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

1. The facility failed to ensure translation services were utilized based on the patients' preferred language when presented and asked to sign the "Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient's responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)" form for two of 30 sampled patients (Patient 13 and Patient 20) in accordance with the facility's policy and procedure regarding patient rights.

This deficient practice had the potential to result in Patient 13 and Patient 20 to not fully understand what they were agreeing to, nor what their patient rights were upon signing the COA form. (Refer to A-0117)

2. The facility failed to ensure one of 30 sampled patients' (Patient 26) "Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient's responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)" form not in Patient 26's preferred language was signed by the patient or patient's representative in accordance with the facility's policy and procedure regarding admitting procedures.

This deficient practice had the potential for Patient 26 to not fully understand their patient rights, treatment, billing process, payments, and services rendered by the facility. (Refer to A-0117)

3. The facility failed to ensure its nursing staff obtained a physician order for restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 30 sampled patients (Patient 24) in accordance with the facility's policy and procedure on restraints use when Patient 24 was placed in soft restraints (padded, fabric-based devices designed to temporarily restrict a patient's movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes) without a physician order for three hours and 3 minutes.

This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 24 which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). (Refer to A-0168)

4. The facility failed to ensure two of 30 sampled patients (Patient 17 and Patient 24), who were placed on soft restraints (padded, fabric-based devices designed to temporarily restrict a patient's movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes), were monitored by nursing staff every two hours in accordance with the facility's policy and procedure regarding restraints.

This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 17 and Patient 24, which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death). (Refer to A-0175)

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

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

1. The facility failed to ensure an individualized nursing care plan (a document that helps a patient's care team communicate and organize patient care) was initiated for seven of 30 sampled patients (Patient 3, Patient 16, Patient 18, Patient 22, Patient 23, Patient 25 and Patient 27) in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying patients' needs and risks and could lead to patients not receiving safe and effective care. (Refer to A-0396)

2. The facility failed to ensure five of 30 sampled patients (Patient 8, Patient 11, Patient 16, Patient 23, and Patient 26) had intravenous (IV, a tube going directly into the vein) sites labeled with the insertion (placement) date and the nurse's initials in accordance with the facility's policy and procedure regarding IV therapy management.

This deficient practice had the potential to place patients at risk for a skin infection (infection, a growth of germs that can cause illness), a blood infection, blood clots (a gel-like clump of blood), and tissue (a body part that performs a specific function, such as skin) damage at the IV insertion site. (Refer to A-0398)

3. The facility failed to ensure one of 30 sampled patients (Patient 16) wore a fall risk armband in accordance with the facility's policy and procedure regarding falls prevention.

This deficient practice had the potential for Patient 16 falling and becoming injured due to not being provided extra fall risk monitoring and precautions. (Refer to A-0398)

4. The facility failed to ensure antibiotic medications (medications for infection) were given as ordered for two of 30 sampled patients (Patient 11 and Patient 12) in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice had the potential for Patient 11 and Patient 12 experiencing drug complications due to not maintaining a constant therapeutic level of a drug in their bodies. (Refer to A-0405)

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

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

1. Ensure translation services were utilized based on the patients' preferred language when presented and asked to sign the "Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient's responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)" form for two of 30 sampled patients (Patient 13 and Patient 20) in accordance with the facility's policy and procedure regarding patient rights.

This deficient practice had the potential to result in Patient 13 and Patient 20 to not fully understand what they were agreeing to, nor what their patient rights were upon signing the COA form.

2. Ensure one of 30 sampled patients' (Patient 26) "Conditions of Admission/Services (COA, a legal contract between a patient and a hospital outlining the patient's responsibilities, including payment for services, understanding of treatments, and providing informed consent for medical care and potential hospital policies)" form not in Patient 26's preferred language was signed by the patient or patient's representative in accordance with the facility's policy and procedure regarding admitting procedures.

This deficient practice had the potential for Patient 26 to not fully understand their patient rights, treatment, billing process, payments, and services rendered by the facility.

Findings:

1. a. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/1/2025, the H&P indicated Patient 13 was admitted to the facility on 9/1/2025 for epigastric pain for eight months related to acute cholecystitis (sudden inflammation of the gallbladder).

