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Based on interviews and record reviews, the facility failed to ensure a patient's right to receive care in a safe setting for 1 of 30 sampled patients (Patient 1) by not adhering to its policies and protocols regarding sepsis (a widespread infection with life threatening organ dysfunction) screening and assessment, escalation, and treatment when the hospital failed to recognize the signs and symptoms of Patient 1's clinical deterioration (characterized by low blood pressure, no urine output, poor oral intake, and vomiting) and did not escalate care or initiate aggressive treatment and rescue for sepsis and septic shock over a 25-hour period (Refer to A-0144).

This failure resulted in Patient 1's clinical deterioration and a delay in transfer to a higher level of care within the hospital and delayed transfer to another facility capable of managing her life threatening symptoms. This failure contributed to Patient 1's death due to septic shock approximately 18 hours post transfer to an outside facility.

The cumulative effect of these systemic problems resulted in the hospital's inability to comply with the statutorily mandated Conditions of Participation for Patient Rights.

Based on interviews and record reviews, the hospital failed to provide quality medical care to 1 of 30 sampled patients (Patient 1), when Medical Doctors (MDs) did not follow policies, procedures, and bylaws related to sepsis (a widespread infection with life threatening organ dysfunction) treatment and rescue interventions when:

1. The hospital's MDs delayed transfer to a higher level of care (Intensive Care Unit- a specialty unit to manage patients who require constant monitoring and life support) despite clear signs of clinical deterioration which included low blood pressure, anuria (no urine output), poor oral intake, and vomiting; symptoms consistent with septic shock (the most severe stage of sepsis), which persisted for 25 hours (Refer to A-0347), and

2. The hospital's MDs failed to transfer Patient 1 to a facility better equipped to provide lifesaving interventions including stable intravenous (IV- a catheter inserted into a vein to provide fluids and medications) access for fluid resuscitation (rapidly replacing fluids during shock/ sepsis to restore blood pressure to ensure organ function) (Refer to A-0347).

The failures led to Patient 1's clinical deterioration, causing a delay in transfer to a higher level of care within the hospital and transfer to another facility capable of managing her life threatening symptoms. This ultimately contributed to Patient 1's death from septic shock approximately 18 hours after being transferred to an outside facility.

The cumulative effect of these systemic problems resulted in the hospital's inability to comply with the statutorily mandated Conditions of Participation for Medical Staff.

Based on interviews and record reviews, the facility failed to follow its policies and procedures and did not provide quality nursing care for five of 30 sampled patients (Patients 1, 2, 3, 8, and 13) when:

1. Nursing staff failed to conduct complete and accurate sepsis (a widespread infection with life-threatening organ dysfunction) screenings for Patients 1, 2, 3, and 13, which included a full set of vital signs, proper use and documentation of sepsis screening tools and escalation to a medical doctor as indicated (Refer to A-0398); and,

2. Nursing staff failed to ensure medications were administered in accordance with medical doctor orders for Patients 2, 8, and 13 (Refer to A-0405).

These failures resulted in inaccurate and incomplete sepsis screenings, which may have precluded nursing staff and medical doctors from recognizing and appropriately responding to changes in Patients 1, 2, 3, and 13's conditions. Further, the nursing staff failed to recognize the urgency of Patient 1's prolonged clinical deterioration, which included low blood pressure, anuria (no urine output), poor oral intake, and vomiting, all consistent with sepsis and septic shock (the most severe stage of sepsis) for 25 hours. This oversight contributed to Patient 1 developing septic shock (dangerously low blood pressure and organ failure and expiring approximately 18 hours after being transferred to another hospital. These failures also placed Patients 2, 8 and 13 at potential risk of experiencing adverse side effects, worsening symptoms, deteriorating health conditions, the development of new complications, and even death when medications were not administered according to medical doctors' order parameters.

The cumulative effect of these systemic problems resulted in the hospital's inability to comply with the statutorily-mandated Condition of Participation for Nursing Services.

Based on interview and records review, the facility failed to ensure that one of 30 sampled patients (Patient 1), who experienced clinical deterioration (low blood pressure, no urine output, low oral intake, and vomiting), received appropriate and timely rescue interventions. Patient 1, later diagnosed with sepsis (a widespread infection with life-threatening organ dysfunction) had signs and symptoms of sepsis and septic shock (most severe stage of sepsis marked by dangerously low blood pressure and organ failure) for 18 hours prior to being transferred to the intensive care unit (ICU- a specialty unit for critically ill patients) and then transferred out to another hospital better equipped to provide life saving interventions.

This failure resulted in Patient 1 developing septic shock and expired after a delayed transfer to another facility, approximately 18 hours post transfer.

The State Agency (SA) determined the facility's noncompliance with one or more requirements of participation had contributed to Patient 1's death and was likely to cause serious injury, serious harm, serious impairment, or death to other patients.

On 10/14/25 at 8:28 p.m., the SA provided the CMS (Centers for Medicare and Medicaid Services) Immediate Jeopardy (IJ) Template to the Chief Nursing Officer (CNO) and Chief Operating Officer (COO) and verbally informed them that IJ existed related to Medical Staff tag A-0347 [42CFR 482.22 (b)], Patient Rights tag A-0144 [42CFR 482.13(c)(2)], and Nursing Services tag A-0398 [42CFR 482.23(b)(6)] that began on 8/25/25 at 5:00 p.m.

The hospital developed and submitted an acceptable action plan that addressed the IJ situation, and the immediacy was removed onsite on 10/15/25 at 10 a.m. The hospital implemented immediate corrective actions to address the issues.

The survey team validated the facility's corrective actions, and the facility provided an acceptable IJ removal plan. The IJ was lifted onsite on 10/15/25 at 1:30 p.m. The facility remained out of compliance at A-0144, A-0347, and A-0398.

Findings:

During a review of Patient 1's "History and Physical (H&P)," dated 8/8/25, the H&P indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. During Patient 1's hospital stay, she was able to wean off dialysis and produce her own urine..

During a record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1's Nursing Progress Notes (NPN) and Vital Signs (VS), dated 8/25/25, 8/26/25 and 8/27/25 were reviewed and revealed the following:

Patient 1's VS on 8/25/25 at 12:48 p.m., indicated Patient 1's blood pressure (BP) was 123/88 (normal blood pressure reading is at or below 120/80).

Patient 1's VS indicated on 8/25/25 at 9:00 p.m., Patient 1's BP dropped to 83/58.

At 10 p.m., Patient 1's VS indicated BP was 88/49. The NPN indicated medical doctor (MD) 1 was notified at 10 p.m. of Patient 1's low BP and low urine output. MD 1 ordered to encourage fluids (orally) and if unable to drink fluids to start an intravenous (IV-fluids given directly into the bloodstream) line. The NPN indicated Patient 1 complained of difficulty swallowing.

At 11:30 p.m., Patient 1 had normal saline (NS) IV fluids started at 75 ml/hr (milliliter per hour- a measure of volume flow rate).

Patient 1's VS and NPN indicated on 8/26/25 from 12 a.m. to 5:30a.m., Patient 1's VS were as follows:

12 a.m. BP 82/47, heart rate (HR, the number of times the heart beats per minute [bpm]) was 102 (Normal heart rate is 60-100 bpm)

1 a.m. BP 84/52

2 a.m. BP 71/56

3 a.m. BP 76/40

4 a.m. BP 71/46

5 a.m. BP 76/42

5:15 a.m. BP 64/44

5:30 a.m. BP 70/40

At 5:30 a.m., a NPN revealed an on-call MD was notified of continued hypotension (low blood pressure) and low urinary output. An order for oral medication, Midodrine (causes the small arteries and veins throughout your body to tighten or constrict), 10 mg (milligram) tablet to be given one time was noted.

During a continued record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1's NPN and VS, dated 8/26/25 were reviewed, and indicated the following:

6 a.m. BP 84/40

6:27 a.m. BP 113/89, HR 92

At 7 a.m. IV intake 600 ml NS

At 8:52 a.m., the Case Manager met at the bedside with Patient 1 and Patient 1's family member and there was a discussion regarding discharge home or discharge to a skilled nursing facility (SNF). Patient 1 and Patient 1's family member agreed that Patient 1 would be discharged to a SNF on 8/27/25.

