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


1.The facility failed to ensure one of 30 sampled patients' (Patient7) consent for debridement (medical procedure to remove damaged, dead or infected tissue from wound) procedures was obtained in accordance with the facility ' s policy and procedures.



This deficient practice resulted in Patient 7 ' s consent was not obtained that jeopardizing patient safety and violating patients ' right to be appropriately informed prior to consenting to the procedure. (Refer to A-0131).



2. The facility failed to ensure for two of 30 sampled patients (Patient 19 and Patient 30), personal privacy was provided when, Patient 19 and Patient 30 ' s room door was not closed and there were no privacy curtains in Patient 19 and Patient 30 ' s room during Patient 19 and Patient 30 ' s treatment care.



These deficient practices resulted in Patient 19 and Patient 30 ' s right to dignity and personal privacy violated by being exposed to the general public within the patient care area. (Refer to A-0143).



3. The facility failed to ensure one of six sampled employees (Wound Care Coordinator (WCC)), had a background check completed upon hiring to the facility.



This failure had the potential to result in the facility not providing care in a safe setting. (Refer to A-0144).







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

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

1.The facility failed to develop a nursing care plan (a document addressing a patient ' s health and care needs, along with a plan to meet those needs) addressing diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pain (an unpleasant sensory and emotional experience), hypertension (HTN, high blood pressure), sepsis (when the body ' s response to an infection spirals out of control), restraint (a device that limit a person ' s movement) use, and bleeding (loss of blood) for four of 30 sampled patients (Patient 3, Patient 5, Patient 6, Patient 9).

This deficient practice had the potential to result in Patient 3, Patient 5, Patient 6, and Patient 9 not receiving the right level of care and not meeting the needs for the identified patient ' s concerns. (Refer to A-0396).

2.The facility failed to:

A. Based on interview and record review the facility failed to ensure their staff adhered to the policy and procedure (P&P) for "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," when the facility ' s staff failed to provide safety checks and monitoring every two hours and provide a physician ' s order for restraint (a device that limit a person ' s movement) for one of 30 sampled patients (Patient 3) while on physical restraints.

This deficient practice had the potential to result in life-threatening harm and injury to Patient 3 due to the lack of assessments (evaluation) and monitoring by the facility ' s staff and violate Patient 3 ' s rights by not ensuring medical necessity for the use of restraints and false imprisonment (unlawful restraint of a person against their will). (Refer to A-0398).





B. Ensure facility ' s staff document all meal intake assessments on multiple days per facility policy for one of 30 sampled patients (Patient 13).

This failure had the potential to result in lack of documentation to indicate if Patient 13 was receiving adequate nourishment throughout her admission at the facility. (Refer to A-0398).

C. For one of 30 sampled patients (Patient 14), to ensure wound care was completed on Patient 14 ' s pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) located on his sacrum (triangular bone at the base of the spine), left lateral (side) thigh (the part of the human leg between the hip and the knee), right ischium (a paired bone forming the lower and back part of the hip bone), and right ischial tuberosity (sit bone) on multiple days per facility policy.

This failure resulted in unnecessary pain and suffering through the development of Patient 14 ' s pressure injuries which could have caused infection. (Refer to A-0398).

D.. For one of 30 sampled patients (Patient 30), to ensure Patient 30 ' s mitten restraint (a manual method, physical or mechanical device that prevent patients from pulling out nutrition tubes or fluid lines that are being used to give medication) safety checks were being assessed and completed as ordered while mitten restraint was used on Patient 30.



This deficient practice had the potential for Patient 30 to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc. could have resulted in injury to Patient 30 or even death due to lack of monitoring. (Refer to A-0398).

E. Ensure three of 30 sampled patients (Patient 20, Patient 21, and Patient 25) were turned and repositioned (to change someone's body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin) and pressure injury prevention.



These deficient practices resulted in the potential for Patient 20, Patient 21 and Patient 25 to develop a pressure injury (PI, breakdown of skin/tissue due to prolonged pressure, often over a bony part of the body) and/or worsen an existing PI, which may lead to complications such as infection, the need for surgery to debride (remove) dead tissue, etc. (Refer to A-0398).

F. Document pain level for one of 30 sampled patients (Patient 11) for pain reassessment after receiving pain medication in medical record.

This deficient practice had the potential result in Patient 11 ' s pain level was not reassessed and evaluate for effectiveness of administration of pain medication in the medical record per hospital policy. (Refer to A-0398).

3. The facility failed to:

Ensure pain medication was administered correctly per physician order for three of 30 sampled patients (Patient 14, Patient 27, and Patient 29).

This failure resulted in Patient 14 ' s safety being at risk due to higher drug levels being administered than originally ordered, which could have led to respiratory failure or even death. And had the potential for Patients 27 and Patient 29 ' s medical condition to not be managed and had the potential to cause adverse health outcomes which could negatively affect the patients ' health and safety due to unsafe medication administration and may lead to prolonged hospitalization. (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's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide policy and procedures (P&P, formal guidelines that a hospital uses to manage its operations and ensure consistent performance include step by step instructions for implementing the performance) for elopement (the act of leaving a facility unsupervised and without prior authorization) to ensure the facility's staff protects patients and provides a safe environment of care and quality patient care.

This deficient practice resulted in Patient 26, who had allegedly eloped (escaped) from the facility and identified as danger to self. Patient 26 was unable to be located this may have the potential to result in Patient 26 harming self and could cause injury and/or death to the patient. This deficient practice also had the potential in putting other patients at risk for injury due to lack of an elopement policy and procedures in place.

