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Based on observation, interview and record review the facility failed to ensure the policy and procedure (P&P) for providing care in a safe setting was maintained and implemented when:

1. Emergency Department (ED- a unit in the hospital where the patients come for immediate care) call signal system was not functioning and readily available for patient care area for 43 of 43 licensed beds.

2. Environmental service (a department meant for cleaning and sanitation to ensure safe and hygienic environment) was unable to provide cleaning log for ED rooms from October 12, 2025 till October 15, 2025.

3. Patient 24's room was visibly soiled and found with used /soiled chuck and syringe on the countertop.

These failures had the potential to compromise patient safety by leaving them unable to signal for help in case of medical emergency, unwanted exposure to infections which will increase the risk for infection, prolonged hospitalizations and have negative impact on the health and wellbeing of patients.

Findings:

1a. During a concurrent observation and interview on November 17, 2025, at 9:50 AM, in ED, with Patient 26, Patient 26 was lying in her bed connected to intravenous fluids (IV - liquid infused to a patient's body through vein), Patient 26 stated, she came to the facility on November 16, 2025, at 7:45 PM, and there was no call signal system. Patient 26 further stated, if she needs help, she will get out of bed and call loud for nurses.

During a review of Patient 26's "Admission Record" (demographic record), the "Admission record" indicated patient 26 was admitted to the facility on November 16, 2025, at 7:45 PM, with the diagnosis of Gastrointestinal problems.

b. During a concurrent observation and interview on November 17, 2025, at 10:00 AM, in ED, with patient 27, Patient 27 was lying in his bed with no call signal system at bedside. Patient 27 stated, he does not have a call light or a bell to call the staff since he came to the ED room on November 16, 2025. Patient 27 further stated, he was concerned about falling when he did not have a call light.

During a review of Patient 27's "Admission Record", the "Admission Record" indicated, Patient 27 was admitted to the facility on November 16, 2025, at 9:31 AM, with the chief complaint of blood in urine.

c. During a concurrent observation and interview on November 17,2025, at 10:05 AM, in ED, with patient 28, Patient 28 was lying in his bed with no call signal system at bedside. Patient 28 stated, he came to the ED since November 16, 2025 and had no call light. Patient 28 further stated, he usually calls the staff loudly so they could come and help.

During a review of the facility's document titled "admission record", the "admission Record" indicated, Patient 28 was admitted to the facility on November 16,2025, at 8:48 AM with the complaints of shortness of breath.

d. During a concurrent observation and interview on November 17, 2025, at 10:30 AM, in ED, with patient 29, Patient 29 was lying in her bed, able to answer questions and family was at bedside, with no call signal system at bedside. Patient 29 stated, she came to the ED on November 16, 2025, because of her high blood glucose level. Patient 28 further stated, nobody gave her a call light or a bell to call the staff. Patient 28 further stated, she usually calls out loud for help or assistance.

During a review of the Patient 29's "admission record", the "admission Record" indicated, Patient 29 was admitted to the facility on November 16, 2025, at 7:51 AM, with the complaints of altered mental status brought in by ambulance.

During a review of Patient 29's "history and physical", dated November 16, 2025, at 11:32 AM, the "history and physical" indicated, Patient 29 had the past medical history of type 2 diabetes mellitus( a condition in which the blood sugar is high) on insulin( a medication used to treat high blood sugar) and hypertension (a condition in which patient has high blood) presenting due to altered mental status starting this morning. Glasgow Coma Scale (GCS - a tool used to evaluate the level of consciousness on scale of 3-8 as severe ,9-12 as moderate and 13-15 as mild ,3 - considered as deep coma and 15 fully alert) on arrival was 11.

During a concurrent observation and interview on November 17, 2025, at 9:55 AM, with ED Assistant Manager (ED AM), in ED, the ED AM stated, that the call signal system was not functional for more than two to three years and small portable bell was an alternative for call lights. The ED AM further stated that it was the primary nurse's responsibility to provide a bell to each patient and ensure that the bell is easily available to reach. The ED AM acknowledged that patients 26, 27,28 and 29 did not have a bell or a call light within reach.