At 11:49 a.m., the VS indicated Patient 1's BP was 78/44. MD 1 was notified of Patient 1's persistent low BP, and gave a verbal order to administer a 500 ml bolus of NS rapidly through the vein. Additionally, MD 1 instructed to continue the IV NS at a rate of 75 ml/hr, conduct blood tests and cultures to check for infection, and to replace the urinary catheter (a tube inserted into the bladder to drain or collect urine).

At 12:15 p.m., Patient 1 had a urinary catheter removed and then another one attempted without urine return. The Resource Nurse (RN) and House Supervisor (HS) were informed and also attempted to place a catheter without urine return, so they consulted with MD 1.

At 1:20 p.m., MD 1 ordered another 500 ml bolus of NS for Patient 1. However, Patient 1's IV leaked, and the HS was notified.

At 2:15 p.m., the Case Manager noted that per MD 1, there was a change in condition and that discharge would likely be delayed for 2 days. Transportation was canceled and the skilled nursing facility notified.

At 2:30 p.m. progress note indicated, Patient 1's IV was non-functional, and staff attempted to establish a new IV without success. The HS and Director of Nursing (DON) were informed.

At 3 p.m., nursing attempted to place a new urinary catheter , with no urine return, and the urinary catheter was removed. It was noted that Patient 1's midline IV (a long, thin, flexible tube inserted into a vein in the upper arm to give medication, fluids, or draw blood) access, used for continuous IV fluid, was leaking and could not be used.

At 4:30 p.m. the progress note revealed further attempts to place an IV and a urinary catheter for Patient 1 were unsuccessful. An MD made an order for IV placement and nursing staff notified the contracted IV placement company. Patient 1's IV antibiotic Ceftriaxone was delayed for later that evening due to lack of IV access.

At 4:54 p.m., Patient 1 had a 22-gauge (small plastic tube) IV inserted on her left antecubital (front of the elbow) by nursing staff at the facility.

At 5 p.m., Patient 1's midline catheter "appears to be coiled" in the right upper extremity (not usable) and Patient 1's bed sheet was wet under the left upper extremity (IV site is not usable and leaking).

At 5:05 p.m., nursing noted Patient 1's midline catheter was still leaking. A new IV site was attempted, and a third urinary catheter insertion failed with no urine output. The contracted IV company was contacted for an estimated time of arrival (which was multiple hours). MD 1 was informed.

At 7:06 p.m., Patient 1's BP was 76/49, the nurse noted "Patient [1] remained hypotensive with low urine output throughout the shift. Continuous IVF [IV fluid] NS running at 75 ml/hour, and midodrine 10 mg tablet given. MD [1] is aware of blood pressure and urine output."

At 8 p.m., Patient 1 had a peripheral IV (PIV) placed in the left forearm with a 20-gauge needle, and NS started at 125 ml/hour for re-hydration. .

At 8:51 p.m., Patient 1's BP was 87/44.

At 10:19 p.m. Patient 1 was transferred to the ICU. The registered nurse (RN) documented, "Patient [1] was placed on continuous monitoring. Patient [1] appears disoriented ...Blood pressure is currently low 79/52, NS infusing at 125 ml/hour."

Review of Patient 1's ICU NPN and VS, dated 8/26/25 from 11:50 p.m. to 8/27/25 11:06 a.m. indicated, on 8/26/25 at 11:50 p.m., MD 2 was contacted, and orders were given to administer a NS 1000 ml bolus over one hour and Ceftriaxone (antibiotic, effective against many common types of bacteria that can cause sepsis) 2 grams was given.

On 8/27/25 at 12:32 a.m., Patient 1's B/P was 64/32.

At 2:18 a.m., BP 66/46 and Patient 1 became lethargic and restless.

At 4:06 a.m., BP 57/37 and Patient 1 had no urine output.

At 4 a.m., a bladder scan (an ultrasound image to see how much urine is in the bladder) was performed but no urine volume reading was generated. It was not possible to determine if urine retention was present based on the scan.

At 4:28 a.m., MD 2 notified of Patient 1's completion of the 1000 ml NS bolus. Despite this, Patient 1 continued to experience persistent hypotension with a BP of 57/37, and Patient 1 appeared pale and cool. According to the NPN, MD 2 ordered "Levophed [an emergency medicine used to raise very low blood pressure] infusion to support blood pressure. Supervisor notified."

At 5:19 a.m. Patient 1 had Levophed started at 10 mcg/kg (micrograms per kilogram- a drug dose measurement per body weight) with an increase of BP to 136/84.

At 5:20 a.m., BP was 175/110

At 5:22 a.m., BP was 158/99 and Levophed was decreased to 8 mcg/kg.

At 5:35 a.m., BP was 130/77 and Levophed was decreased to 6 mcg/kg.

At 5:46 a.m., BP was 99/65, and the HR was103.

At 5:50 a.m., BP was 83/64, HR was 110, and Levophed decreased to 2 mcg/kg.

At 6:59 a.m., BP was 135/77, and HR was 100.

At 7:08 a.m., the MD notified that Patient 1 had urinary retention (unable to urinate). Levophed was infusing at a rate of 2mcg/kg, and the leaking urinary catheter was changed.

At 7:31 a.m., Patient 1's BP was 99/61 and HR was at 108. Levophed continued infusing at 2mcg/kg. The note indicated Patient 1 "was very hypotensive still" and "hard to get BP reading due to edema [swelling]". The note continued NS not running, "per Noc (night) shift nurse told to d/c [discontinue] by noc shift MD".

At 7:50 a.m., Patient 1's HR was 143 and Levophed at 2mcg/kg continued.

At 8:05 a.m., Patient 1's VS indicated BP was 73/55.
Also, at 8:05 a.m., the NPN indicated inability to get BP due to Patient 1's edema and MD 2 aware.

At 9:02 a.m., the BP was 54/64, and HR was 104.

At 9:20 a.m., the BP was 80/65, and the HR was 99.

At 9:43 a.m., the NPN indicated, "Chunk of something came from Patient [1's] throat. Not sure what it is. Cousin would like [Patient 1] to go to a higher level hospital. Will inform MD [1]."

At 10:05 a.m. the BP was 77/61, and Levophed continued infusing at 2 mcg/kg.

At 10:16 a.m., Patient 1's BP was 75/50.

At 10:31 a.m., Patient 1's BP was 68/42, and Levophed continued infusing at 2 mcg/kg.

At 10:38 a.m., the NPN indicated MD 1 requested continuous IV fluids be restarted. Nursing alerted MD 1 about chunks of blood coming from the patient's throat. MD 1 stated this "was okay and continue to monitor". The family member wanted Patient 1 to go to a higher level of care hospital, but the note revealed, "per doctor's orders, we waited."

At 10:57 a.m., Patient 1's BP was 72/49.

At 11 a.m., the dialysis nurse was able to draw blood from Patient 1's dialysis port (a medical device, inserted into a patient, used to provide access to the bloodstream for dialysis).

At 11:06 a.m., Patient 1's BP was 70/50.

At 11:38 a.m., Patient 1 was sent to a higher-level hospital emergency room. The NPN indicated, "Levophed dc'd [discontinued], paramedics said they did not have the right equipment to keep Patient 1 on the Levophed."

Per the NPN at 11:39 a.m., the note indicated Patient 1 was hypotensive, had no [urinary output] at all, her level of consciousness had been changing from the night prior and had become increasingly confused. The note indicated staff was having difficulty getting a BP every 15 minutes and MD 1 was aware. Patient 1 received 750ml out of the 1000ml IVF ordered. The note indicated the Paramedics also had difficulty getting a BP and revealed Patient 1's extremities were cold and swollen. Patient 1 was given nausea medicine for nausea and vomiting.

During a record review of the [higher level of care hospital] document titled, "Discharge Death Summary [Death Summary]," dated 8/28/25 at 11:58 a.m., the "Death Summary" indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (low oxygen levels), and acute kidney injury on 8/27/25, and subsequently died on 8/28/25 at 6:17 a.m. The "Death Summary" indicated the cause of death as septic shock, multiorgan failure, and septic right hip joint with acute kidney injury as a contributing factor to the cause of death.