During a review of Patient 13's "Discharge Plan/Social Worker Evaluation," dated 9/2/2025, the evaluation indicated Patient 13's preferred language was Mandarin. The note also indicated Patient 13 required language assistance.

During a concurrent interview and record review on 9/3/2025 at 3:10 PM with Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 13's "Condition of Admission/Service (COA)," dated 9/2/2025, was reviewed. The COA, printed in English, indicated Patient 13 signed the form without the indication of a translation service being used to interpret and explain the form to her in Mandarin. The CSQ 1 stated no translation service for Mandarin was indicated on the signed form. The CSQ 1 also stated the risk of not using a translation service was that the patient would not be fully aware of their rights as a patient.

During an interview on 9/4/2025 at 2:08 PM with the Associative Administrator of Patient Access (APA), the APA stated an interpreter identification number should be indicated on the COA itself if the patient did not receive a COA in their preferred language.

During a review of the facility's policy and procedure (P&P) titled, "Patients' Rights/Responsibilities," dated 2/2022, the P&P indicated, "Patients have the right to care in a private, confidential, and safe environment where they can communicate their needs . . . Patients have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, beliefs and preferences . . . Receive information . . . in terms they can understand".

1. b. During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/29/2025, the H&P indicated Patient 20 was admitted to the facility on 8/29/2025 for high creatine kinase (CPK - creatine phosphokinase provides energy for muscle contraction; normal level of 55 to 170 in males and 30 to 135 in females) level of 689. Patient 20 had a past medical history of schizophrenia (a mental illness that is characterized by disturbances in thought), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). The H&P also indicated Patient 20 was placed on seizure precautions (safety measures taken to prevent or minimize injuries during a seizure) due to his history of seizure disorder.

During a review of Patient 20's "Discharge Plan/Social Worker Evaluation," dated 8/29/2025, the evaluation indicated Patient 20's preferred language was primarily Cantonese and was limited English speaking.

During a concurrent interview and record review on 8/29/2025 at 10:50 AM with Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 20's "Condition of Admission/Service (COA)," dated 8/29/2025, was reviewed. The COA, printed in English, indicated Patient 20 verbally consented to the form without the indication of a translation service being used to interpret and explain the form to him. The CSQ 1 stated no translation service for Cantonese was indicated on the sign form. The CSQ 1 also stated the risk of not using a translation service was that patient would not be fully aware of their rights as a patient.

During an interview on 9/4/2025, at 2:08 PM, with the Associative Administrator of Patient Access (APA), the APA stated an interpreter identification number should be indicated on the COA itself if the patient did not receive a COA in their preferred language.

During a review of the facility's policy and procedure (P&P), titled, "Patients' Rights/Responsibilities," dated 2/2022, indicated, "Patients have the right to care in a private, confidential, and safe environment where they can communicate their needs . . . Patients have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, beliefs and preferences . . . Receive information . . . in terms they can understand".

2. During a review of Patient 26's "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 8/31/2025, the H&P indicated Patient 26 was admitted to the facility on 8/31/2025 for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) from a boarding care facility.

During a review of Patient 26's COA form, dated 8/31/2025 at 8:35 p.m., the COA indicated that Patient 26 was unable to sign "due to medical condition" and was witnessed by two staff with their signatures.

During a review of Patient 26's "Discharge Plan/Social Worker Evaluation", dated 9/1/2025, the Evaluation indicated Patient 26 was Spanish speaking, self-responsible, independent, and able to engage in conversation with the social worker. The Evaluation further indicated Patient 26 was able to provide information about their medical history and answer questions independently.

During an interview on 9/4/2025 at 2:10 p.m. with Admitting Manager (AM), AM stated that the purpose of the COA was to inform patients about their rights, billing information, expected behavior, and consent for photograph. All patients or patient's representatives (PR) should be informed of the conditions of admission (COA) and obtain signature from patient or PR. If patients were not able to sign the COA during the first attempt, the admitting staff should make another attempt to follow the patients on the floor for completion of COA signature.