During an interview on November 19, 2025,at 8:44 AM, with Registered Nurse 5 (RN5),RN5 stated, the call signal system was not working for years and the primary RN should be responsible in giving a bell for the patients.RN5 further stated, it is important to give call bell so that patient can reach out to the nurses in case of emergency.

During an interview on November 19,2025, at 9:41 AM, with ED Director (ED D), the ED D stated that the call signal system was not functioning for more than four years. The ED D further stated it was expected to give bells for all patients who are in an ED room to call the nurses. The ED D verified that all 43 rooms in ED does not have a call signal system.

During a concurrent interview and record review on November 19, 2025, at 10:00 AM, with the ED D, the facility's policy and procedures (P&P) titled, "system failure", dated July 11, 2025, was reviewed. The P&P indicated, " .... ix. Failure of: Nurse call system .... C. Responsibilities of nursing, bedside clinician and users, Bells supplies by engineering services until repairs are complete. The ED D stated, the policy was not followed.

During a concurrent interview and record review on November 19, 2025, at 10:05 AM, with the ED D, the facility's policy and procedures (P&P) titled "Patient Rights", dated April 26, 2023, was reviewed. The P&P indicated, " .... Procedure: ...C ...6. Receive care in a safe setting." The ED D stated, we did not follow the policy. The ED D acknowledged that the policy was not followed as there was no bell easily available for patients in ED.

During a concurrent interview and record review on November 19, 2025, at 5:00 PM, with Assistant Chief Nursing Officer ED (ACNO ED), the facility's document titled " Job description for ED Registered Nurse" (JD), dated September ,2025, was reviewed. The document indicated, " ...Position duties and Responsibilities Duties may include, but are not limited to, the following: ... ...5. practice safety measures in all activities associated with patient care". The ACNO ED stated, the nurse should have given the bell to each patient when they come into the ED rooms.

During a concurrent interview and record review on November 19, 2025, at 5:15 PM, with ACNO ED, the facility's P&P titled "Fall Program", dated November 7,2022, was reviewed. The P&P indicated, " .... Procedures.. iii. Implement standard fall prevention interventions for patients scoring 0-44. A. Safe environment (I. e. Bed in low position, call light within reach ..." The ACNO ED stated, that it is right that the call light should be within reach. The ACNO ED further stated, we will take this as an opportunity to improve call lights.

2. During an interview on November 19, 2025, at 9:15 AM, with the Manager of Environmental Services (EVSM- a person who is responsible for cleaning and environmental protection), the EVSM stated, the ED cleaning log was not fully electronic as they are transitioning the paper documents and the ED has 43 beds and waiting areas. The EVSM further stated, the supervisors have the documentation for the cleaning.

During a review of the facility's document titled "EVS staff assignment" for October 12, 2025 till October 15,2025, the "EVS staff assignment" indicated only staff's name assigned to ED unit. Document did not have information indicating whether each room was soiled or cleaned as per the assignment.

During a review of the facility's document titled "Environmental services Supervisor's checklist", dated October 12,2025 through October 18,2025, the "Environmental services Supervisor's checklist" indicated, that the supervisor has the generalized daily checklist which included about the staff call off, daily environmental concerns in each areas. The document did not indicate a specific section for the supervisor or the staff would check each room for cleanliness.

During an interview on November 20, 2025, at 9:05 AM, with EVSM, the EVSM stated, there was no cleaning log for the ED rooms. The EVSM further stated, the only document the facility had was the supervisor check list which includes daily rounding.

During a concurrent Interview and record review on November20, 2025, at 9:15 AM, with EVSM, the facility's document titled "position description Hospital Environmental services Supervisor -Environmental Service (EVS)", dated April ,2022, was reviewed. The "position description Hospital Environmental services Supervisor -Environmental Service (EVS)" indicated, " .... Position duties and responsibilities 1. Supervise the day-to-day activities of the environmental services department.2. Evaluate environmental services being performed by department staff, maintain, and monitor cleanliness, safety, and quality of work, ensure proper staffing at all times.3. Plan, assign, review and evaluate the work of supervising custodians and other support staff, council staff regarding performance, conduct, attendance, and other related matters, handle or participate in disciplinary or hiring actions". The EVSM stated, there was no other document specifically to indicate each ED room cleanliness other than the supervisor's checklist to indicate the cleanliness of the rooms.