During a concurrent interview and record review on 10/14/25 at 10:25 a.m., with the CNO, Patient 1's 8/25/25 to 8/27/25 NPN and VS were reviewed. The VS indicated, from 8/25/25 at 9 p.m. until 8/26/25 at 10:19 p.m., Patient 1's blood pressure dropped, Patient 1 had no urine output, and no IV access, yet stayed on a Medical-Surgical floor (a lower level of care environment for non-critical patients with stable VS). The CNO stated such patients commonly stayed on the Medical- Surgical floor and that nurses received sepsis training during onboarding and annually.

During a concurrent interview and record review on 10/14/25 at 2:25 p.m., with MD 1 and DON, Patient 1's 8/25/25 to 8/27/25 NPN and VS were reviewed. MD 1 stated, "We don't always have ICU beds, so this type of patient is the norm[al] for the floor [Medical-Surgical nursing unit]." MD 1 indicated Patient 1 was scheduled to be discharged home, and stated, "[Patient 1] was looking fine" and was improving. MD 1 stated Patient 1 was able to be managed safely on the medical surgical unit. MD 1 stated that Patient 1 developed sepsis and the importance was to give IV fluids and antibiotics and that could be done at the facility by a medical surgical nurse. MD 1 stated the patient did not require a transfer to a higher level of care within the facility, for example to the ICU, or to another hospital and Patient 1 was doing fine when he saw her, had normal vital signs, and was scheduled to be discharged home. MD 1 stated Patient 1 had appropriate interventions and did not feel that Patient 1 went too long without intervention, escalation, or IV access because they were trying IV attempts and waiting on the "PICC nurse" (a contracted company available for inserting larger and deeper IV access).

During a continued concurrent interview and record review on 10/14/25 at 2:25 p.m., with the DON and MD 1, the DON indicated that he was assisting with Patient 1's IV placement and was unsuccessful in getting IV access and MD 1 was aware of Patient 1's status.

During a telephone interview on 10/15/25 at 9:50 a.m. with the Corporate Medical Director (CMD), he stated "Many steps were missed in the care of this patient [Patient 1] and that sepsis is a critical condition that requires early intervention."

During a phone interview on 10/16/25 at 2:35 p.m., with RN 2, RN 2 stated she was the day House Supervisor on 8/26/25 but could not recall the event. She indicated that if a patient became hypotensive, the nurse must notify the MD, transfer the patient to ICU if a bed was available, obtain MD orders for IV access, if needed, assess for sepsis protocol criteria (defines how to recognize and manage sepsis and its symptoms), and escalate to the DON and upper management if needed.

During a review of the facility's policy and procedures (P&P) titled, "Patient Rights," dated 1/24/23, the P&P indicated, "Medical Care ...To receive the care and health services that the hospital is required to provide by law ...Transfers ... To be transferred to another facility ...if the current hospital is unable to provide the level of appropriate medical care appropriate to meet your needs ..."

During a review of the facility's P&P titled, "Sepsis", dated 11/15/24, the P&P indicated, "To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality ....This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines ...Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory ...Definitions ...Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...Septic Shock: subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher mortality ...SIRS (Systemic Inflammatory Response Syndrome): Two or more of the following. Temperature >38° Celsius or <36° Celsius, HR >90 bpm [respiratory rate] RR>20/min ...SBP (systolic BP) less than 100 ...A score >2 suggests high risk of poor outcome."

Further review of the facility's P&P titled, "Sepsis", dated 11/15/24, the P&P indicated, " ... Positive screen triggers sepsis or septic shock ...Measure lactate level (a lab test which is elevated in sepsis due to lack of oxygen at the cellular level) ...Obtain blood cultures before administering antibiotics ...Administer broad spectrum antibiotics ...Begin rapid administration of 30 mL/kg of ...fluid for hypotension ...Apply vasopressors (medications to increase blood pressure)...Ongoing management within 6 hours ...Reassess hemodynamics (VS- specifically BP), urine output, and tissue perfusion...Recheck lactate if initial elevated ...De-escalate antibiotics based on culture results and infectious disease consultation ...Initiate supportive measures (oxygen, ventilator ...) ...Transfer to higher level of care (ICU) as indicated."

Based on interview and record review, the medical staff failed to adhere to Governing Body Bylaws to ensure the provision of quality medical care to one of 30 sampled patients (Patient 1) when Patient 1 showed prolonged clinical deterioration, including low blood pressure, anuria (no urine output), poor oral intake, and vomiting, and met clinical criteria for sepsis (widespread infection with life-threatening organ dysfunction caused by infection) while on a medical-surgical floor (a lower level of care environment for non-critical patients with stable vital signs). Patient 1 did not receive timely and appropriate rescue interventions or transfer to a higher level of care with symptoms of septic shock (most severe stage of sepsis with organ failure) for 18 hours prior to transferring to an Intensive Care Unit (ICU- a specialty unit for critically ill patients requiring constant monitoring and life support). The facility's inability to obtain intravenous (IV- a catheter placed in a vein to provide fluids for hydration) access in a timely manner further delayed critical treatment. Additionally, transfer to an external hospital capable of providing advanced, life-saving interventions was not initiated promptly, contributing to a delay in definitive care.

These failures resulted in Patient 1 developing septic shock with multi-organ failure, experiencing prolonged periods of dangerously low blood pressure without IV access for sepsis treatment, and a delayed transfer to both internal and external higher levels of care. These delays and omissions in care significantly contributed to Patient 1's death.

The State Survey Agency (SA) determined the facility's noncompliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to patients.

On 10/14/25 at 8:28 p.m., the SA provided the CMS (Centers for Medicare and Medicaid Services) Immediate Jeopardy (IJ) Template to the Chief Nursing Officer (CNO) and Chief Operating Officer (COO) and verbally informed them that IJ existed related to Medical Staff tag A-0347 [42CFR 482.22 (b)], Patient Rights tag A-0144 [42CFR 482.13(c)(2)], and Nursing Services tag A-0398 [42CFR 482.23(b)(6)] that began on 8/25/25 at 5:00 p.m.

The hospital developed and submitted an acceptable action plan that addressed the IJ situation, and the immediacy was removed onsite on 10/15/25 at 10 a.m. The hospital implemented immediate corrective actions to address the issues.

The survey team validated the facility's corrective actions and the facility provided an acceptable IJ removal plan. The IJ was lifted onsite on 10/15/25 at 1:30 p.m. The facility remained out of compliance at A-0144, A-0347, and A-0398.

Findings:

During a review of Patient 1's "History and Physical [H&P]," dated 8/25, the H&P indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. The H&P indicated, during Patient 1's hospital stay, she was able to wean off dialysis and make her own urine.

During a record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1's Nursing Progress Notes (NPN) and Vital Signs (VS), dated 8/25/25, 8/26/25 and 8/27/25 were reviewed and revealed the following:

Patient 1's VS on 8/25/25 at 12:48 p.m., indicated Patient 1's blood pressure (BP) was 123/88 (normal blood pressure reading is at or below 120/80).

Patient 1's VS on 8/25/25 at 9:00 p.m., indicated Patient 1's BP dropped to 83/58.

At 10 p.m., Patient 1's VS indicated BP was 88/49. The NPN indicated medical doctor (MD) 1 was notified at 10 p.m. of Patient 1's low BP and low urine output. MD 1 ordered to encourage fluids (orally) and if unable to drink fluids to start an intravenous (IV-fluids given directly into the bloodstream) line. The NPN indicated Patient 1 complained of difficulty swallowing.

At 11:30 p.m., Patient 1 had normal saline (NS) IV fluids started at 75 ml/hr (milliliter per hour- a measure of volume flow rate).

Patient 1's VS and NPN on 8/26/25 from 12 a.m. to 5:30 a.m. indicated the following:

12 a.m. BP 82/47, heart rate (HR, the number of times the heart beats per minute [bpm] ) 102 (Normal heart rate is 60-100 bpm)

1 a.m. BP 84/52

2 a.m. BP 71/56

3 a.m. BP 76/40

4 a.m. BP 71/46

5 a.m. BP 76/42

5:15 a.m. BP 64/44

5:30 a.m. BP 70/40

At 5:30 a.m., a NPN revealed an on-call MD was notified of continued hypotension (low blood pressure) and low urinary output. An order for an oral medication, Midodrine (causes the small arteries and veins throughout your body to tighten or constrict), 10 mg (milligram) tablet to be given one time was noted.