During a review of Patient 26's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/9/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). Patient 26 had history of subdural hematomas (a pool of blood between the brain and its outermost covering) post evacuation (surgery to remove subdural hematomas).

During a concurrent interview and record review on 7/22/2025 at 2:22 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's "Change of condition," (a decline in a patient's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care) dated 5/23/25 at 09:40 a.m., indicated "patient (Patient 26) eloped the building at around 08:30 a.m. I was in the medication room pulling out medications to be given for my patient's. My attention was called because the patient was roaming around the building. Charge Nurse and other nurses walked in the medication room and I asked the patient if he could take his morning medications and go back to the designated room, unfortunately he refused to take his medications, so I went back in the med room and return the meds. And then I heard code gray (a hospital-wide call for help indicates "security emergency/combative person"), then went out to check where because it was announced where. Unfortunately, the patient went out the building because everyone who approached him could not touch him and he doesn't listen or follow any instructions."

During a concurrent interview and record review on 7/22/2025 at 2:22 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's "Change of condition," dated 5/23/25 at 09:40 a.m., indicated hospital personnel tried to stop the patient (Patient 26) but was unable to prevent the patient to walk out of the hospital. The police arrived and patient (Patient 26) was escorted back to the hospital.

During a concurrent interview and record review on 7/22/2025 at 2:22 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's "Change of condition," dated 5/23/25 at 09:40 a.m., indicated Registered Nurse (RN) 9 "I (RN 9) spoke with security personnel regarding the incident of the patient's elopement, and he said to secure the lock in the front door entrance."

During a concurrent interview and record review on 7/22/2025 at 3:03 p.m., with Registered Nurse (RN) 9, RN 9 stated on the morning of 5/23/2025 Patient 26, was restless and insisted in going home. RN 9 stated the patient was dressed in civilian clothes, but she did not believe Patient 26 would eloped. RN 9 stated she when to get Patient 26's medications and when she returned to Patient 26's room he was not there. RN 9 stated she recalled hearing the announced code gray "indicating security emergency or combative person." RN 9 stated she did not know immediately that Patient 26 had eloped as the hospital does not have a code for elopement (to alert everyone of a missing /eloping patient who is determined to be a danger to themselves or has been identified as a safety risk).
During a concurrent interview and record review on 7/22/2025 at 2:22 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's "Change of condition," dated 5/23/25 at 09:40 a.m., indicated "I (RN 9) spoke with security personnel regarding the incident of the patient's elopement, and he said to secure the lock in the front door entrance."

During a concurrent interview and record review on 7/22/2025 at 3:40 with Director of Quality (DQ) and Nursing Supervisor (NS) 2, NS 2 verified the facility did not have a policy and procedures on patient elopement and no guidelines. NS 2 stated the facility used code gray (security emergency or combative person) for patient elopement. NS 2 verified the facility did not have policy and procedures on code gray. NS 2 stated it was important to have a policy and guidelines regarding patient elopement to provide a safe environment of care.

During a concurrent interview and record review on 7/22/2025 at 3:40 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's physicians notes titled, "Patient Care Summary (Progress Notes)," dated 5/23/25 at 5:07 p.m., indicated "The patient (Patient 26) is seen this morning. He is in restraints. He is sedated. Apparently, I am informed that the patient attempted to run away from the hospital in a psychotic state. He is back. We are examining him as noted."

During a concurrent interview and record review on 7/22/2025 at 3:40 p.m., with Nursing Supervisor (NS) 2, NS 2 verified Patient 26's physicians notes titled, "Patient Care Summary (Progress Notes)," dated 5/23/25 at 11:32 p.m., indicated "Patient (Patient 26) is on room air, he is currently lying in bed, sitter at bedside. Patient seemed calm. Per nursing patient had an elopement earlier today at approximately 08:30 a.m. Per incident reported, patient became very agitated, noncompliant and combative and ran out of hospital into the street on Slauson. A code grey was called for assistance, and the patient was returned to his room with the assistance of the hospital personnel and the police ..."

During a concurrent interview and record review on 7/22/2025 at 3:49 p.m., with Chief Operating Officer (COO), COO stated he was notified Patient 26 was out of the unit and attempting to leave the hospital. COO stated "I was with him (Patient 26) the entire time. I caught him at the same time patient was walking out of the hospital, the police arrived, and house supervisor, nurses, and security staff was present." COO stated Patient 26 appeared confused and was combative verbalizing something in Spanish. COO stated the facility uses code gray for patient elopement.

During a concurrent interview on 7/24/2025 at 3:18 p.m., with Director of Quality (DQ), DQ stated policies and procedures came from corporate. DQ stated the facility was in the process of creating a guideline for patient elopement. DQ verified the facility did not have policy and procedures for code gray (facility uses code gray to indicate patient elopement).

During a concurrent interview, on 7/24/2025 at 4:50 p.m., with the Chief of Staff (CS), CS stated the facility's GB has the ultimate responsibility and authority of the hospital including patient safe environment. The CS stated it is important to have a policy and procedure for code gray (facility uses code gray to indicate patient elopement) to ensure patient safety and to have a standardized education response protocol. CS stated the facility required two different policies and procedures (P&P) one referring to code gray "indicating security emergency or combative person" and the other P&P referring to "patient elopement" because providing a safe environment of care is their responsibility.