During an interview on 9/4/2025 at 2:10 p.m. with Associative Administrator of Patient Access (AAPA), AAPA stated that per their department's internal record, the admitting staff did not make another attempt to go to the floor to follow up the COA with Patient 26. AAPA further stated there was a gap in that process that the staff did not follow the policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Conditions of Admission – Admitting Consent Forms," last revised on 1/2022, the P&P indicated, "USC Arcadia Hospital will maintain a registration process that complies with federal, state and laws and payer requirements. The forms must be signed by the patient and/or the patient's legal representative: e.g. parent, conservator or legal guardian on admission."

Based on interview and record review, the facility failed to ensure its nursing staff obtained a physician order for restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use for one of 30 sampled patients (Patient 24) in accordance with the facility's policy and procedure on restraints when Patient 24 was placed in soft restraints (padded, fabric-based devices designed to temporarily restrict a patient's movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes) without a physician order for three hours and 3 minutes.

This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 24 which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death).

Finding:

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/30/2025, the H&P indicated Patient 24 was admitted to the facility for advanced dementia (conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), uncontrolled atrial fibrillation (condition where the heart's upper chambers [atria] beat irregularly and rapidly, without adequate medical management), and recurrent (having two or more episodes within a six-month period, or three or more episodes within one year) urinary tract infection (UTI, an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra).

During a concurrent interview and record review on 9/3/2025 at 3:40 p.m. with Stroke Program Coordinator (SPC), Patient 24's "Restraint" flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/30/2025, was reviewed. The flowsheet indicated Patient 24 was placed on restraints on 8/30/25 at 11:00 p.m., then Patient 24's restraints were assessed on 8/31/2025 at 2:32 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m. Concurrently, Patient 24's physician order for restraints was reviewed. The order indicated that the first order for soft wrist restraints for Patient 24 was ordered on 8/31/25 at 2:04 a.m. There was no physician order when nursing staff initiated the restraints on 8/30/2025 at 11:00 p.m. Patient 24 was placed in restraints without a physician order from 8/30/2025 at 11:00 p.m. to 8/31/2025 at 2:03 a.m. for a total of three hours and three minutes. SPC stated that the nurse should obtain a physician order for any type of physical restraint.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 7/2025, the P&P indicated, "All patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff ... Use of restraints must be in accordance with the order by a physician or licensed practitioner who is primarily responsible for the care of the patient and authorized to write restraint orders. Orders for restraint use are episode specific. Removal of physical restraints prior to order expiration requires a new order if new need is identified. Orders for the use of restraints must never be written as a standing order, ' as needed' or on a PRN basis. A trial release constitutes a PRN order; therefore, a new order will be required to re-apply physical restraints."

Based on interview and record review, the facility failed to ensure two of 30 sampled patients (Patient 17 and Patient 24), who were placed on soft restraints (padded, fabric-based devices designed to temporarily restrict a patient's movement by securing their wrists and ankles to prevent patients from disrupting life-saving treatment, such as pulling at IV lines, catheters, or other tubes), were monitored by nursing staff every two hours in accordance with the facility's policy and procedure regarding restraints.

This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of restraints for Patient 17 and Patient 24, which may lead to complications such as skin breakdown (a break in the skin) and strangulation (compression of the neck that may lead to death).

Findings:

1. During a review of Patient 17's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/26/2025, the H&P indicated Patient 17 was admitted to the facility for worsening altered mental status related to septic shock (a life-threatening condition that occurs due to infection) and bacteremia (bacteria present in the blood). Patient 17 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities) and recent hip repair.

During a review of Patient 17's physician order, dated 8/26/2025, the order indicated Patient 17 was ordered to be placed on bilateral (both) soft wrist restraints.

During a concurrent interview and record review on 9/4/2025 at 10:17 AM with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 17's "Restraint" flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/26/2025, was reviewed. The flowsheet indicated Patient 17 was monitored and checked on 8/26/2025 at: 7:30 AM, 9:30 AM, 11:30 AM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM. The CSQ 1 stated Patient 17 was not monitored and checked every two hours on 8/26/2025 during restraint use at 1:30 PM and 3:30 PM. The CSQ 1 also stated restraints were to be checked every two hours for patient safety to ensure patient's wellbeing, check circulation, and assess the necessity of restraint itself.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 7/2025, indicated, "Ongoing monitoring content and restraints flowsheet documentation - At a minimum every 2 hours".