During a concurrent interview and record review on November 20, 2025, at 9:20 AM, with EVSM, the facility's policy and procedure (P&P) titled "Patient Rights", dated April 26, 2023 was reviewed. The P&P indicated, " ....6. Receive care in a safe setting". The EVSM stated, that the policy was not followed. The EVSM further stated, that there should be an EVS cleaning log for ED.


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3. During a review of Patient 24's "Demographics" (a summary document in a medical record that provides a quick overview of a patient's key information), indicated, Patient 24 was admitted to the facility on November 10, 2025.

During a review of Patient's 24's "History and Physical" (H&P), dated November 10, 2025, the H&P indicated, the Chief complaint, was "Motor Vehicle Crash" ...

During a concurrent observation and interview on November 17, 2025, at 10:28 AM, in Patient 24's room, with the Unit Manager, the floor was noted with used alcohol pad, used white paper, wrinkled clear plastic, clear plastic tip, countertop with multi stained colors, a visibly soiled chuck with brown stuff on the countertop, and the soap dispenser was backing with old brown stained. The family member in the room stated that "I think this is from last night." The Unit Manager stated she was unsure whether the room was cleaned. Unit manager further stated her expectation of the rooms to be kept cleaned.

During an interview and concurrent record review on November 19, 2025, at 9:45 AM, with the Administrator of Operation (AO) and Manager of Environmental and linens services (EVSM), the facility's policy and procedures (P&P), titled "Cleaning Patient Room-Occupied", dated March 30, 1999, was reviewed. The P&P indicated, "All patient rooms will be cleaned daily." EVSM stated his expectation was the room to be cleaned every day. EVSM stated that all areas of assignment would be auto populated at 7:00AM to the assigned staff. The EVSM stated first thing in the morning staff takes out trash, soiled linens and staff mop and clean the whole room. The EVSM further stated, the staff should have done their job.

During a joined interview on November 19, 2025, at 2:10 PM, with Custodian Environmental services (CEVS), and EVSM, the EVSM stated, she picked up trash, moped the floor, cleaned the sink, countertop and dust. CEVS stated, first, she removes the dust, takes out trash, biohazard bag, and dirty linens. CEVS stated, after her breaks she moped the floor, wiped the sink, countertop and furniture. She stated she follows cleaning process. CEVS further stated, she did not work on Monday.

During a second observation and concurrent interview on November 19, 2025, at 3:05 PM, in Patient 24's room with AO, CEVS, Unit Manager, Registered Nurse, (RN) escort, and Epidemiology RN (IP), observed countertop with multi stained colors, soiled chuck laying on a countertop with large dirty syringe. Soap dispenser backing with brown old stained and the base of the faucet and sink with brown stuff. CEVS, stated he was not sure where the stained-on countertop comes from and how long it has been there. The unit manager stated she does not know what it was and does not remember how long the multicolored stain has been on the countertop. The IP stated it was not acceptable to have a dirty countertop in patient room. IP expectation wass countertop and room to be cleaned.

During an interview and concurrent record review on November 20, 2025, at 9:20 AM, with EVSM, the facility's procedures, titled "EVS-7 Step Cleaning Process" dated November 15, 2017, was reviewed. The P&P indicated, Patient Room Daily Cleaning, 3 ..., "then proceed to disinfecting everything in the room with Germicidal solution. This includes B, Furniture, Trash, and Bio, closets, Linen containers and wall fixtures ...ed," EVSM stated, facility did not follow the procedures when the room was visibly soiled. EVSM further stated, the supervisor uses check list to go around visually inspect the room. There was no document provided for Patient 24's room inspection.

Based on observation, interview and record review, the facility failed to protect the private health information for one of 32 sampled patients (Patient 32), when Patient 32's specimen label was found on the floor in a shared room that was accessible to the public.

This failure had the potential for Patient 32's private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations.