During a review of the facility's GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) titled, "Bylaws of (facility's name)," dated 06/2023, the document indicated, "The Board shall conduct itself as a forum for the discussion of matters of Hospital policy and practice, especially those pertaining to efficient and effective patient care so as provide medico-administrative liaison between the Board, the medical staff, and the Hospital CEO. It shall further have the responsibility for development and continuing review of the Hospital's statutory, regulatory and accreditation program ...The Board shall communicate with the Medical Staff regarding its activities and actions. The Board will require the medical staff and hospital staff as appropriate to revise policies and procedures as needed and to ensure review of all department policies and procedures at least annually ..."

Based on observation, interview, and record review, the facility failed to ensure one of thirty 30 sampled patients' (Patient 7) consent for debridement (medical procedure to remove damaged, dead or infected tissue from wound) procedures was obtained in accordance with the facility ' s policy and procedures.



This deficient practice resulted in Patient 7 ' s consent was not obtained that jeopardizing patient safety and violating patients ' right to be appropriately informed prior to consenting to the procedure.



Findings:



During a review of Patient 7 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/27/2019, indicated that Patient 7 was admitted on 2/25/2019 with respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), quadriplegia (paralysis from the neck down, affecting all four limbs), and sacral fracture ( a break in the sacrum, a triangular bone at the base of the spine that connects to the pelvis).



During a concurrent interview and record review on 7/22/2025 at 10:15 a.m. with Nursing Supervisor (NS1), Patient 7 ' s Electronic Medical Record (EMR) of progression note (written records detailing a patient's clinical status and treatment during a hospital stay or outpatient care) was reviewed. The progress note indicated that Patient 7 had a total of 13 times (4/1/2019, 4/5/2019, 4/8/2019, 4/10/2019, 4/11/2019, 4/12/2019, 4/14/2019, 4/15/2019, 4/16/2019, 4/17/2019, 4/18/2019, 4/22/2019, and 4/23/2019) sharp wound debridement on sacral area (tailbone) that was performed by the General Surgeon (MD2).



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/1/2019, indicated "Sharp excisional (surgical removal of tissue by cutting it out) debridement was undertaken utilizing (use) scissors through all the tissue through muscle and through some fascia (tissue that surround and support every structure in the body) in the midportion of this large area of unstable wound (full thickness tissue loss that can not be assess due to the center being block)". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.

During a review of Patient 7 ' s Progress Note that created by general surgeon (MD2) dated 4/5/2019, indicated "again surgically sharp debridement with excisional in nature utilizing scissors down to tissue ...". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/8/2019, indicated "I have sharply excisionally utilizing scissors debrided as much tissue that is wet and the necrotic as possible ...". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/10/2019, indicated "Sharp excisional debridement is undertaken of all the areas that are necrotic (dead) all the way down to the bone". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/11/2019, indicated "Again I debrided". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/12/2019, indicated "The area again is debrided extensively utilizing scissors down throughout the wound ...". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/14/2019, indicated "Sharp excisional debridement utilizing scissors was undertaken this morning again ...". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/15/2019, indicated "I have elected again to debride the wound today excisional deep with scissors". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by general surgeon (MD2) dated 4/16/2019, indicated "I have personally again now debrided the areas that will not help the purulence (thick yellowish fluid). There is moderate granulation (process of forming grains) noted in the periphery (outside of something). Have nicely debrided". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/17/2019, indicated "I have personally again now debrided the wound again on a consecutive day through all tissue levels. Excisional with scissors ...". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General surgeon (MD2) dated 4/18/2019, indicated "I have elected again to debride to debride it today excisional sharp with scissors". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/22/2019, indicated "I did debride a small area of residual necrosis (dead) posteriorly(behind), but down to some areas of bone". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a review of Patient 7 ' s Progress Note that created by General Surgeon (MD2) dated 4/23/2019, indicated "I locally debrided with scissors to try and remove as much as possible". There was no indication that MD2 obtained sharp wound debridement consent from Patient 7.



During a concurrent interview and record review on 7/22/2025 at 10:45 a.m. with Nursing Supervisor (NS1), Patient 7 ' s paper chart was obtained from medical records department. Reviewed paper chart with NS1, NS1 state was unable to find the signed debridement consent forms for all 13 times (4/1/2019, 4/5/2019, 4/8/2019, 4/10/2019, 4/11/2019, 4/12/2019, 4/14/2019, 4/15/2019, 4/16/2019, 4/17/2019, 4/1820/19, 4/22/2019, and 4/23/2019) debridement procedures.



During a concurrent interview and record review on 7/22/2025 at 1:15 p.m. with Medical Doctor (MD1) stated provider should document in the progress note and obtained signed consent for any sharp wound debridement. Reviewed Patient 7 ' s progress note dated 4/1/2019 with MD1, indicated that MD2 documented "Sharp excisional debridement was undertaken utilizing scissors through all the tissue through muscle and through some fascia in the midportion of this large are of unstable wound". Concurrently on the same progress note; no indication of any form of consent were given and obtained from Patient 7.



During a review of the facility ' s policy and procedure (P&P) titled, Conservative Sharp Wound Debridement, policy number H-PC 10-012, original date 8/2012 and release date 6/2018, indicated, "explain the procedure to the patient or caregiver to include: advantages, disadvantages, risks, potential complications and obtain signed consent form as appropriate. H-CO-026-0000 informed consent for conservative sharp debridement/nonexcisional debridement."