2. During a review of Patient 24' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/30/2025, the H&P indicated Patient 24 was admitted to the facility for advanced dementia (conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), uncontrolled atrial fibrillation (condition where the heart's upper chambers [atria] beat irregularly and rapidly, without adequate medical management), and recurrent urinary tract infection (UTI, is defined as having two or more episodes of a UTI within a six-month period, or three or more episodes within a one-year).

During a concurrent interview and record review, on 9/3/2025 at 3:40 p.m., with Stroke Program Coordinator (SPC), Patient 24's "Restraint" flowsheet (document to record the use and ongoing monitoring of patient restraints that document chronological account of a restraint episode to ensure patient safety), dated 8/30/2025, was reviewed. The flowsheet indicated Patient 24 was placed on restraints on 8/30/2025 at 11:00 p.m. Patient 24 was checked and monitored on 8/31/2025 at 2:32 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m. while on restraints.

The SPC stated Patient 26 was not checked and monitored every two hours between 8/30/2025 at 11:00 p.m. to 8/31/2025 at 2:32 a.m. for a total of three hours and 32 minutes. SPC stated that restraints were to be checked every two hours for patient safety to ensure patient's wellbeing, check circulation, and assess the necessity of restraint itself.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 7/2025, indicated, "Ongoing monitoring content and restraints flowsheet documentation - At a minimum every 2 hours".

Based on interview and record review, the facility failed to ensure an individualized nursing care plan (a document that helps a patient's care team communicate and organize patient care) was initiated for seven of 30 sampled patients (Patient 3, Patient 16, Patient 18, Patient 22, Patient 23, Patient 25 and Patient 27) in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying patients' needs and risks and can lead to patients not receiving safe and effective care.

Findings:

1. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/31/2025, the H&P indicated Patient 3 was admitted to the facility for acute hypoxic respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the body's tissues leading to low oxygen levels).

During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with Clinical Quality Specialist (CQS) 2, Patient 3's "Adult Patient Profile", dated 8/31/2025, was reviewed. The Adult Patient Profile indicated Patient 3's preferred language was Chinese.

During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with CQS 2, Patient's 3's "Personalized Care Flowsheet," dated 9/02/2025, was reviewed. The Personalized Care Flowsheet indicated Patient 3 was Mandarin speaking and very hard of hearing (HOH, a condition where a person has reduced hearing ability).

During a concurrent interview and record review on 9/03/2025 at 2:30 p.m. with CQS 2, Patient 3's "Plan of Care" was reviewed. CQS 2 verified Patient 3's Plan of Care, Assessment and Interventions did not include care plans for language preference (Mandarin) or the hearing impairment.

During an interview on 9/03/2025 at 2:30 p.m. with CQS 2, CQS 2 stated it was "definitely important to address interventions so they're individualized for him (Patient 3)."

During a review of the facility's P&P titled, "Interdisciplinary Plan of Care," dated 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient's primary problem and co-morbidity."

2. During a review of Patient 16's "H&P," dated 8/29/2025, the H&P indicated Patient 16 admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 had a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure).

During a review of Patient 16's "Adult Assessment Interventions," dated 8/28/2025, the "Interventions" indicated Patient 16's Morse Fall Scale (a clinical assessment tool used by healthcare professionals to determine a patient's risk of falling with low fall risk score being 0 to 24 points, moderate fall risk score being 25 to 45 points and high fall risk score being 45 points and greater) score on 8/28/2025 at 5:30 PM was 95 (high fall risk). The "Interventions" further indicated the only safety intervention placed was an activated bed alarm.

During a concurrent interview and record review on 9/3/2025 at 4:00 PM, with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 16's "Adult Plan of Care," dated 8/28/2025 was reviewed. The "Plan of Care" indicated Patient 16 did not have a fall risk care plan initiated. The CSQ 1 stated Patient 16's plan of care for fall risk was not initiated. The CSQ 1 also stated the importance of initiating the fall risk care plan was to ensure the staff are aware of the patient's goals of care and maintain patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Falls Prevention," dated 5/2024, the P&P indicated, "Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls." The P&P also indicated, "Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . "Initiate Fall Risk Care Plan - a plan of care is developed with appropriate interventions individualized to patient needs."