During a continued record review on 10/14/25 at 7:55 a.m., with the CNO, Patient 1's NPN and VS, dated 8/26/25 were reviewed, and indicated the following:

6 a.m. BP 84/40

6:27 a.m. BP 113/89, HR 92

At 7 a.m. the total amount of IV NS received over a seven hour period was 600 ml.

At 8:52 a.m., the Case Manager met at the bedside with Patient 1 and Patient 1's family member, and there was a discussion regarding discharge home or discharge to a skilled nursing facility (SNF). Patient 1 and Patient 1's family member agreed that Patient 1 would be discharged to a SNF on 8/27/25.

At 11:49 a.m., the VS indicated Patient 1's BP was 78/44. MD 1 was notified of Patient 1's persistent low BP, and gave a verbal order to administer a 500 ml bolus of NS rapidly through the vein. Additionally, MD 1 instructed to continue the IV NS at a rate of 75 ml/hr, conduct blood tests and cultures to check for infection, and to replace the urinary catheter (a tube inserted into the bladder to drain or collect urine).

At 12:15 p.m., Patient 1 had a urinary catheter removed and then another one attempted without urine return. The Resource Nurse (RN) and House Supervisor (HS) were informed and also attempted to place a catheter without urine return, so they consulted with MD 1.

At 1:20 p.m., MD 1 ordered another 500 ml bolus of NS for Patient 1. However, Patient 1's IV leaked (not functional), and the HS was notified.

At 2:15 p.m., the Case Manager noted that per MD 1, there was a change in condition and that discharge would likely be delayed for 2 days. Transportation was canceled and the skilled nursing facility notified.

At 2:30 p.m. the progress note indicated, Patient 1's IV was non-functional, and staff attempted to establish a new IV without success. The HS and Director of Nursing (DON) were informed.

At 3 p.m., nursing attempted to place a new urinary catheter , with no urine return, and the urinary catheter was removed. It was noted that Patient 1's midline IV (a long, thin, flexible tube inserted into a vein in the upper arm to give medication, fluids, or draw blood) access, used for continuous IV fluid, was leaking and could not be used.

At 4:30 p.m. the progress note revealed further attempts to place an IV and a urinary catheter for Patient 1 were unsuccessful. An MD made an order for IV placement and nursing staff notified the contracted IV placement company. Patient 1's IV antibiotic medication, Ceftriaxone (antibiotic, effective against many common types of bacteria that can cause sepsis), was delayed for later that evening due to lack of IV access.

At 4:54 p.m., Patient 1 had a 22-gauge (small plastic tube) IV inserted on her left antecubital (front of the elbow) by nursing staff at the facility.

At 5 p.m., Patient 1's midline catheter "appears to be coiled" in the right upper extremity (not usable) and Patient 1's bed sheet was wet under the left upper extremity (IV site is not usable and leaking).

At 5:05 p.m., nursing noted Patient 1's midline catheter was still leaking. A new IV site was attempted, and a third urinary catheter insertion failed with no urine output. The contracted IV company was contacted for an estimated time of arrival (which was multiple hours). MD 1 was informed.

At 7:06 p.m., Patient 1's BP was 76/49, the nurse noted, "Patient [1] remained hypotensive with low urine output throughout the shift. Continuous IVF [IV fluid] NS running at 75 ml/hour, and midodrine 10 mg tablet given. MD [1] is aware of blood pressure and urine output."

At 8 p.m., Patient 1 had a peripheral IV (PIV) placed in the left forearm with a 20-gauge needle, and NS started at 125 ml/hour for re-hydration.

At 8:51 p.m., Patient 1's BP was 87/44.

At 10:19 p.m. Patient 1 was transferred to the ICU. The registered nurse (RN) documented, "Patient [1] was placed on continuous monitoring. Patient [1] appears disoriented ...Blood pressure is currently low 79/52, NS infusing at 125 ml/hour."

Review of Patient 1's ICU NPN and VS, dated 8/26/25 from 11:50 p.m. to 8/27/25 11:06 a.m. indicated, on 8/26/25 at 11:50 p.m., MD 2 was contacted, and orders were given to administer a NS 1000 ml bolus over one hour and Ceftriaxone 2 grams was given.

On 8/27/25 at 12:32 a.m., Patient 1's B/P was 64/32.

At 2:18 a.m., BP 66/46 and Patient 1 became lethargic and restless.

At 4:06 a.m., BP 57/37 and Patient 1 continued to have no urine output.

At 4 a.m., a bladder scan (an ultrasound image to see how much urine is in the bladder) was performed but no urine volume reading was generated. It was not possible to determine if urine retention was present based on the scan.

At 4:28 a.m., MD 2 was notified of Patient 1's completion of the 1000 ml NS bolus. Despite this, Patient 1 continued to experience persistent hypotension with a BP of 57/37, and Patient 1 appeared pale and cool. According to the NPN, MD 2 ordered "Levophed [an emergency medicine used to raise very low blood pressure] infusion to support blood pressure. Supervisor notified."

At 5:19 a.m. Patient 1 had Levophed started at 10 mcg/kg (micrograms per kilogram- a drug dose measurement per body weight) with an increase of BP to 136/84.

At 5:20 a.m., BP was 175/110

At 5:22 a.m., BP was 158/99 and Levophed was decreased to 8 mcg/kg.

At 5:35 a.m., BP was 130/77 and Levophed was decreased to 6 mcg/kg.

At 5:46 a.m., BP was 99/65, and the HR was 103.

At 5:50 a.m., BP was 83/64, HR was 110, and Levophed decreased to 2 mcg/kg.

At 6:59 a.m., BP was 135/77, and HR was 100.

At 7:08 a.m., the MD was notified that Patient 1 had urinary retention (unable to urinate). Levophed was infusing at a rate of 2 mcg/kg, and the leaking urinary catheter was changed.

At 7:31 a.m., Patient 1's BP was 99/61 and HR was at 108. Levophed continued infusing at 2 mcg/kg. The note indicated Patient 1 "was very hypotensive still" and "hard to get BP reading due to edema [swelling]". The note continued, IV NS not running, "per Noc (night) shift nurse told to d/c [discontinue] by noc shift MD".

At 7:50 a.m., Patient 1's HR was 143 and Levophed at 2 mcg/kg continued.

At 8:05 a.m., Patient 1's VS indicated BP was 73/55.
Also, at 8:05 a.m., the NPN indicated an inability to get a BP due to Patient 1's edema and MD 2 aware.

At 9:02 a.m., the BP was 54/64, and HR was 104.

At 9:20 a.m., the BP was 80/65, and the HR was 99.

At 9:43 a.m., the NPN indicated, "Chunk of something came from Patient [1's] throat. Not sure what it is. Cousin would like [Patient 1] to go to a higher level hospital. Will inform MD [1]."

At 10:05 a.m. the BP was 77/61, and Levophed continued infusing at 2 mcg/kg.

At 10:16 a.m., Patient 1's BP was 75/50.

At 10:31 a.m., Patient 1's BP was 68/42, and Levophed continued infusing at 2 mcg/kg.

At 10:38 a.m., the NPN indicated MD 1 requested continuous IV fluids be restarted. Nursing alerted MD 1 about chunks of blood coming from the patient's throat. MD 1 stated this "was okay and continue to monitor". The family member wanted Patient 1 to go to a higher level of care hospital, but the note revealed, "per doctor's orders, we waited."

At 10:57 a.m., Patient 1's BP was 72/49.

At 11 a.m., the dialysis nurse was able to draw blood from Patient 1's dialysis port (a medical device, inserted into a patient, used to provide access to the bloodstream for dialysis).

At 11:06 a.m., Patient 1's BP was 70/50.

At 11:38 a.m., Patient 1 was sent to a higher-level hospital emergency room. The NPN indicated, "Levophed dc' d [discontinued], paramedics said they did not have the right equipment to keep Patient 1 on the Levophed."