Based on observation, interview, and record review, the facility failed to ensure for two of 30 sampled patients (Patient 19 and Patient 30), personal privacy was provided when, Patient 19 and Patient 30 ' s room door was not closed and there were no privacy curtains in Patient 19 and Patient 30 ' s room during Patient 19 and Patient 30 ' s treatment care.



These deficient practices resulted in Patient 19 and Patient 30 ' s right to dignity and personal privacy violated by being exposed to the general public within the patient care area.



Findings:



1. During a record review of Patient 19 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 05/15/25, indicated Patient 19 was admitted on 05/15/25 from a Skilled Nursing Facility (SNF- a facility that provides 24-hour medical care and rehabilitation services for individuals recovering from illness, injury, or surgery) with a diagnosis of Congestive Heart Failure (CHF – a heart disorder which causes the heart to not pump the blood efficiently), pneumonia (an infection/inflammation in the lungs), a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), plural effusion (a buildup of fluid around the lungs), hypoxia (low levels of oxygen in your body tissues), acute respiratory failure (when the lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning) requiring intubation (a medical procedure where a tube is inserted into the body, most commonly through the mouth or nose and into the trachea [wind pipe], to establish and maintain an open airway).



During a record review of Inpatient GI Procedure Note dated 05/30/35, the Inpatient GI Procedure Note indicates a placement of Patient 19"s g-tube (thin flexible tube inserted into through abdominal wall into the stomach) indicated for feedings.



During an observation on 7/23/25 at 9:20 a.m. in hallway located outside of Patient 19 ' s room, it was observed Licensed Vocational Nurse (LVN) 1 administering Patient 19 a g-tube treatment. LVN 1 then removed gloves, washed hands with hand sanitizer, donned a new pair of gloves, and readjusted Patient 19 ' s heel protectors and covered Patient 19 with a blanket. The door to the room was open during the treatments and there was no privacy curtain surrounding Patient 19 ' s bed.



During an interview on 7/23/25 at 9:30 a.m. in hallway outside of Patient 19 ' s room, LVN 1 stated he was checking Patient 19 ' s residuals (aspirating stomach contents to assess the amount of fluid remaining in the stomach before or during a g-tube feeding) and g-tube placement. LVN 1 stated he had also completed Patient 19 ' s bath prior to checking residuals.



During a concurrent observation and interview on 7/23/25 at 9:35 a.m. with the Resource Chief Operating Officer (RCOO) in hallway outside of Patient 19 ' s room, the absence of curtains around Patient 19 ' s bed was observed. RCOO stated, "I don ' t know why. I ' ll get on it. I will check on it. I think it [privacy curtains being removed from around the beds in room] happened last night." RCOO stated it was important to always provide privacy to patients.



During a review of the facility ' s policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2022, the P&P indicated, "This policy establishes guidelines to provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patients..."





During a review of the facility ' s patient admission document titled, "Patient ' s Rights and Responsibilities," (undated), the document indicated, "7. The right to full consideration of privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual."





2. During an observation on 7/23/2025 at 9:25 a.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 30 ' s room door was observed wide open and had no privacy curtains. The LVN was inside Patient 30 ' s room, providing Patient 30 ' s gastrostomy tube (GT- a flexible tube surgically inserted through the abdominal wall into the stomach for the administration of food and medication) treatment care. Patient 30 was expose to anyone walking through during the GT treatment care.



During an interview on 7/23/2025 at 9:30 a.m., with LVN 1, LVN 1 stated he was providing GT treatment care for Patient 30. The LVN 1 stated Patient 30 ' s room did not have a privacy curtain and anyone walking outside Patient 30 ' s room could see the Patient 30 ' s GT site. LVN 1 stated Patient 30 ' s room should have a privacy curtain. LVN 1 stated it is the patient ' s right to have privacy.



During an interview on 7/23/2025 at 9:35 a.m., with Resource Chief Operating Officer (RCOO), RCOO stated the patient ' s door or privacy curtains should be closed when performing a treatment of care to protect the patient ' s privacy. RCOO stated Patient 30 ' s room does not have a privacy curtain, and the patient ' s room door should have been closed for privacy.



During a review of Patient 30 ' s "History and Physical (H&P, a document containing a patient ' s medical information), dated 2/12/2025, the H&P indicated Patient 30 was admitted for sepsis (a life-threatening blood infection).



During a review of the facility ' s policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2022, the P&P indicated, "This policy establishes guidelines to provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patients..."



During a review of the facility ' s patient admission document titled, "Patient ' s Rights and Responsibilities," (undated), the document indicated, "7. The right to full consideration of privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual."

Based on interview and record review, the facility failed to ensure one of six sampled employees (Wound Care Coordinator (WCC)), had a background check completed upon hiring to the facility.



This failure had the potential to result in the facility not providing care in a safe setting.



Findings:



During a concurrent record review and interview on 7/24/2025 at 11:54 PM with the Education Manager (EM), the employee personnel record for the Wound Care Coordinator (WCC) was reviewed. The record indicated no background check was ever documented to be completed for the WCC. The EM stated all employees should have a background check completed upon hiring to the facility.



During an interview on 7/24/2025 at 3:40 PM with the Director of Quality (DQ), the DQ stated, the importance of background checks being completed for all employees upon being hired was to ensure the employee being hired did not have any criminal history because they would not want any person with a criminal history to care for the patients at their facility due to risk for patient safety.