During a review of the facility's P&P titled, "Interdisciplinary Plan of Care," dated 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient's primary problem and co-morbidity."

3. During a review of Patient 18's "H&P," dated 8/31/2025, the H&P indicated Patient 18 was admitted to the facility on 8/31/2025 for worsening peripheral edema (swelling in the extremities, typically the feet, ankles, legs, and arms). Patient 18 had a past medical history of chronic kidney disease stage III (moderate damage to organ that filters waste products from the blood), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).

During a review of Patient 18's "Adult Assessment Interventions," dated 8/31/2025, the "Interventions" indicated Patient 18's Morse Fall Scale score on 8/31/2025 at 7:45 PM was 35. The record indicated the only safety intervention placed was an activated bed alarm.

During a concurrent interview and record review on 9/4/2025 at 10:33 AM with the Clinical Quality Specialist Registered Nurse (CSQ 1), Patient 18's "Adult Plan of Care," dated 8/31/2025, was reviewed. The record indicated Patient 18 did not have a fall risk care plan initiated. The CSQ 1 stated Patient 18's plan of care for fall risk was not initiated. The CSQ 1 also stated the importance of initiating the fall risk care plan was to ensure staff were aware of the patient's goals of care and maintain patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Falls Prevention," dated 5/2024, the P&P indicated, "Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls." The P&P also indicated, "Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . "Initiate Fall Risk Care Plan - a plan of care is developed with appropriate interventions individualized to patient needs."

During a review of the facility's P&P titled, "Interdisciplinary Plan of Care," dated 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care plan will be reviewed and/or updated as needed . . . RN will initiate Care Plan Problems/ Focus of Care that addresses the patient's primary problem and co-morbidity."

4. During a review of Patient 22's "H&P," dated 9/1/2025, the H&P indicated Patient 22 was admitted to the facility on 9/1/2025 for pericardial effusion (an abnormal accumulation of fluid in the pericardial sac, the thin membrane that surrounds the heart) and small bowel obstruction (SBO, a condition that occurs when the flow of food, fluid, and gas through the small intestine is blocked).

During a concurrent interview and record review on 9/3/2025 at 3:00 p.m. with the Stroke Program Coordinator (SPC), Patient 22's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 22's diagnoses of small bowel obstruction for this admission. The APC stated the nurse should develop an individualized plan of care for Patient 22 regarding SBO and develop a care for all actual or potential patient's needs to plan patient care such as relieving symptoms, maintaining fluid and electrolyte balance (the body's essential process of regulating the correct amount of water and electrically charged minerals [electrolytes like sodium and potassium] to maintain stable, healthy internal conditions), and interventions toward meeting those needs, but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," reviewed 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation" and "14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list."

5. During a review of Patient 23's "H&P," dated 8/31/2025, the H&P indicated Patient 23 was admitted to the facility for sepsis (a body's overwhelming and life-threatening response to infection), hypertension (high blood pressure), and right obstructive uropathy (condition where the flow of urine from the right kidney to the bladder is blocked).

During a concurrent interview and record review on 9/3/2025 at 3:20 p.m. with the Stroke Program Coordinator (SPC), Patient 23's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 23's diagnoses of right obstructive uropathy for this admission. The APC stated the nurse should develop a plan of care for Patient 23 regarding right obstructive uropathy and develop a care plan for all actual or potential patients' needs to plan patient care, such as monitoring fluid balance, intake, and output (measuring and recording how much fluid goes in and out of a patient's body), promoting bladder emptying and complete voiding (urinating), and interventions toward meeting those needs, but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," reviewed 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation" and "14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list."

6. During a review of Patient 25's "H&P," dated 8/30/2025, the H&P indicated Patient 25 was admitted to the facility for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) and urinary tract infection (UTI, an infection in any part of the urinary system).

During a concurrent interview and record review on 9/3/2025 at 3:20 p.m. with the Stroke Program Coordinator (SPC), Patient 25's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 25's diagnoses of UTI for this admission. The APC stated the nurse should develop a plan of care for Patient 25's UTI and develop a care plan for all actual or potential patients' needs to plan patient care such as monitoring dysuria (pain while urinating), urgency (intense desire to urinate), frequency (having to urinate too often in a small time interval), fever, chills, flank (the sides of the lower back between the ribs and hips) pain, and malaise (general feeling of discomfort), and interventions toward meeting those needs, but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," reviewed 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation" and "14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list."

