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Based on interview, medical record review, and facility P&P review, the hospital failed to transfer one of six sampled patients (Patient 1) to a higher level of care in a timely manner as order by their physician to treat an intra-abdominal abscess. This delay in care had the potential to negatively impact Patient 1's well-being.

Findings:

Review of the Hospital's 2025 Organizational Plan for the Delivery of Patient Care, Treatment and Services showed, Patient services at the hospital occur through an organized and systematic process designed to ensure the delivery of safe, effective and timely care, treatment and services. The same document also showed, Patient care, treatment and services will be planned, coordinated, provided, delegated and supervised by professional health care providers who recognize the unique physical, emotional and spiritual needs of patient/family teaching, patient advocacy and research.

On 7/8/25 at 1400 hours, a medical record review for Patient 1 was conducted with the Director of Quality Management. Patient 1's medical record showed Patient 1 was admitted to the hospital on 3/22/25.

Review of Patient 1's History and Physical examination dated 3/22/25 showed Patient 1 was admitted to the hospital for an intra-abdominal infection and had a history of kidney and liver transplantation.

Review of Patient 1's Physician Order dated 4/6/25 at 1718 hours, showed an order to request transfer back to the liver transplant team at Hospital A for persistent intra-abdominal abscess measuring 4.5 cm. The order was to be initiated on 4/7/25 at 0600 hours. Further review of the order showed it was acknowledged by RN 1 on 4/6/25 at 1840 hours.

On 7/9/25 at 1300 hours a telephone interview was conducted with RN 1. RN 1 stated since it was after hours and case management was not available, the order to arrange for transfer of Patient 1 to Hospital A was endorsed to the night shift nurse to be followed up the next morning. RN 1 stated RN 1 was unaware if the order was passed on to the Case Management.

On 7/9/25 at 1057 hours, an interview was conducted with the Director of Case Management. The Director of Case Management stated the order to transfer Patient 1 to Hospital A "fell through the cracks" and they were not notified of the order until 4/9/25. The Director of Case Management stated Patient 1 could have potentially been transferred to Hospital A on 4/7/25, if they were made aware of the order at that time.

Review of the Discharge Note of Current Condition dated 4/9/25 at 2018 hours, showed a call was received from Patient 1's provider at Hospital A accepting Patient 1 for transfer on 4/9/25 at 1745 hours.

On 7/10/25 at 1045 hours, the Director of Quality Management and Chief Operating Officer were notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for making corrections to the paper medical records for two of six sampled patients (Patients 2 and 3). Illegible medical records posed the risk of adverse health outcomes and compromised patient safety.

Findings:

Review of the hospital's P&P titled Procedure-Corrections to the Medical Record dated April 2025 showed to make corrections to a paper medical record:
a. In black ink, draw a single line through the incorrect data.
b. Write "error" above the incorrect data.
c. Write the correct data below the lined-out material.
d. Sign, date and time the correction.

1. Medical record review for Patient 2 was initiated on 7/9/25.

Review of Patient 2's Blood/Blood Component Transfusion Record dated 7/6/25 at 1410 hours, showed that instead of drawing a single line through the error, the nurse wrote over several original entries, which included dates, times, and vital signs, which compromised the integrity and legibility of the medical record.

2. Medical record review for Patient 3 was initiated on 7/9/25.

Review of Patient 3's Blood/Blood Component Transfusion Records dated 6/28/25 at 1730 and 2220 hours, showed that instead of drawing a single line through the error, the nurse wrote over several original entries of the documented times, which compromised the integrity and legibility of the medical record.

On 7/9/25 at 0920 hours, the above findings for Patients 2 and 3 were shared with the Director of Quality Management who acknowledged the entries were not legible.


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Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the physician's order and the hospital's P&P on administering medications intravenously for one of six sampled patients (Patient 4). This failure posed the risk of adverse health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Administration of Medications via Injection dated June 2022 showed to administer IV Push medications no faster than 1 ml per minute or slower if recommended by the drug reference or physician order.

Review of the manufacturer's drug reference for pantoprazole sodium (a medication that is commonly used to treat certain stomach and esophagus problems, such as acid reflux) showed to reconstitute pantoprazole sodium for injection with 10 ml of 0.9% sodium chloride and to administer the medication intravenously over a period of at least two minutes.

On 7/9/25 at 0845 hours, an observation was conducted of RN 2 administering medication to Patient 4.

RN 2 was observed aspirating 4 ml of 0.9% sodium chloride and injecting it into a vial containing 40 mg of pantoprazole sodium to reconstitute the medication. RN 2 was later observed administering the medication via IV push over 15 seconds.

RN 2 verified the findings following the medication administration observation.

On 7/9/25 at 0940 hours, an interview and concurrent review of Patient 4's medical record was conducted with RN 2.

Patient 4's medical record showed the patient was admitted to the hospital on 6/30/25.

Review of Patient 4's physician's order dated 6/30/25, showed to administer pantoprazole sodium 40 mg every 12 hours. The order specified the vial should be diluted with 10 ml of normal saline and the medication should be administered via IV push over two minutes.

RN 2 verified the findings during the interview and record review.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the provider's orders and the hospital's P&P for the administration of blood and blood products for one of six sampled patients (Patient 2) as evidenced by:

a. The provider's order to transfuse two units of packed red blood cells was not followed timely.

b. Complete vital signs were not assessed or documented after the blood transfusion was completed.

These failures posed a risk to overall patient safety.

Findings:

a. Medical record review for Patient 2 was initiated on 7/9/25.

Patient 2's medical record showed the patient was admitted to the hospital on 6/9/25.

Review of Patient 2's Physician Orders dated 7/4/25 at 0816 hours, showed to start transfusing two units of packed red blood cells on 7/4/25, as needed (with no provided parameters), with instructions indicating one unit per execution and to stop after two executions.

Review of Patient 2's Lab Hematology Flowsheet dated 7/4/25, showed the patient's hemoglobin level was 6.2 g/dL (a protein in red blood cells that carries oxygen from the lungs to the rest of the body; the normal range for men is 13.8 to 17.2 g/dL).

Review of Patient 2's Progress Note dated 7/4/25, showed, "pending two units of packed red blood cells due to hemoglobin 6.1."

However, review of Patient 2's Blood/Blood Component Transfusion Records showed only one unit of packed red blood cells was transfused on 7/4/25, and the second unit was not transfused until two days later, on 7/6/25 at 1410 hours.

On 7/9/25 at 0840 hours, an interview and concurrent record review was conducted with the Director of Quality Management.

Review of Patient 2's medical record did not show a physician's order or progress note entry to hold the second unit.

The Director of Quality Management stated the hospital's process was to transfuse the first unit, recheck the patient's hemoglobin levels, and transfuse the second unit only if the hemoglobin level was under 7 g/dL. However, the Director of Quality Management was unable to provide the hospital's P&P to support this process. The Director of Quality Management acknowledged that the physician's order should be more specific and include parameters or instructions to recheck the patient's hemoglobin levels after transfusion of the first unit and to transfuse the second unit only if the hemoglobin level was under 7 g/dL.

b. Review of the hospital's P&P titled Transfusion Therapy dated June 2023 showed to obtain vital signs 15 minutes after transfusion initiation, then hourly until the unit is complete. The last set of vital signs is obtained 30 minutes after transfusion is complete.

Review of Patient 2's Blood/Blood Component Transfusion Record dated 7/6/25, showed the transfusion was started at 1410 hours and ended at 1740 hours. There was no documented evidence the patient's vital signs were obtained 30 minutes after the transfusion was completed.

On 7/9/25, the Director of Quality Management verified the findings during the interview and record review.