During a review of the facility ' s Employee Handbook, undated, the handbook indicated, "in order to protect the patient under our care . . . [name of facility] conducts various types of screenings after an individual has been extended an offer of employment. These screenings may include . . . criminal background checks. All offers of employment are conditional upon the successful completion of any required background checks."

Based on interview and record review, the facility failed to develop a nursing care plan (a document addressing a patient ' s health and care needs, along with a plan to meet those needs) addressing diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), pain (an unpleasant sensory and emotional experience), hypertension (HTN, high blood pressure), sepsis (when the body ' s response to an infection spirals out of control), restraint (a device that limit a person ' s movement) use, and bleeding (loss of blood) for four of 30 sampled patients (Patient 3, Patient 5, Patient 6, and Patient 9).

This deficient practice had the potential to result in Patient 3, Patient 5, Patient 6, Patient 9 not receiving the right level of care and not meeting the needs for the identified patient ' s concerns.



Findings:

A. During a review of Patient 3 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/2/25, with the Market Clinical Analyst (MCA), the H&P indicated Patient 3 was admitted with right-sided weakness and slurred speech. Patient 3 ' s past medical history include high blood pressure (HTN,), depression (feeling of sadness and loss of interest), stroke (cerebrovascular accident [CVA], loss of blood flow to a part of the brain) in 2024, post right knee replacement (procedure where damaged parts of knee joint are replaced with components made of metal and plastic), hypothyroidism (condition where the thyroid gland doesn ' t produce enough thyroid hormone), migraine (headache with other symptoms like nausea, sensitivity to light and sound, and visual disturbances), and chronic pain syndrome (persistent pain that lasts weeks to years).



During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA stated there was no care plan for restraint use. MCA further stated care plans for restraint use were not included in the patient ' s Electronic Medical Record (EMR-digital version of the patient ' s medical information) Per the MCA, restraint orders and care plans were kept in the patient ' s paper chart located at the nursing station(s).



During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA stated there was no care plan addressing Patient 3 ' s pain. MCA stated Patient 3 has a history of chronic pain; therefore, a care plan should have been initiated. MCA further stated a care plan was important to identify Patient 3 ' s needs and manage interventions for pain management.



During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA stated there was no care plan addressing Patient 3 ' s risk for bleeding. MCA stated a care plan was important to address the bleeding risk as Patient 3 was receiving anticoagulants (medications that prevent or treat blood clots). MCA further stated having a care plan was important due to Patient 3 ' s past medical history of CVA (cerebrovascular accident-loss of blood flow to a part of the brain) and thrombectomy (remove a blood clot).



During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA stated there was no care plan addressing Patient 3 ' s HTN (high blood pressure). MCA stated a care plan for HTN was needed to avoid a repeat of Patient 3 ' s past medical history, including CVA and hypertensive emergency (a severe and life-threatening condition with a sudden and significant increase in blood pressure). MCA stated a plan of care was important to keep Patient 3 ' s blood pressure under control to prevent complications.



During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA states there was no care plan addressing Patient 3 ' s diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). MCA stated a plan of care was important to prevent diabetic associated complications. MCA further stated this was significantly important for a patient, like Patient 3, with multiple co-morbidities (the simultaneous presence of two or more medical conditions in a patient).



During an interview on 7/22/25 at 4:18 p.m., with the Director of Quality (DQ), DQ stated all restraint use required a physician ' s order and care plan. DQ further stated Patient 3 should be monitored every two hours by staff with documentation entered on the safety check log.



During a review of Patient 3 ' s "Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)", (undated), on 7/22/25 at 4:18 p.m., with MAC, Patient 3 ' s MAR indicated Patient 3 was taking losartan (medication to treat high blood pressure [BP]), Labetolol (medication used to treat high blood pressure), Plavix (a medication used to prevent platelets [small cell in our blood that form clots and prevent bleeding] from sticking together and forming clots), Lovenox (anticoagulant medication, to treat and prevent blood clots), nifedipine (medication used to treat high blood pressure and chest pain), and insulin (medication used to manage blood sugar levels in patients with diabetes).

During a review of the facility ' s policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-Assessment", policy number H-PC 02-001, original date 08/2013, release date 06/2023, indicated on pages two and three of 10:

5). Nursing Department

c. The admission assessment data is a primary source for the Registered Nurse (RN) to determine and prioritize nursing needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient ' s goal and the nursing care to be provided to meet the patient specific needs.

f. Patients are re-evaluated by a licensed nurse (RN, Licensed Practical Nurse [LPN]/Licensed Vocational Nurse [LVN] – according to state specific practice acts) at a minimum every 12-hour shift-based on level f care and patient care needs.

iii. An LPN/LVN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurse(s), RN and/or LPN/LVN may update the patient ' s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse.



B. During a review of Patient 5's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/16/2025, with the Market Clinical Analyst (MCA), the H&P indicated Patient 5 was admitted with respiratory insufficiency (lungs can ' t properly exchange gases), liver failure (when the liver can no longer work properly), and acute on chronic kidney disease (CKD, sudden worsening of the kidneys not working properly). Patient 5 ' s past medical history includes diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), high blood pressure, pancreatitis (inflammation of the pancreas), and EtOH abuse (alcohol abuse).