7. During a review of Patient 27's "H&P," dated 8/29/2025, the H&P indicated Patient 27 was admitted to the facility on 8/30/2025 for possible subacute cerebrovascular accident (stroke, when a blood vessel in the brain becomes blocked or ruptures, cutting off blood flow to the brain) and hypertension (high blood pressure).

During a review of Patient 27's "Face Sheet" (concise summary of a patient's essential demographic, financial, and clinical information), the "Face Sheet" indicated Patient 27's preferred language was Spanish.

During a concurrent interview and record review on 9/4/2025 at 10:10 a.m. with the Stroke Program Coordinator (SPC), Patient 27's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 27's language barrier that the patient's preferred language was Spanish. The SPC stated the nurse should develop a plan of care for Patient 27's language barrier, such as interventions using qualified professional medical interpreters and translated materials that meet those needs, but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," reviewed 5/2025, the P&P indicated, "Care Plan will be initiated within 24 hours of admission. Care Plan will be reviewed and/or updated as needed. Care Plan will include nursing diagnosis, planning, and evaluation" and "14.1 Care Plan Addendum: If other problems need to be addressed and are not included in Care Plan use the Care Plan Addendum to develop additional problem list."

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

1. Ensure five of 30 sampled patients (Patient 8, Patient 11, Patient 16, Patient 23, and Patient 26) had intravenous (IV, a tube going directly into the vein) sites labeled with the insertion (placement) date and the nurse's initials in accordance with the facility's policy and procedure regarding IV therapy management.

This deficient practice had the potential to place patients at risk for a skin infection (infection, a growth of germs that can cause illness), a blood infection, blood clots (a gel-like clump of blood), and tissue (a body part that performs a specific function, such as skin) damage at the IV insertion site.

2. Ensure one of 30 sampled patients (Patient 16) wore a fall risk armband in accordance with the facility's policy and procedure regarding falls prevention.

This deficient practice had the potential for Patient 16 falling and becoming injured due to not being provided extra fall risk monitoring and precautions.

Findings:

1. a. During a review of Patient 8's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/29/2025, the H&P indicated Patient 8 was admitted to the facility for a right ankle wound and sepsis (a life-threatening blood infection).

During a concurrent observation and interview on 9/02/2025 at 2:45 p.m. with Nurse Manager (NM) 2 at Patient 8's bedside, Patient 8 had an IV insertion site in his right posterior (back part) hand without an insertion date or initials of nurse who inserted the IV. NM 2 stated she did not observe an insertion date or initials of nurse who inserted the IV written on Patient 8's right hand IV site. NM 2 stated it was important to have an insertion date, time, and initials of nurse because "the possibilities of issues are we didn't insert it (the IV), we don't know when it was inserted."

During a concurrent observation and interview on 9/02/2025 at 2:45 p.m. with Pediatric Emergency Care Coordinator (PECC) at Patient 8's bedside, Patient 8 had an IV insertion site in his right posterior (back part) hand without an insertion date or initials of nurse who inserted the IV. PECC stated she did not observe an insertion date or initials of nurse who inserted the IV on Patient 8's right posterior hand IV site.

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy Management Guidelines," dated 4/2023, the P&P indicated, "All IV sites will be labeled with the insertion date and the nurse's initials."

1. b. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/1/2025, the H&P indicated Patient 11 was admitted to the facility on 9/1/2025 for infection related to a cat bite on their thumb. Patient 11 had a past medical history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol), and hypertension (high blood pressure).

During a concurrent observation and interview on 9/2/2025 at 2:02 PM with the Director of the Emergency Department (DED), in Patient 11's room, Patient 11's left forearm IV site was observed to be missing a label with a date, time and initials of the staff member who placed the IV. The DED stated she did not observe the IV site to be labeled. The DED also stated all IV sites should be labeled at the time of insertion.

During an interview on 9/1/2025 at 2:13 PM with Registered Nurse 2 (RN 2), RN 2 stated, "Whoever inserts the IV should label, date, time and initial the site and document this in the chart as well. All IVs are to be changed every 4 days and as needed."