Per the NPN at 11:39 a.m., the note indicated Patient 1 was hypotensive, had no urinary output at all, her level of consciousness had been changing from the night prior and had become increasingly confused. The note indicated staff had difficulty getting a BP every 15 minutes and MD 1 was aware. Patient 1 received 750 ml out of the 1000 ml IVF ordered. The note indicated the paramedics also had difficulty getting a BP and revealed Patient 1's extremities were cold and swollen. Patient 1 was given medicine for nausea and vomiting.

During a record review of [Name of higher level of care hospital] document titled, "Discharge Death Summary," dated 8/28/25, the "Death Summary" indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (body does not have enough oxygen, leading to low oxygen in the blood), and acute kidney injury on 8/27/25. Patient 1 died on 8/28/25 at 6:17 a.m. The "Death Summary" indicated the cause of death as "septic shock, multi-organ failure, and septic right hip joint (infected hip joint)" with acute kidney injury (a sudden decline in kidney function) as a contributing factor to the cause of death.

During a concurrent interview and record review on 10/14/25 at 2:25 p.m., with MD 1 and DON, Patient 1's 8/25/25 to 8/27/25 NPN and VS were reviewed. MD 1 stated, "We don't always have ICU beds, so this type of patient is the norm[al] for the floor [Medical-Surgical nursing unit]." MD 1 indicated Patient 1 was scheduled to be discharged home, and stated, "[Patient 1] was looking fine" and was improving. MD 1 stated Patient 1 was able to be managed safely on the medical surgical unit. MD 1 stated that Patient 1 developed sepsis and the importance was to give IV fluids and antibiotics and that could be done at the facility by a medical surgical nurse. MD 1 stated the patient did not require a transfer to a higher level of care within the facility, for example to the ICU, or to another hospital and Patient 1 was doing fine when he saw her, had normal vital signs, and was scheduled to be discharged home. MD 1 stated Patient 1 had appropriate interventions and did not feel that Patient 1 went too long without intervention, escalation, or IV access because they were attempting to get IV access and waiting on the "PICC nurse" (a contracted company available for inserting larger catheters and deeper IV access).

During a continued concurrent interview and record review on 10/14/25 at 2:25 p.m., with the DON and MD 1, the DON indicated that he was assisting with Patient 1's IV placement and was unsuccessful in getting IV access and MD 1 was aware of Patient 1's status.

During a telephone interview on 10/15/25 at 9:50 a.m. with the Corporate Medical Director (CMD), he stated, "Many steps were missed in the care of this patient [Patient 1] and that sepsis is a critical condition that requires early intervention."

During a phone interview on 10/16/25 at 2:35 p.m., with RN 2, RN 2 stated she was the day HS on 8/26/25 but could not recall the event. She indicated that if a patient became hypotensive, the nurse must notify the MD, transfer the patient to ICU if a bed was available, obtain MD orders for IV access.

During a review of the facility's document titled "Governing Body Bylaws", dated 1/22/20, the bylaws indicated, "Ensure that adequate resources and systems are allocated for maintaining safety and quality care, treatment and services, and to review and advise management and the Medical Staff on ... program selection and implementation ...Analyze findings and recommendations from the Hospital's administrative review and evaluation activities, including system or process failures and actions taken to improve safety, both proactively and in response to actual occurrences ...Perform such other duties concerning ... safety and quality of care matters as may be necessary."

During a review of the facility's document titled "Medical Staff Bylaws," dated 2023, the bylaws directed, "The Medical Staff's responsibilities are: To provide quality patient care ... Review and evaluation of the quality of patient care provided through valid and reliable care evaluation procedures ...An organizational structure and mechanism that allow on-going monitoring of patient care practices; ... A continuing education program based at least in part on needs demonstrated through the medical care evaluation program."

During a review of the facility's policy and procedures (P&P) titled, "Sepsis", dated 11/15/24, the P&P indicated, "To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality ....This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines ...Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory ...Definitions ...Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...Septic Shock: subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher mortality ...SIRS (Systemic Inflammatory Response Syndrome): Two or more of the following. Temperature >38° Celsius or <36° Celsius, HR >90 bpm [beats per minute]; RR>20/min ...SBP [systolic BP] less than 100 ...A score >2 suggests high risk of poor outcome."

Further review of the facility's P&P titled, "Sepsis", dated 11/15/24, the P&P directed, "Positive screen triggers sepsis or septic shock ...Measure lactate level ...Obtain blood cultures before administering antibiotics ...Administer broad spectrum antibiotics ...Begin rapid administration of 30 mL/kg of ...fluid for hypotension ...Apply vasopressors ...Ongoing management within 6 hours ...Reassess hemodynamics [blood pressure], urine output, and tissue perfusion ...Recheck lactate if initial elevated ...De-escalate antibiotics based on culture results and infectious disease consultation ...Initiate supportive measures (oxygen, ventilator ...) ...Transfer to higher level of care (ICU) as indicated."

Based on interviews and record review, the facility failed to ensure nursing staff followed its established policies and procedures for four out of 30 sampled patients (Patients 1, 2, 3, and 13) when nursing failed to accurately perform, assess, document, and escalate positive sepsis screenings (a tool used by the facility to identify life-threatening bloodstream infections). Furthermore, the nursing leadership failed to provide adequate nursing oversight when they were unaware nursing staff were not completing the assessment and documentation for septic screening correctly.

These failures resulted in inaccurate and incomplete sepsis screenings, which may have precluded nursing staff and medical doctors from recognizing and appropriately responding to changes in patients' conditions. This lack of timely intervention contributed to Patient 1's death and placed Patients 2, 3, and 13 at increased risk for serious harm or death.

Findings:

During a concurrent interview and record review on 10/14/25 at 8:15 a.m. with Licensed Vocational Nurse 4 (LVN 4), of a document titled, "Septic Screening Parameters", undated, was reviewed. LVN 4 stated one point is given for each screening parameter that pertains to the patient's condition during the sepsis screening. LVN 4 stated a score of 2 was considered moderate sepsis and a score of 3 was severe sepsis. The following are the "Septic Screening Parameters":

-Temperature greater than 38 degrees Celsius (a unit of temperature measurement, 36.1-37.2 is normal adult body temperature)
-Temperature less than 36 degrees Celsius
-Heart Rate (HR) greater than 90 beats per minute or significant change from baseline (normal adult HR is 60-100)
-Respiratory Rate (RR) for greater than 20 breaths per minute
-Blood pressure (BP) decrease of 20 mmHg (millimeters of mercury- a measurement of blood pressure) from baseline without medication changes
- Hypotension (low BP) less than 100 systolic (the pressure in the arteries when the heart pumps blood)
-Progressive edema (swelling)
-Altered level of consciousness (drowsy or difficult to arouse)
-Low White Blood Cell count less than 4,000 (cells per microliter)
-High White Blood Cell count higher than 12,000 (cells per microliter)
-Positive blood cultures (a laboratory test that detects the presence of bacteria in the
bloodstream)
-NO SYMPTOMS AT THIS TIME (No points assigned if no symptoms).

a. During a review of Patient 1's "History and Physical [(H&P])," dated 8/8/25, the "H&P" indicated Patient 1 was admitted to the medical surgical unit and had a history of an infected right hip with multiple previous surgical revisions, recurrent dislocations following a total hip arthroplasty (a surgery where a damaged hip joint is replaced with an artificial one to relieve pain and improve movement), diabetes mellitus (high blood sugar), obesity, and past stroke. According to the H&P, Patient 1 had a diagnosis of end stage renal disease (kidneys with severely impaired function), which required temporary dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one month prior to admission. During Patient 1's hospital stay, she was able to wean off dialysis and produce her own urine.

During a review of the document titled "Patient Progress Notes [note]" dated 8/23/25 at 7 a.m., the note indicated Patient 1's BP was 94/54, and HR was 112. According to the facility's sepsis screening parameters, this would result in a sepsis score of two but was documented as having a "negative" septic screen with "no symptoms at this time". Additionally, there was no evidence that MD was notified of abnormal vital signs or potential sepsis indicators.

During a review of the document titled "Patient Progress Notes," dated 8/24/25 at 9:30 a.m. the note indicated Patient 1 did not have any vital signs documented by nursing staff at or around 9:30 a.m.