During a concurrent interview and record review on 7/22/25 at 9:57 a.m., with MCA, MCA stated there was no care plan addressing Patient 5 ' s DM. MCA further stated a plan of care should have been initiated to address Patient 5 ' s DM needs to maintain a healthy blood glucose level (simple sugar in the blood) and prevent associated complications like diabetic coma (a life-threatening period of prolonged unconsciousness resulting from very high blood sugar or very low blood sugar) .

During a concurrent interview and record review on 7/22/25 at 9:57 a.m., with MCA, MCA stated there was no care plan addressing Patient 5 ' s high blood pressure. MCA stated that a care plan was important to address Patient 5 ' s high blood pressure since Patient 5 required anti-hypertensive medication (used to treat high blood pressure) and to prevent complications that may further complicate Patient 5 ' s diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD, sudden worsening of the kidneys not working properly).

During a concurrent interview and record review on 7/22/25 at 9:57 a.m., with MCA, MCA stated there was no care plan addressing Patient 5 ' s pain. MCA stated that a care plan was important to manage Patient 5 ' s comfort, evaluate interventions (actions taken to improve a situation), and attempt to identify the underlying cause (reason).

During a review of Patient 5 ' s "Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)", with MCA, Patient 5 ' s MAR indicated Patient 5 received insulin lispro(medication used to manage blood sugar levels in patients with diabetes) with units based on a sliding scale based on Patient 5 ' s glucose levels before meals and at bedtime, and oxycodone immediate release (a strong opioid pain medication used to manage moderate to severe pain) every four hours as needed for pain.

During a review of the facility ' s policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-Assessment", policy number H-PC 02-001, original date 08/2013, release date 06/2023, indicated on pages two and three of 10:

Nursing Department

c. The admission assessment data is a primary source for the Registered Nurse (RN) to determine and prioritize nursing needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient ' s goal and the nursing care to be provided to meet the patient specific needs.

f. Patients are re-evaluated by a licensed nurse (RN, Licensed Practical Nurse [LPN]/Licensed Vocational Nurse [LVN] – according to state specific practice acts) at a minimum every 12-hour shift-based on level f care and patient care needs.

iii. An LPN/LVN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurse(s), RN and/or LPN/LVN may update the patient ' s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse.

C. During a review of Patient 6's History &Physical (H&P) dated 5/12/2025, with Market Clinical Analyst (MCA,) the H&P indicated Patient 6 was admitted with a history of hypothyroidism (the thyroid gland does not produce enough thyroid hormone) and depression (feeling of sadness and loss of interest). Patient 6 was also treated for gram-positive sepsis (a life-threatening blood infection caused by bacteria that give a positive result in the Gram stain test) and pneumonia (an infection/inflammation in the lungs). Patient 6 had a history of methicillin-resistant staphylococcus aureus (MRSA) pneumonia (an infection in the lungs caused by a bacteria that does not respond to antibiotics).



Patient 6 had a past medical history of schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), HTN (high blood pressure), subarachnoid hemorrhage (bleeding in the brain), cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), nephrolithiasis, epilepsy (seizure disorder – a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). Patient 6 was in a board and care facility (a small, residential setting that provides housing, meals, and personal care assistance) and became unresponsive and started shaking.



During a concurrent interview and record review on 7/22/25 at 2:13 p.m., with MCA, MCA stated there was no care plan addressing Patient 6 ' s hypertension (high blood pressure). MCA stated this was concerning since Patient 6 currently required norepinephrine (medication used as an intravenous [IV] drip in critical care settings to address hypotension [low blood pressure]) and midodrine (medication to treat low blood pressure). MCA stated it was important to update Patient 6 ' s care plan to ensure Patient 6 was not receiving antihypertensive medication (use to lower blood pressure) which may contribute to low blood pressure. MCA further stated it was important to have a care plan in place if Patient 6 ' s blood pressure returns to a high state.

During a concurrent interview and record review on 7/22/25 at 2:13 p.m., with MCA, MCA stated there was no care plan addressing Patient 6 ' s epilepsy. MCA stated this was important to ensure Patient 6 ' s safety. MCA further stated Patient 6 had a history of traumatic brain injury and subarachnoid hemorrhage; therefore, safety measures during seizure activity were required to prevent further injury. MCA stated having a plan to prevent injury was important for patients with seizure activity due to the involuntary jerking movements exhibited by a patient during seizure activity.

During a concurrent interview and record review on 7/22/25 at 2:13 p.m., with MCA, MCA stated there was no care plan addressing Patient 6 ' s bleeding. MCA stated a care plan was important to prevent hemorrhaging (excessive bleeding resulting in significant loss of blood) due to Patient 6 ' s history of subarachnoid hemorrhage. MCA further stated that a plan was also important due to Patient 6 being on Heparin (a medication that prevents blood clots from forming).

During a review of Patient 6 ' s Medication Administration Record (MAR-document use to track every medication administered to a patient), with MCA Patient 6 ' s MAR indicated Patient 6 received meropenem (antibiotic used to treat various bacterial infections) one gram daily, heparin (prevent and treat blood clots) 5,000 units every 12 hours, levetiracetam (an antiepileptic drug used to manage and control seizures caused by epilepsy) 1,000 milligrams (mg) every 12 hours, and insulin lispro (lower blood sugar) with units based on Patient 6 ' s glucose levels every six hours and as needed.