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy Management Guidelines," dated 4/2023, the P&P indicated, "All IV sites will be labeled with the insertion date and the nurse's initials."

1. c. During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/29/2025, the H&P indicated, Patient 16 was admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 had a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure).

During a concurrent observation and interview on 9/2/2025 at 2:36 PM with the DED, in Patient 16's room, Patient 16's left upper forearm IV site was observed to be missing a label with a date, time and initials of the staff member who placed the IV. The DED stated she did not observe the IV site to be labeled. The DED also stated all IV sites should be labeled at the time of insertion.

During an interview on 9/1/2025 at 2:13 PM with Registered Nurse 2 (RN 2), RN 2 stated, "Whoever inserts the IV should label, date, time and initial the site and document this in the chart as well. All IVs are to be changed every 4 days and as needed."

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy Management Guidelines," dated 4/2023, the P&P indicated, "All IV sites will be labeled with the insertion date and the nurse's initials."

1. d. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/31/2025, the H&P indicated Patient 23 was admitted to the facility for sepsis (a body's overwhelming and life-threatening response to infection), hypertension (high blood pressure), and right obstructive uropathy (condition where the flow of urine from the right kidney to the bladder is blocked).

During a concurrent observation and interview on 9/02/2025 at 2:05 p.m. with Clinical Quality Specialist (CQS2) in Patient 23's room, Patient 23 had two IV insertion sites on left antecubital (inner front area of the elbow) and right antecubital. Both IV insertion sites were observed without an insertion date or initials of the nurse who inserted the IV. CQS2 confirmed that both insertion sites had no date or initials of nurse. CQS2 stated it was important to have an insertion date, time, and initials of the nurse because without labeling the date, it could compromise the IV site for risk of infection.

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy Management Guidelines," dated 4/2023, the P&P indicated, "All IV sites will be labeled with the insertion date and the nurse's initials."

1. e. During a review of Patient 26's "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 8/31/2025, the H&P indicated Patient 26 was admitted to the facility on 8/31/2025 for syncope (a temporary loss of consciousness and muscle tone caused by a sudden decrease in blood flow to the brain) from a boarding care facility.

During a concurrent observation and interview on 9/02/2025 at 2:25 p.m. with Clinical Quality Specialist (CQS2) in Patient 26's room, Patient 26 had two IV insertion sites on the left mid-forearm and right mid-forearm. Both IV insertion sites were observed without an insertion date or initials of the nurse who inserted the IV. CQS2 confirmed that both insertion site had no date or initials of nurse. CQS2 stated it was important to have an insertion date, time, and initials of nurse because without labeling the date, it could compromise the IV site for risk of infection.

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy Management Guidelines," reviewed 4/2023, the P&P indicated, "IV sites will be rotated at an interval not longer than 96 hours unless there are no other peripheral (located in the arms or legs) sites available," and "All IV sites will be labeled with the insertion date and the nurse's initials."

2. During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/29/2025, the H&P indicated Patient 16 was admitted to the facility on 8/28/2025 for hip pain related to intertrochanteric (hip bone) fracture (break in bone) of left hip. Patient 16 has a past medical history of dementia (a progressive state of decline in mental abilities), atrial fibrillation (irregular heartbeat), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure).

During a review of Patient 16's "Adult Assessment Interventions," dated 8/28/2025, the " Interventions" indicated Patient 16's Morse Fall Scale (a clinical assessment tool used by healthcare professionals to determine a patient's risk of falling with low fall risk score being 0 to 24 points, moderate fall risk score being 25 to 45 points and high fall risk score being 45 points and greater) score on 8/28/2025 at 5:30 PM was 95 (high fall risk). The " Interventions" indicated the only safety intervention placed was an activated bed alarm.

During a concurrent observation and interview on 9/2/2025 at 2:40 PM with the Nurse Manager 3 (NM 3) in Patient 16's room, Patient 16 was observed to not have a yellow fall risk identification armband on, despite being identified as a fall risk with the use of fall risk precaution signage on the door entry way. The NM 3 stated Patient 16 should have a yellow fall risk armband on to indicate to staff that Patient 16 was a fall risk and to take proper fall risk precautions.