Findings:

During a review of Patient 32's "Demographics" (a summary document in a medical record that provides a quick overview of a patient's key information), indicated, Patient's 32 was admitted on November 16, 2025.

During a review of Patient's 32 History and Physical (H&P), dated November 16, 2025, the H&P indicated, Chief complaint, was "Patient presents with knee pain ...

During a concurrent observation and interview on November 17, 2025, at 11:51 AM, with Clinical Director II (CD) in Patient 32's room. Patient 32 was asleep. A specimen label was observed on the floor. Clinical Director II (CD) picked up the specimen label from the floor. The CD stated, it was a urine specimen label. The CD verified and acknowledged that the specimen label belonged to Patient 32 and the label had patient name, Medical Record Number and date of birth. The CD further stated this should not have happened.

During an interview on November 19, 2025, at 9:05 AM with CD, the CD stated facility must always protect patient information. The CD further stated the extra label from urine collection should have been shredded.

During an interview and concurrent record review on November 19, 2025, at 10:50 AM, with the Administrator, Quality & Accreditation and Chief Compliance Officer (QA&CCO), the facility's policy and procedures (P&P), Titled "Patient Privacy Protections" dated March 25, 2021, was reviewed. The P&P, indicated ... "I. Written Information, A. When possible, patient names shall be kept out of public view ...VI, Expectations and Best Practice Guidelines. A. "Shred all paper containing confidential health information or place in closed locked shred receptacles ..."

A continued review with the QA&CCO on November 19, 2025, at 10:55AM, the facility's P&P titled "Patient's Rights" dated May 26, 2005, was reviewed. The P&P indicated, ...8. "The confidentiality of his/her clinical records pertaining to patient's care and stay in the hospital." The QA&CCO stated, the facility did not follow the policy. The QA&CCO further stated, the patient has the right to have their information protected.

During an interview on November 19, 2025, at 11:35 AM, with Registered Nurse (RN1), RN 1 stated, when he had extra specimen label, he would place it inside the specimen bag and send it to the laboratory, or he would shred it. RN 1 further stated he would not leave it in the room.

Based on observation, interview, and record review, the facility failed to ensure nursing staff adhered to the facility's policies and procedures (P&P) for three of 32 sampled patients (Patient 3 ,27 and 31) when:

1. Seizure (sudden burst of abnormal electrical activity in the brain that causes changes in behavior, movement, feeling, or awareness) precautions were not consistently implemented for Patient 3 who had a history of seizures and known seizure risk.

2. For Patient 27, appropriate isolation precautions were not used and crash cart (a cart on wheels with all essential medications and equipment for a life treating emergency) was left inside the patient room, who was on contact isolation precautions (a set of precautions like wearing personal protective including gown, gloves before entering to the room).

3. For Patient 31, inter department transfer and communication was not documented as per the facility P&P.

4. For Patient 31, intake (the amount of food or fluids consumed by a patient) and output (the quality of excretion) was incomplete.

These failures had the potential to result in patient harm, including falls, aspiration, head injury, or other complications, due to the lack of appropriate safety interventions and increase the risk of cross contamination (spreading of infection from person to another), unclear about the nutritional status of patients which would affect the psychosocial and wellbeing of patients.

Findings:

1. During a review of Patient 3's face sheet (contains demographic and medical information), the face sheet indicated, Patient 3 was admitted to the facility on November 12, 2025, with diagnoses, such as toxic encephalopathy (brain dysfunction caused by exposure to toxins [chemicals, drugs that can mess with brain function]) and hepatitis C (virus that infects the liver and causes inflammation and long-term damage over time).

A review of Patient 3's "History and Physical" (H&P) dated November 13, 2025, the H&P indicated a history of seizure activity in the past.

A review of Patient 3's "Physician Progress Note" dated November 13, 2025, indicated, " ...wife noticed patient exhibiting seizure-like activity ...ED [Emergency Department] Course: ...Received 2L (liter) LR (lactated ringer's- sterile IV fluid to replace fluid and electrolytes in the body), Aspirin (pain reliever, fever reducer, anti-inflammatory) 324mg (milligram), and 1000mg Keppra (medication used to prevent and control seizures) x1 (one time) @2:15 [AM] in ED ..." A further review of the H&P document showed Patient 3 had a past medical history of seizures.