During a review of the facility ' s policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-Assessment", policy number H-PC 02-001, original date 08/2013, release date 06/2023, indicated on pages two and three of 10:

Nursing Department

c. The admission assessment data is a primary source for the Registered Nurse (RN) to determine and prioritize nursing needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient ' s goal and the nursing care to be provided to meet the patient specific needs.

f. Patients are re-evaluated by a licensed nurse (RN, Licensed Practical Nurse [LPN]/Licensed Vocational Nurse [LVN] – according to state specific practice acts) at a minimum every 12-hour shift-based on level f care and patient care needs.

iii. An LPN/LVN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. The licensed staff nurse(s), RN and/or LPN/LVN may update the patient ' s needs/problems and plan of care based on results of clinical findings gathered by the licensed nurse.



D. During a review of Patient 9's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/15/2025, the H&P indicated Patient 9 ' s was admitted on 7/1/2025 due to respiratory insufficiency ( the respiratory system can't adequately exchange gases, leading to low blood oxygen), sepsis (a body ' s overwhelming and life-threatening response to infection), and cellulitis (an infection of the deeper layers of skin and the underlying tissue).



During a review of Patient 9's Physician Order dated 7/15/24 at 10:12 p.m., hydromorphone (Dilaudid - is a powerful opioid analgesic used to treat moderate to severe pain) was ordered intravenous (IV) 0.5 milligram (mg-unit of weight) every 4 hours as needed for severe pain (subjective experience that doctors often rate on a pain scale of 1 to 10, with 7 and above considered severe).



During a concurrent interview and record review on 7/23/2025 at 10:55 a.m., with Clinical Supervisor (CS2), Patient 9's Medication Administration Record (MAR- document use to track every medication administered to a patient) was reviewed and it indicated the patient was complaining of pain daily and requested pain medication daily since admission. Concurrently, care plan was also reviewed. The care plan indicated no plan of care for pain management was developed for Patient 9. CS2 stated the nurse should have developed a plan of care for acute pain for Patient 9. The nurse must develop a care plan for all actual or potential patient's needs to plan patient care 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, Patient Care Planning, dated 8/2019, indicated the Plan of Care/Problem list is individualized and based upon the patient needs, patient goals, timeframes, settings and services required to meet the patient's needs and/or goals and the data collected during the interdisciplinary assessment process. Expected patient outcomes and/or goals will be realistic and measurable. The Care Plan/Problem List will be reviewed and updated every shift and as patient condition, and progress indicates.

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

A. Ensure their staff adhered to the policy and procedure (P&P) for "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," when the facility ' s staff failed to provide safety checks and monitoring every two hours and provide a physician ' s order for restraint (a device that limit a person ' s movement) for one of 30 sampled patients (Patient 3) while on physical restraints.

This deficient practice had the potential to result in life-threatening harm and injury to Patient 3 due to the lack of assessments (evaluation) and monitoring by the facility ' s staff and violate Patient 3 ' s rights by not ensuring medical necessity for the use of restraints and false imprisonment (unlawful restraint of a person against their will).

B. Ensure facility ' s staff document all meal intake assessments on multiple days per facility policy for one of 30 sampled patients (Patient 13).

This failure had the potential to result in lack of documentation to indicate if Patient 13 was receiving adequate nourishment throughout her admission at the facility.

C. For one of 30 sampled patients (Patient 14), to ensure wound care was completed on Patient 14 ' s pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) located on his sacrum (triangular bone at the base of the spine), left lateral (side) thigh (the part of the human leg between the hip and the knee), right ischium (a paired bone forming the lower and back part of the hip bone), and right ischial tuberosity (sit bone) on multiple days per facility policy.

This failure resulted in unnecessary pain and suffering through the development of Patient 14 ' s pressure injuries which could have caused infection.

D. For one of 30 sampled patients (Patient 30), to ensure Patient 30 ' s mitten restraint (a manual method, physical or mechanical device that prevent patients from pulling out nutrition tubes or fluid lines that are being used to give medication) safety checks were being assessed and completed as ordered while mitten restraint was used on Patient 30.



This deficient practice had the potential for Patient 30 to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc. could have resulted in injury to Patient 30 or even death due to lack of monitoring.

E. Ensure three of 30 sampled patients (Patient 20, Patient 21, and Patient 25) were turned and repositioned (to change someone's body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin) and pressure injury prevention.



These deficient practices resulted in the potential for Patient 20, Patient 21 and Patient 25 to develop a pressure injury (PI, breakdown of skin/tissue due to prolonged pressure, often over a bony part of the body) and/or worsen an existing PI, which may lead to complications such as infection, the need for surgery to debride (remove) dead tissue, etc.

F. Document pain level for one of 30 sampled patients (Patient 11) for pain reassessment after receiving pain medication in medical record.

This deficient practice had the potential result in Patient 11 ' s pain level was not reassessed and evaluate for effectiveness of administration of pain medication in the medical record per hospital policy.