The respiratory therapist documented an incomplete set of vital signs that did not include blood pressure or temperature, so would not be able to use for a sepsis screening, but Patient 1's nursing note indicated a negative septic screen with "no symptoms at this time".

During a review of the document titled, "Patient Progress Notes", dated 8/24/25 at 7:15 p.m., the note indicated Patient 1's HR was 103 and BP was 92/48. This was indicative of a sepsis score of 2.

During a review of the document titled, "Patient Progress Notes," dated 8/24/25 at 8:30 p.m., the note indicated a negative septic screen, and there were "no symptoms at this time", and there was no evidence an MD was notified of abnormal vital signs or potential sepsis indicators.

During a review of the document titled, "Patient Progress Notes," dated 8/25/25 at 11:30 a.m., Patient 1's note indicated there was a negative sepsis screen, there were "no symptoms at this time", and no vital signs taken on or around 11:30 a.m. The most recent full set of vital signs taken had been taken 4 hours prior to the septic screen.

During a review of Patient 1's document titled, "Patient Progress Notes," dated 8/25/25 from 8 p.m. through 11:30 p.m., the note indicated there was no septic screen performed for the night shift nurse assessment at 8 p.m., however an on-call (after-hours) MD was notified at 10 p.m. that Patient 1 had low blood pressure and low urine output. The MD responded to encourage oral intake first and then start continuous intravenous (IV- fluid delivered into the vein) if unable to tolerate oral intake. At 11 p.m. oral fluids were offered to Patient 1, who complained of difficulty swallowing, and nurse documented that oral fluids would continue to be offered and encouraged. Per the nurse's note, continuous IV fluids were started at 75 ml/hr (milliliters per hour- a unit of measure) at 11:30 p.m. per an MD order.

During a review of the document titled, "Patient Progress Notes," dated 8/26/25 from 12 a.m. until 8 a.m., Patient 1's notes indicated BP was recorded 9 times between midnight and 6 a.m., with all systolic blood pressures ranging from 64 to 84 mmHg. At 6:27 a.m., an incomplete set of vital signs was documented, missing Patient 1's temperature. Additionally, no vital signs were recorded at or around 7:30 a.m., when a septic screen was documented as negative with "no symptoms" despite the absence of supporting vital sign data.

During a continued review of the document titled, "Patient Progress Notes," dated 8/26/25 at 11:45 a.m., Patient 1's note indicated that a nurse reported Patient 1's low blood pressure to MD 1 and there was no evidence that a septic screening was completed at that time, despite the presence of abnormal vital signs.

During a review of the document titled, "Patient Progress Notes," dated 8/26/25 between 10:19 p.m. and 10:50 p.m., the notes indicated Patient 1 was transferred to ICU for closer monitoring and management, was placed on continuous telemetry (heart monitoring), placed on BiPAP (a bilevel positive airway pressure machine to assist with breathing). The note also indicated that Patient 1 became disoriented, had a BP of 79/52, and was receiving IV fluids at a rate of 125 ml/hr. At 10:31 p.m., the note indicated that an incomplete set of vital signs was recorded for Patient 1, including a HR of 98, BP of 79/52 with no temperature documented. At 10:50 p.m., a partial sepsis screening was completed for Patient 1, which reflected positive screening parameter findings for low blood pressure and elevated WBC count which would indicate a score of 2. However, no sepsis score was documented. Additionally, Patient 1's HR above 90 was not included in the screening and would have increased the score to a 3 (severe sepsis).


During a review of the document titled, "Patient Progress Notes," dated 8/26/25 at 10:51 p.m., the note indicated a temperature was not documented, HR was 102, and BP was 87/44. The sepsis screening parameters showed hypotension, and an elevated WBC were acknowledged, but a sepsis score was not documented to complete the septic screening. Additionally, Patient 1's HR above 90 was not included in the screening parameters which would have increased the sepsis score toof a 3 with the available vital signs and labs. available.

During a review of the document titled, "Patient Progress Notes," dated 8/26/25 from 8:52 a.m. through 4:18 p.m., Patient 1's notes indicated that at 8:52 a.m., the Case Manager met with Patient 1 and Patient 1's family member to discuss discharge planning and that a decision was made for discharge to a skilled nursing facility (SNF). At 2:15 p.m., the Case Manager noted there was a change in Patient 1's condition and the planned discharge on 8/27/25 was cancelled. At 4:15 p.m., the Case Manager further noted that discharge was held due to change in condition due to "possible sepsis" and discharge was tentatively rescheduled for two days later.

During a review of the document titled, "Patient Progress Notes," dated 8/27/25 between 7:50 a.m. and 11:38 a.m., Patient 1's notes indicated at 8 a.m., the septic screening parameters selected included: "No symptoms at this time", hypotension, HR greater than 90, and high WBC greater than 12,000" with a sepsis score of "3 or more", consistent with severe sepsis. Patient 1's vital signs taken at 8 a.m. showed a BP of 73/55, no documented HR; a previously documented HR at 7:50 a.m. was 143. No symptoms at this time were documented despite having a sepsis score of 3 or more, indicating severe sepsis. At 8:05 a.m., an MD was notified of inability to obtain a BP. At 8:10 a.m., nursing documented that Patient 1's BP could not be read from 7:31 a.m. until 9:02 a.m. despite trying multiple different extremities. At 9:43 a.m., Patient 1's family requested Patient 1 be transferred to a higher level of care hospital. Patient 1 was transferred to a higher level of care hospital at 11:38 a.m. where she passed away less than a day later.

During a record review of [Name of higher level of care Hospital] document titled, "Discharge Death Summary," dated 8/28/25, the "Death Summary" indicated that Patient 1 was admitted with hypovolemic shock (an emergency condition in which severe fluid loss makes the heart unable to pump enough blood to the body and organs), septic shock, acute hypoxemic respiratory failure (body does not have enough oxygen, leading to low oxygen in the blood), and acute kidney injury on 8/27/25. Patient 1 died on 8/28/25 at 6:17 a.m. The "Death Summary" indicated the cause of death as "septic shock, multiorgan failure, and septic right hip joint (infected hip joint)" with acute kidney injury (a sudden decline in kidney function) as contributing factor to the cause of death.



b. During a review of Patient 2's H&P, dated 10/9/25, the H&P indicated that Patient 2 had a history of hypertension (high blood pressure), encephalopathy (a condition that affects brain function due to lack of oxygen) related to respiratory failure (breathing problems), heart failure (a weak heart), and encephalomalacia (serious brain injury involving loss of brain tissue) from a prior stroke (brain injury caused from lack of blood flow to brain).

During a review of Patient 2's "Review-Septic Screening Parameters, [sepsis screen]" dated 10/9/25 at 8:45 p.m., the sepsis screen indicated that the RR was greater than 20 and the patient had hypotension, indicating a score of 2.

During a review of the document titled "Vital Signs Review [vital signs]," dated 10/9/25 at 8:45 p.m., the vital signs indicated that Patient 2's RR was 28, BP was 82/57, and HR as 145. Per the sepsis screening parameters, sepsis score should have been a 3 and was documented as a 2.

During a review of Patient 2's "Vital Signs Review," dated 10/10/25 at 7:55 a.m., the vital signs indicated that a temperature was not taken.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/10/25 at 8 a.m., the sepsis screen indicated that HR was greater than 90 and RR was greater than 20 and that the septic screening score was a 2.
During a review of Patient 2's "Vital Signs Review," dated 10/10/25 at 7:55 a.m., the vital signs indicated that no temperature was taken.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/11/25 at 8 a.m., the sepsis screen indicated that the HR was greater than 90 and had a septic screen of 1 symptom. Without a temperature taken, the sepsis screen was incomplete with the possibility of being inaccurate.

During a review of "Vital Signs Review," dated 10/11/25 at 8:00 a.m., the vital signs indicated that Patient 2's RR was 31, HR was 130, and there was no temperature documented. This indicated a sepsis score should have been a 2, and not a 1, per the sepsis screening parameters with available vital signs documented.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/11/25 at 8:45 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen was documented as "negative".