A review of Patient 3's "Medication Administration Record" (MAR) dated November 13, 2025, the MAR indicated Patient 3 was administered Keppra (anti-seizure medication) 1000mg during the admission in the Emergency Department (ED).

A review of Patient 3's "Inpatient Consult to Neurology," dated November 13, 20 25, indicated, " ...Reason for consult? Seizure like activity ...Summary: ...Given this patient's history of alcohol abuse, seizures due to alcohol withdrawal are suspected ..."

During an observation on November 17, 2025, at 10:04 AM, Patient 3 was observed resting in bed, with side-rails up and no padding strapped to the rails. No other seizure precautions, such as suction set up, were visible despite Patient 3's identified seizure risk.

During a concurrent interview and record review on November 17, 2025, at 3:50 PM, with Registered Nurse Educator (RNE), Patient 3's nursing flowsheet titled, "Precautions," dated November 14, 2025-November 17, 2025, was reviewed. "Precautions," was documented with the following:

- November 14, 2025: "fall; seizure"
- November 15, 2025: "fall"
- November 16, 2025: "fall"
- November 17, 2025: none
No seizure precautions were documented throughout November 15, 2025-November 17, 2025. RNE confirmed Patient 3 met the criteria for seizure precautions and there were none documented in Patient 3's medical chart from November 15, 2025-November 17, 2025.

During an interview on November 19, 2025, at 2:56 PM, with Registered Nurse 1 (RN 1), RN 1 stated when a patient admits to the facility with a history of seizure or active seizure activity, it would be a nursing judgement and per facility protocol to implement seizure precautions. RN 1 further stated, the precautions would need to be documented per shift in the patient's chart.

During a concurrent interview and record review on November 19, 2025, at 4:35 PM, with Unit Manager 1 (UM 1), the facility's policy and procedure (P&P) titled "Patient Care References", policy no. 413.00 Issue 6, with no revision date, was reviewed. The P&P specified, " ...Seizure precautions prevent patients from incurring injury from a fall or seizure ...Implementation: ...For patient with history of seizures, keep bed in lowest position with side rails up ...Pad rails if patient is at risk for head injury and, as an option, offer protective headgear. Have oral suction and oxygen equipment ready for use ..." UM 1 stated Patient 3 would fall under the category of needing seizure precautions, but the facility did not follow P&P for Patient 3.



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2. During a review of the facility's document titled "admission record" (demographic data), indicated, Patient 27 was admitted to the facility on November 16,2025, at 9:31 AM, with the chief complaint of blood in urine.

During a review of the facility's document titled "initiate contact isolation", dated November 16,2025, the "initiate contact isolation" indicated patient 27 should be on contact isolation by physician 1 (P1). The document also indicated that the patient should be on contact isolation for every admission.

During an observation on November 17,2025, at 10:00 AM, in Emergency department (ED- a unit in the hospital where the patients come for immediate care) Patient 27 was lying in Bed C in Rapid POD ( an area where patients are responded as rapid) and the crash cart was observed to be in the corner of the room. Patient 27 did not have any contact isolation signage posted and was placed on standard precautions (a set of basic infection control practices used for all patients in health care to prevent the spread of infection).

During a concurrent interview and record review on November 17,2025, at 3:30 PM, with Registered Nurse 4 (RN 4), the facility's "electronic heath record for isolation status" (EHR- an electronic documentation of patient care) was reviewed. The EHR indicated ,Patient 27 should be on contact isolation precautions from November 16,2025,at 7:26 PM for infected with ESBL( Extended spectrum Beta Lactamase- a bacteria),Acinetobacter -MDR (a bacteria which is resistant to multi drug),CRE (carbapenem resistant enterobacterial- a bacteria which is resistant to carbapenem drug),Candida auris rule out ( a multi drug resistant fungal infection),Carbapenem resistant pseudomonas aeruginosa (CRPA- a bacteria which is resistant for carbapenems).RN 4 acknowledged and stated that Patient 27 was a patient who should be in contact precaution.

