of removal, or by the end of case in procedural areas.

Based on observation and staff interview, the facility failed to ensure each Crash Cart/Code Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate [to bring someone back to life when their heart and breathing have stopped] a patient experiencing cardiac arrest [when the heart stops beating suddenly]) in the facility ' s Emergency Department (ED) had an inventory sheet of Crash Cart/Code Cart content attached to two out of seven Code Carts (Code Cart 3 Adults and Code Cart 3 Pediatric[Peds]).

The facility ' s failure to implement their policy and procedure had the potential to affect over 200 patients that visit the ED daily by not responding in an emergency adequately and/or creating a delay in care.

Findings:

During a concurrent interview and observation of the ED on 4/1/2025 at 2:50 p.m., with the Director of Emergency Services (DES) and Quality Management Specialist (QMS 1), two Crash Carts (Crash Cart 3 Adults and Crash Cart 3 Peds) was observed without a content list attached to each Crash Cart. DES stated there are no content list of medications on the outside of the Crash Carts labeled as Crash Cart #3 Adults and Crash Cart # 3 Peds.

During a concurrent interview and observation on 4/1/2025 at 3:00 p.m., with DES and QMS 1, Crash Carts # 5 Adults, Crash Cart # 5 Peds and Crash Cart # 2 were reviewed in the ED with each having an itemized content list in a red folder on the outside of each of the three Crash Carts (Crash Cart # 5 Adults, Crash Cart # 5 Peds, and Crash Cart # 2). QMS 1 acknowledged that two out of five of the Crash Carts reviewed in the ED did not have a Crash Cart/Code Cart content list attached to the Crash/Code Cart.

During a review of the facility ' s policy and procedure (P&P) titled, "Code Cart (Adult, Pediatric, NICU)", effective 6/2024, the P&P indicated, "To assure all emergency carts/trays/boxes are in a state of readiness for use in an emergency situation ...An inventory sheet of Code Cart content is attached to each cart and reviewed by Code Blue Committee."

Based on observation, interview, and record review the failed to follow facility policy regarding IV (way of administering fluids, medications, or nutrients directly into a vein) site dressing maintenance for 1 of 35 sampled patients (Patient 22); This deficient practice may lead to the introduction of infection through the unprotected IV site (insertion site of the flexible IV tube on the skin).

Findings:

During an observation on 4/2/2025 at 10:45 AM, there was an op site dressing (transparent dressing placed over the IV site used to prevent contamination) over Patient 22 ' s right wrist. The dressing was halfway detached from the IV site and appeared wet.

During an interview on 4/2/2025 at 10:45 AM, the Nurse Manager of the 5NE Medical/Surgical Unit (NM5NE) stated IV dressings should be changed every 96 hours and more frequently when soiled or damaged. NM5NE proceeded to gather the supplies needed to change the dressing at this time.

During a review of the policy ' Comprehensive Vascular Access Management ' ID 13167446, this document indicated the following for maintenance of IV sites:

-Dressings are to be changed every seven days or earlier if soiled, camp, or loose.

-Gauze dressings are to be changed every 48 hours and as needed.