During a review of the "Vital Signs Review," dated 10/11/25 at 8:45 p.m., the vital signs indicated that Patient 2's RR was 32, HR was 136, and there was no documented temperature. This indicated that the sepsis score should have been a 2, and not a negative sepsis score, per the sepsis screening parameters with available vital signs documented.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/12/25 at 8:30 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen as a score of 2 with the available vital signs documented.

During a review of Patient 2's "Vital Signs Review," dated 10/12/25 at 8:30 p.m., the vital signs indicated that Patient 2 did not have a temperature documented.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/12/25 at 10:30 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and septic screen as a score of 2 with the available vital signs documented.

During a review of Patient 2's "Vital Signs Review," dated 10/12/25 at 10 p.m., the vital signs indicated that Patient 2 did not have a temperature documented.

During a review of Patient 2's "Patient Progress Notes," dated 10/13/25 at 7:45 a.m., the notes indicated, "Septic screening parameters: NO SYMPTOMS AT THIS TIME. Septic Screen: Negative."

During a review of "Vital Signs Review," dated 10/13/25 at 7:45 a.m., the vital signs indicated that the HR for Patient 2 was 131and respiratory rate was 31. Despite two positive septic screen indicators, a negative screen was documented instead of a score of 2.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/13/25 at 3:51 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and hypotension with a sepsis score of 3 with the available vital signs documented.

During a review of Patient 2's "Vital Signs Review," dated 10/13/25 at 3:50 p.m., the vital signs indicated that Patient 2 did not have a temperature documented.

During a review of Patient 2's "Review-Septic Screening Parameters," dated 10/14/25 at 8 p.m., the sepsis screen indicated that the HR was greater than 90, RR greater than 20, and a sepsis score was not documented despite having two positive sepsis screen indictors with available vital signs.

During a review of Patient 2's "Vital Signs Review," dated 10/14/25 at 8 p.m., the vital signs indicated that Patient 2 did not have a temperature documented, RR of 32, HR of 136, and BP of 88/37 which would indicate a sepsis score of 3.

C. During a review of Patient 3's "H&P," dated 8/19/25, the H&P indicated that Patient 3 was admitted with a history of diabetes type 2 (high sugar levels in blood) and had a motor vehicle accident with multiple bone fractures, subdural and subarachnoid hemorrhages (brain bleeds), hemorrhagic shock (illness from losing a lot of blood) from splenic laceration, respiratory failure with tracheostomy (breathing tube), bladder rupture with foley (tube from bladder to outside of body to help urine leave body) placement.

During a review of Patient 3's "Review-Septic Screening Parameters," dated 10/11/25 at 8 a.m., the sepsis screen indicated that there were no sepsis symptoms.

During a review of Patient 3's "Vital Signs Review," dated 10/11/25 at 8 a.m., the vital signs indicated that Patient 3 did not have a temperature documented, RR of 31, and HR of 130 which would indicate a sepsis score of 2 instead of "no sepsis symptoms" with available vital signs documented.

During a review of Patient 3's "Review-Septic Screening Parameters," dated 10/11/25 at 8:45 p.m., the sepsis screen indicated that there were no sepsis symptoms.

During a review of Patient 3's "Vital Signs Review," dated 10/11/25 at 8:40 p.m., the vital signs indicated that Patient 3 did not have a temperature documented, RR of 32, and HR of 130 which would indicate a sepsis score of 2 instead of 0 with available vital signs documented.

During a review of Patient 3's "Review-Septic Screening Parameters," dated 10/13/25 at 7:45 a.m., the sepsis screen indicated that there were no sepsis symptoms.

During a review of Patient 3's "Vital Signs Review," dated 10/13/25 around 7:45 a.m., the vital signs indicated that no vital signs were documented at the time of Patient 3's sepsis screening. The most recent vital signs documented prior to the sepsis screening were taken at 6:30 a.m. and included a RR of 33, and HR of 99, with no temperature recorded. Based on available data, these findings would indicate a sepsis score of 2; however, the screening was documented as having no symptoms.

D. During a review of Patient 13's "H&P" dated 6/15/25, the H&P indicated that Patient 13 was admitted with End Stage Renal Disease (ESRD, chronic kidney failure that prevents toxins from leaving body) requiring hemodialysis (a procedure that filters toxins from the blood), left below the knee amputation, right toe amputations, respiratory failure (breathing problems), fluid overload, anemia (low blood oxygen levels), and sepsis.

During a review of Patient 13's "Review-Septic Screening Parameters," dated 6/22/25 at 9:32 p.m., the sepsis screen indicated that there were no sepsis symptoms.

During a review of Patient 13's "Vital Signs Review," dated 6/22/25 around 9:32 p.m., the vital signs indicated that Patient 13 did not have any vital signs taken. The most recent vital signs taken prior to sepsis screen were taken at 6:15 p.m. with a RR of 24, and HR of 93, which would indicate a sepsis score of 2 instead of 0.

During an interview on 10/16/25 at 9:36 a.m. with Registered Nurse 9 (RN 9), RN 9 stated that a full sepsis screening included temperature, BP- assessing for hypotension, RR, HR, level of consciousness, labs, and blood cultures. RN 9 stated that without a recorded temperature, the sepsis screen was not considered complete or accurate because it was important to have a full clinical picture, including all vital signs, for the doctor to accurately assess for sepsis. RN 9 stated that the sepsis screen needed to be documented in the flowsheet.

During an interview on 10/16/25 at 3:25 p.m. with the Chief Nursing Officer (CNO), the CNO indicated that a positive sepsis screen was two or more and a provider should be notified. The CNO stated that if sepsis screen was not done accurately or fully completed, the provider may not get notified when needed. The CNO stated that a sepsis screen included a full set of vital signs that included temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. The CNO acknowledged there were incomplete and inaccurate sepsis screenings for Patient 1, 2, 3, and 13. The CNO confirmed nursing leadership was unaware of the identified gaps with the sepsis screenings.

During a review of the facility's policy and procedure (P&P) titled,. "Sepsis," dated 11/15/24, the P&P indicated, "I. Purpose [:] To ensure the early identification and evidence-based management of patients with suspected or confirmed sepsis in order to reduce morbidity, mortality, and length of stay in the Long-Term Acute Care Hospital (LTACH) setting. This protocol establishes standardized processes for screening, escalation, and treatment consistent with current clinical guidelines. II. Policy Statement [:] All [Facility Name] staff shall follow this protocol for patients presenting with or developing signs of infection or systemic inflammatory response. Early detection, rapid communication, and prompt initiation of evidence-based interventions are mandatory. III. Definitions [:] Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection ...A score equal to or greater than 2 suggests high risk of poor outcome. 1. All patients shall be screened using the Sepsis Screening Tool: On admission. Every shift (once per 12 hours minimum). With any change in condition (fever, hypotension, tachypnea [faster than normal breathing], altered mentation [change in a person's brain function that affects thoughts, awareness, and behavior], elevated lactate [a molecule produced in the body when there is a high demand for energy and not enough oxygen]) 2. Positive screen triggers Sepsis Alert and provider notification."

During a review of the facility's P&P titled, "CHANGE IN PATIENT CONDITION Early Recognition and Intervention," dated 11/14/24, the P&P indicated, " ...SIGNIFICANT CHANGE IN CONDITION DESCRIBED: 1. The following could describe a significant change in condition ...Any single finding ...requires Assessment, Documentation, and Notification ...A positive sepsis screen. ASSESSMENT AND BASIC RECOMMENDATIONS: 1 ...It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs in a timely fashion, and to gather other relevant data. 2. Data should be obtained includes but is not limited to: A complete set of vital signs including accurate temp[erature]-rectal or tympanic membrane [a measure of temperature using an tool placed in the ear] ...NOTIFICATION: (use SBAR [A communication tool with a situation, background, assessment, and recommendation format] format to communicate all critical information) ...DOCUMENTATION: 1. The complete assessment should appear on the nursing flowsheet. The SBAR form will be used to document communication about the patient to the MD and will be placed in the progress notes section of the medical record ..."