During an interview on November 17,2025, at 4:03 PM, with the Infection Control Nurse (IC N), the IC N stated, crash cart should not be left inside an isolation patient's room. IC N further stated, Patient 27 should be on isolation precautions as soon as the laboratory results came positive for infection.

During an interview on November 17,2025, at 4:05 PM, with ED Assistant Manager (ED AM), the ED AM stated, the crash cart is usually kept in the corner of Bed C in Rapid POD and usually isolation patients are not placed in that room. The ED AM further stated, that Patient 27 should be in contact isolation and the crash cart should have moved out of the room.

During a concurrent interview and record review on November 19,2025, at 10:00 AM, with the ED Director (ED D) the facility's policy and procedure(P&P) titled 1) "Crash Carts", dated September 28,2022, was reviewed. The P&P indicted, " ... Procedure B. Crash carts are not brought inside the room of patients in isolation precautions." The ED D stated, the policy was not followed.

During a concurrent interview and record review on November 19,2025, at 10:05 AM, with ED D, the facility's P&P titled "Standard and Isolation Precautions", dated February 2022, was reviewed. The P&P indicated, " ...A. General Principles 1. Transmission -based precautions are the second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission ...6. a sign indicating the type of precautions required is posted on the outside of the patient room door until isolation precautions are discontinued or the patient is discharged or transferred ...7. An isolation cart is required for isolation patients who are not in a room with an anteroom. a. Sterile processing department (SPD) provides isolation carts. b. Place the cart outside the patient room.c.do not use isolation cart to store other patient care supplies, meal trays or other items...D. Contact Isolation Precautions 1. In Addition to standard precaution, use contact isolation precautions, for patients with non all suspected infections that represent an increased risk for contact transmission.2. Use of PPE a. Wear clean exam gloves add a disposable isolation gown whenever in patient's room, even if not intending to have direct contact with patient or with any item/surface in the patients room. Ensure that the gown is secured at the neck and waist. b. Remove and discard PPE before exiting the patients room or area.3. Patient placement a. Place the patient in a private room. b. When a private room is not available, place the patient in a room with a patient who has active infection or colonization with the same microorganism but with no other infection (cohorting- a group of people sharing the same characteristic). When A private room is not available and cohorting it's not achievable, consider the epidemiology off the microorganism and the patient population when determining patient placement. The ED D acknowledged that the policy was not followed. The ED D stated, it was not acceptable to keep the crash cart in an isolation precaution room.


3. During a review of Patient 31's "Admission record" dated October 12,2025, the "Admission record " indicated, Patient 31 was admitted to the facility on October 12,2025, at 10:52 PM, with the diagnosis of melena( a condition in which patient has black ,tarry stools caused by bleeding in the upper gastrointestinal tract).

During a concurrent interview and record review on November 18,2025, at 10:30 AM, with Registered Nurse 4 (RN 4), Patient 31's "flowsheet" (electronic document where the patient data is charted), dated October 12,2025 through October 15,2025, was reviewed. The "flowsheet" indicated, Patient 31 was transferred from ED to telemetry floor (an area where the patient is connected to a cardiac monitor [ a heart rhythm monitoring equipment]) to a single room on October 14,2025 at 4:03 PM. Patient 31 was transferred from telemetry floor to medical surgical floor (an area where patient is admitted due to a medical or a surgical condition) on October 15,2025, at 12:12 AM, and Patient 31 was discharged on October 15,2025 at 10:00 AM. RN 4 acknowledged that Patient 31 was transferred from telemetry floor to medical surgical floor without any documentation of inter transfer and patient communication with patient or emergency contact person. RN 4 stated, nurses are expected to document the transfer and communication to the patient.

During an interview on November 19,2025, at 3:10 PM, with RN 1, RN 1 stated, that when the patients are transferred from one unit to another it is expected to document about the transfer and notification to family regarding the transfer. RN 1 further stated, nurses can document about the transfer in the "flowsheet" or as a free nurse's note in patient record.