During a review of the facility's P&P titled, "Falls Prevention," dated 5/2024, the P&P indicated, "Adult patients who have scored 25 or greater on the modified Morse Fall Scale are considered to be at high risk for falls." The P&P also indicated the following "interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale . . . "Initiate Fall Risk Care Plan – a plan of care is developed with appropriate interventions individualized to patient needs" . . . "Provide yellow fall risk armband."

Based on interview and record review, the facility failed to ensure antibiotic medications (medications for infection) were given as ordered for two of 30 sampled patients (Patient 11 and Patient 12) in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice had the potential for Patient 11 and Patient 12 experiencing drug complications due to not maintaining a constant therapeutic level of a drug in their bodies.

Findings:

1. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/1/2025, the H&P indicated Patient 11 was admitted to the facility on 9/1/2025 for infection related to a cat bite on the thumb. Patient 11 had a past medical history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol), and hypertension (high blood pressure).

During a concurrent interview and record review on 9/3/2025 at 2:00 PM with the Clinical Quality Specialist Registered Nurse 1 (CSQ 1), Patient 11's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 9/2/2025, was reviewed. The MAR indicated Patient 11 was ordered on 9/2/2025 to receive Ampicillin-Sulbactam (a type of antibiotic medication) 3 grams (a metric unit of measurement used for medication amount) via intravenous piggyback (IVPB, a method of medication administration where a small volume of fluid is given intravenously [into the vein] through a primary fluid infusion) every 8 hours with the first administration on 9/2/2025 at 4:26 AM. The next doses given were on:
a. 9/2/2025 at 10:49 AM (administered one hour and 37 minutes early)
b. 9/2/2025 at 6:57 PM
c. 9/3/2025 at 5:10 AM (administered two hours and 13 minutes late)
d. 9/3/2025 at 11:36 AM (administered one hour and 34 minutes early)
The CSQ 1 stated the medications were not given timely. The CSQ 1 also stated the importance of administering medications timely was to not overload the patient and maintain a therapeutic level of the drug in the blood.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 4/2024, the P&P indicated, "Prior to administering a medication, the licensed independent practitioner or appropriate healthcare professional shall: Verify the five "rights' of medication administration: Right patient, Right medication, Right time, Right dose, Right route."

During a review of the facility's P&P titled, "Medication Administration Time Schedule," dated 11/2024, the P&P indicated, "Non-time critical medications that are prescribed more frequently than daily but no more frequently than every 4 hours are to be given within 1 hour before or after the scheduled time."

2. During a review of Patient 12's "Progress Note," dated 8/20/2025, the note indicated Patient 12 was admitted to the facility on 9/2/2025 for left total knee arthroplasty (replacement). Patient 12 had a past medical history of hypertension (high blood pressure), gastric bypass (a type of weight loss surgery) and hernia (a condition where an organ or tissue protrudes through a weak spot in a muscle or connective tissue) repair and lumbar (part of spine) laminectomy (removal of part of spine).

During a concurrent interview and record review on 9/3/2025 at 2:50 PM with the CSQ 1, Patient 12's MAR, dated 9/2/2025, was reviewed. The MAR indicated Patient 12 was ordered on 9/2/2025 to receive Vancomycin (a type of antibiotic medication) 1,000 milligram (mg, a metric unit of measurement used for medication dosage or amount) via IVPB every 12 hours with the first administration on 9/2/2025 at 8:32 PM. The next dose was given on 9/3/2025 at 11:06 AM (administered two hours and 34 minutes late). The CSQ 1 stated the medication was not given timely.

During an interview on 9/2/2025 at 2:28 PM with the CSQ 1, the CSQ 1 stated the importance of administering medications timely was to not overload the patient and maintain a therapeutic level of the drug in the blood.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 4/2024, the P&P indicated, "Prior to administering a medication, the licensed independent practitioner or appropriate healthcare professional shall: Verify the five "rights' of medication administration: Right patient, Right medication, Right time, Right dose, Right route."

During a review of the facility's P&P titled, "Medication Administration Time Schedule," dated 11/2024, the P&P indicated, "Non-time critical medications that are prescribed more frequently than daily but no more frequently than every 4 hours are to be given within 1 hour before or after the scheduled time."