During a review of the facility document titled, "Job Description: Position Title; Licensed Vocational Nurse," undated, the document indicated, "Job Summary: ...In collaboration with the physician, the LVN assures implementation of the assessment plan, evaluation, and follows up of the plan of care for the patient population ...RESPONSIBILITIES TO THE PATIENT [:] B ...2. Assess safety ...levels for patients ...E. Provides for ...safety in accordance with hospital and nursing policies and procedures ...G. Assures that documents in the medical record are complete, factual, accurate and timely...H. Provides nursing care to meet patient needs. 1. Performs a complete ...assessment of each assigned patient per shift using proper documentation tools. 2. Acts promptly on changes in patient condition, utilizing SBAR method ..."

Based on interview and record review, the facility failed to ensure medications were administered in accordance with orders for 3 of 30 sampled patients (Patients 2, 8, and 13) when:

a. Nursing staff failed to administer the correct dose of oxycodone (an opioid medication used to treat severe pain) according to the physician order to Patient 8 on four occasions over a period of 18 days;

b. Nursing staff failed to administer clonazepam (a medication used to treat seizures) to Patient 2 within parameters ordered and clinically indicated to be administered, and they also failed to notify the physician about holding the medication outside of prescribed parameters; and

c. Nursing staff failed to administer diltiazem (medication used to treat high blood pressure) to Patient 13 as ordered and clinically indicated, and also failed to notify the physician about holding the medication outside of prescribed parameters.

These failures placed Patients 2, 8 and 13 at potential risk of experiencing adverse side effects and/ or worsening symptoms, health conditions, development of new complications, and even death.

Findings:

a. During a review of Patient 8's "History and Physical [H&P]", dated 8/14/25, the "H&P" indicated Patient 8 was admitted with diagnoses that included right hip septic arthritis (bacterial inflammation of the hip joint), acute respiratory failure (occurs when inadequate oxygen passes from the lungs to the blood) and profound physical deconditioning (generalized decline in physical fitness due to a prolonged period of inactivity).

During a review of Patient 8's "Order Details [Orders]," dated 8/14/25, the "Orders" indicated oxycodone IR (immediate release) 5 mg (milligram- a unit of measure), two tablets to equal total dose of 10 mg for severe pain (7-10- a numerical pain scale of 1-10 with 10 indicating the worst pain) and oxycodone HCL IR 5 mg, one tablet to equal total dose of 5 mg for moderate pain (4-6).

During a concurrent interview and record review on 10/16/25 at 2:25 p.m. with the Chief Nursing Officer (CNO), Patient 8's nursing "Progress Notes," dated 8/16/25 to 9/3/25 were reviewed, alongside Patient 8's "Order Details," dated 8/14/25. The "Progress Notes" indicated Patient 8 received four doses of 10 mg of oxycodone for pain levels that were less than severe:

1. On 8/16/25 at 4:31 p.m., Reason: moderate pain (4-6),
2. On 8/23/25 at 10:04 a.m., Reason: mild pain (1-3),
3. On 8/23/25 at 7:27 p.m., Reason: mild pain (1-3), and
4. On 8/24/25 at 5:13 a.m., Reason: mild pain (1-3).

The CNO stated the 10 mg of oxycodone was not given according to the physician's order. The CNO stated it was her expectation for the nurses to give medications according to the doctor's orders. The CNO stated if higher doses of opioids were given to a patient than what was ordered by the physician, there was potential for patient harm that could occur such as respiratory depression (too slow and shallow breathing that could result in inadequate oxygen levels) and increased sedation (reduced alertness).

b. During a review of Patient 2's "H&P", dated 10/9/25, the "H&P" indicated Patient 2 had a history of high blood pressure, encephalopathy (a condition that affects brain function due to lack of oxygen) related to respiratory failure, heart failure, and encephalomalacia (serious brain injury involving loss of brain tissue) from a prior stroke (brain injury).

During a review of Patient 2's "Order Chronology [Orders]," dated 10/10/25 at 12:12 p.m., the "Orders" indicated clonazepam 0.5 mg tablet was to be given every 12 hours by mouth.

A document titled, "Vital Signs Review," dated 10/14/25 at 3:30 a.m., indicated the systolic blood pressure (the top number in a blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood) of Patient 2 was 140 mmHg (millimeters of mercury, a unit of measure).

During a review of the "MAR [Medication Administration Record]," dated 10/14/25 at 4:07 a.m., the "MAR" indicated clonazepam 0.5 mg was not given due to blood pressure. Instructions indicated to hold clonazepam for systolic blood pressure of less than 100 [mmHg].

During a review of Patient 2's electronic medical record (EMR), for the date 10/14/25, the EMR revealed no documented evidence the medical doctor was informed of clonazepam being held outside of ordered parameters.

During a continued review of the "Vital Signs Review," dated 10/14/25 at 11:00 p.m., it indicated the systolic blood pressure for Patient 2 was documented as 122 mmHg.

During a review of the "MAR," dated 10/14/25 at 11:18 p.m., the "MAR" indicated that clonazepam 0.5 mg was not given and to hold for systolic blood pressure of less than 100 [mmHg].

During a review of Patient 2's nursing "Patient Progress Notes," dated 10/14/25 at 12:12 a.m., the notes indicated scheduled clonazepam was not given due to nursing judgement for blood pressure. There was no evidence of notification made to the medical doctor that the medication was held outside of ordered parameters.

c. During a review of Patient 13's "H&P," dated 8/13/25, the "H&P" indicated Patient 13 had a fall at home with a traumatic brain injury, intracranial hemorrhage (brain bleed), and right skull fracture with increasing brain swelling, and confusion.

During a review of Patient 13's, "Ordered Medication", dated 8/13/25, the "Ordered Medication" indicated diltiazem HCL 60 mg IR tablet (Two 30 mg IR tablets to equal a total dose of 60 mg) was ordered to be administered four times per day and to hold if systolic blood pressure less than 100 or if heart rate less than 60 beats per minute (BPM).

During a review of Patient 13's "MAR," dated 10/13/25 at 2 p.m., it indicated diltiazem HCL 60 mg was held at 2 p.m. and there was no documented rationale indicating why the medication was held. Additionally, Hydralazine (a blood pressure lowering medication) was documented as given for a systolic blood pressure of 115 and a heart rate of 96 at 2:24 p.m. indicating that at the time, vital signs were within parameters to give diltiazem as well.

During a review of Patient 13's nursing "Progress Notes," dated 10/13/25, the notes revealed there was no entry around 2 p.m. explaining why diltiazem was held or that the doctor was notified of holding diltiazem outside of ordered parameters.

During an interview with Licensed Vocational Nurse 3 (LVN 3) on 10/13/25 at 4:25 p.m., LVN 3 confirmed that medications were held outside of ordered parameters, that blood pressures were within limits to give the medication, and that the doctor should have been notified of the medication that was held outside of ordered parameters.

During an interview on 10/14/25 at 10:20 a.m. with LVN 4, LVN 4 stated that nurses should notify the doctor if they hold a medication outside of ordered parameters as doctor may want to change dose or medications and should know if medications are not being given as ordered and why. LVN 4 stated that nurses should document why a medication is held in the MAR or nurse's note.


During an interview on 10/16/25 at 1:53 p.m. with the CNO, the CNO stated that the doctor needs to be notified of medications held outside of ordered parameters, nurses need to document the reason they held medications, and recent vital signs documented when parameters indicate needing them. The CNO stated that a patient can be harmed by not administering medications when indicated.

During a review of the facility policy titled, "Medication Administration Policy", dated 2/13/25, the policy indicated, "Registered Nurses, Licensed Vocational Nurses (LVN) ... shall be responsible for the safe and accurate administration and documentation of medications, as is consistent with their scope of practice, professional practice standards and in accordance with applicable laws and regulations ... To ensure patient safety, and decrease the potential for errors, the following procedure shall be followed for each Medication Pass:... Administer medication following the '6 Rights of Medication Administration': Right patient, Right drug, Right dose, Right route, Right time, Right documentation ..."

During a review of the facility document titled, "Job Description: ... Licensed Vocational Nurse," undated, the document indicated, "RESPONSIBILITIES TO THE PATIENT[:] D. Assures that medication is correct and according to the established nursing policies and procedures ...3. Administers medications as ordered ...G. Assures that documents in the medical record are complete, factual, accurate, and timely ...2. Acts promptly on changes in patient condition, utilizing SBAR [a communication framework to notify doctor of concerns] method."