During a concurrent interview and record review on November 19,2025, at 4:01 PM, with Clinical Director (CD), the facility's document titled "position description Registered Nurse Medical Surgical Unit", dated July ,2025, was reviewed. The "position description Registered Nurse Medical Surgical Unit" indicated, " ... Position duties and responsibilities ....2. Document patient care from admission through discharge incorporating the nursing process.4. Practice safety measures in all activities associated with patient care.9. Serve as patient advocate". The CD stated, nurses should have documented Patient 31's transfer from one unit to another.

During a concurrent interview and record review on November 19,2025, at 4:05 PM, with CD, the facility's P&P titled "Patient Transfer in house and interagency", dated July 14,2025, was reviewed. The P&P indicated, " .....PROCEDURE ...2..e. A transfer note is written by the sending nurse to include patient status at the time of transfer, date and time of transfer, mechanism of transportation, who accompanied the patient, where patient was transferred from, where patient is being transferred to ...g. A note is written by the receiving nurse, to include date and time, where patient comes from, name of the receiving unit, mechanism of transportation, who accompanied the patient and an assessment of the patient". The CD stated, the policy was not followed as the nurse did not document regarding the transfer.

During a concurrent interview and record review on November 19,2025, at 4:10 PM, with CD, the facility's P&P titled "Patient Rights", dated April 26,2023, was reviewed. The P&P indicated, " ....PROCEDURE ...16. Know the reason for his/her transfer either within or outside the hospital". The CD stated, the policy was not followed as there was no documentation.

4. . During a review of Patient 31's "Admission record" (demographic data), dated October 12,2025, the "Admission record " indicated, Patient 31 was admitted to the facility on October 12,2025, at 10:52 PM with the diagnosis of melena (a condition in which patient has black tarry stools caused by bleeding in the upper gastrointestinal tract).

During a review of Patient 31's "Patient care TimeLine", dated October 12,2025, through October 14,2025, the "patient care timeline" indicated the following:

October 13,2025, at 12:41 AM: Patient 31's diet order was on nothing per mouth (NPO-patient is not allowed to take any food or liquid by mouth) status.
On October 13,2025, at 8:27 AM: Patient 31's diet order was modified to NPO except sips of water for medications.
On October 13,2025, at 3:30 PM: Patient 31's diet was ordered as adult clear liquid diet (patient will be allowed to have liquid diet).
On October 13,2025, at 10:45 PM: Patient 31's Clear liquid diet was discontinued.
On October 14,2025, at 12:01 AM: Patient 31 was placed on NPO status
On October 14,2025, at 11:35 PM: Patient 31's diet order was modified to NPO except sips of water.
On October 14,2025, at 4:57 PM: Patient 31 diet was modified to regular diet.

During a concurrent interview and record review on November 18,2025, at 11:00 AM, with RN 4, facility's EHR titled "flowsheet for intake and output", dated October 12,2025 through October 15,2025, was reviewed. The "flowsheet for intake and output" indicated, Patient 31's "intake and output" was incomplete, and there was no intake a nd output of 250 ml(milli liter- a unit of measurement) was documented for the day of October 13,2025 and October14, 20 25. RN 4 stated, the nurses are expected to complete the intake and output chart on every shift. RN 4 further stated, Patient 31 was taking the Go Lytle (a medication used in preparation for gastrointestinal procedures) and it should be included in the intake.

During an interview on November 19,2025, at 3:15 PM, with RN1, RN1 stated, that the nursing team is responsible for documenting the intake and output of the patient.RN1 further stated, the intake and output should include the amount of fluid and the food intake and should be updated in timely manner.

During a concurrent interview and record review on November 19,2025, at 5:10 PM, with Assistant Chief Nursing Officer ED (ACNO ED), the facility's P&P titled "Documentation, Nursing", dated July 11,2025, was reviewed. The P&P indicated, " ...PROCEDURE ...V. 24 hour intake and output A. 24 hour I&O totals cover the period from 00:00 to 23:59 the following day. B. The 24 hour I&O totals are calculated within the electronic health record (EHR)...VI. REAL TIME DOCUMENTATION A. Documentation is completed in "real time", at the time the intervention or assessment is performed, as often as possible". The ACNO ED stated, the policy was not followed as nurses did not update the intake and output chart.