Findings:
A. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/2/25, with the Market Clinical Analyst (MCA), the H&P indicated Patient 3 was admitted with right-sided weakness and slurred speech. Patient 3's past medical history include hypertension (HTN-high blood pressure), depression (feeling of sadness and loss of interest), stroke (cerebrovascular accident [CVA], loss of blood flow to a part of the brain) in 2024, post right knee replacement (procedure where damaged parts of knee joint are replaced with components made of metal and plastic), hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone), migraine (headache with other symptoms like nausea, sensitivity to light and sound, and visual disturbances), and chronic pain syndrome (persistent pain that lasts weeks to years).
During a concurrent interview and record review on 7/22/25 at 10:32 a.m., with MCA, MCA stated there was no care plan for restraint. MCA further stated care plans are not included in the patient's electronic medical record. Per MCA, restraint orders and care plans are kept in the patient's paper chart located at the nursing station(s).
During a concurrent interview and record review on 7/22/25 at 3:30 p.m., with MCA, Patient 3's restraint safety checks and monitoring log (document used for a patient on restraints to monitor and assess their needs and safety) was missing documentation on 7/21/25 at 8:00 p.m. through 7/22/25 at 6:00 a.m. MCA validated the missing documentation and stated the missing documentation for Patient 3's restraint safety log should be completed in real time every two hours. MCA further stated documentation and monitoring are important for the patient's safety.
During an interview on 7/22/25 at 4:18 p.m., with the Director of Quality (DQ), DQ stated all restraint use required a physician's order and care plan. DQ further stated Patient 3 should be monitored every two hours by staff with documentation entered on the safety check log.
During a record review on 7/24/25 at 1:10 p.m. of Patient 3's "Paper Chart (a patient's medical information recorded on paper)," Patient 3's restraint documents missing the following:
" 5/2/25 physician's order missing physician signature
" 5/2/25 "Registered Nurse (RN) 30-minute Post Restraint Application Safety Check", of the physician's order, documented as the same time for the initial restraint application.
" 5/3/25 monitoring log missing documentation for 8:00 p.m. through 6:00 a.m. on 5/4/25
" 5/3/25 monitoring log missing patient label to identify patient (original copy located in Patient 3's paper chart)
" 5/5/25 RN 30-minute post safety check of the physician's order, documented as the same time for initial restraint application.
" 5/5/25 physician's order missing indicated reason for restraint use of the "Physician Assessment/Restraint Order Confirmation"
" 5/6/25 missing "Daily Assessment to Determine Need for Restraint(s)" of the monitoring log documentation and the RN's signature, date, and time
" 5/14/25 monitoring log missing "RN ONLY" documentation for 8:00 p.m. through 6:00 a.m. on 5/15/25. RN only documentation addresses circulatory status and pain management
" 5/17/25 physician's order missing "Restraint Applied By" signature, date, and time
" 5/17/25 RN 30-minute post safety check of the physician's order, missing RN signature, date, and time
" 5/17/25 physician's order missing indicated reason for restraint use
" 5/17/25 "Patient Care Plan During Restraint Use", page two of the physician's order, missing RN signature, date, and time
" 5/17/25 monitoring log missing "RN ONLY" documentation for 8:00 p.m. through 6:00 a.m. on 5/18/25
" 5/18/25 monitoring log missing documentation for 8:00 a.m. through 6:00 p.m.
" 5/22/25 monitoring log missing documentation for 800 a.m. through 6:00 p.m.
" 5/22/25 missing "Daily Assessment to Determine Need for Restraint(s)" of the monitoring log documentation and the RN's signature, date, and time
" 5/24/25 physician's order missing "Restraint Applied By" signature
" 5/24/25 RN 30-minute post safety check of the physician's order, missing RN signature
" 5/24/25 physician's order missing indicated reason for restraint use
" 5/24/25 "Patient Care Plan During Restraint Use", page two of the physician's order, missing RN signature, date, and time
" 5/24/25 monitoring log missing documentation for 8:00 a.m. through 6:00 p.m.
" 5/24/25 missing "Daily Assessment to Determine Need for Restraint(s)" of the monitoring log documentation and the RN's signature, date, and time
" 5/26/25 monitoring log missing documentation for 4:00 a.m. through 6:00 a.m. on 5/27/25
" 7/21/25 physician's order, "Type of Restraint", not indicated
" 7/21/25 RN 30-minute safety check of the physician's order, documented as the same time for the initial restraint application
" 7/21/25 physician's order, Type of Restraint", not indicated
" 7/21/25 monitoring log, "Daily Assessment to Determine Need for Restraint" incomplete
7/22/25 monitoring log "Daily Assessment to Determine Need for Restraint" incomplete

During a review of the facility's P&P, titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07-009, dated 09/1993 original date and 06/2023 release date, the P&P indicated:
6. Clinical/Nursing Staff and Physician/Licensed Practitioner (LP)/Allied Health Practitioner (AHP) Responsibilities:
b. Clinical/Nursing Staff Responsibilities - A RN will perform assessment/reassessment at established intervals and as needed, obtain physician orders, facilitate communication, and document assessments in the patient's medical record according to policy. Assessment and reassessment of the patient occurs at appropriate interval(s): at admission, during the restraint episode, and after the restraint episode, including significant changes in the patient's condition that warranted restraint use. The RN must also complete a safety check post-application restraint no later than 30 minutes after applied. The physician must be notified as soon as possible to obtain a telephone order and to communicate the patient's condition.
c. Patient Plan of Care: The RN will create and modify the patient's plan of care. Other licensed staff (LPN/LVN and RT) may modify the patient plan of care after it is initiated by the RN
ii. Monitoring to Fulfill Care Plan Goals:
2) Is accomplished by the RN staff and/or other designated trained staff who report findings to the RN through observation of a patient, direct face-to-face interaction or related direct examination of the patient.
a. Patient's physical response to restraint use.
b. Maintenance of patient's right, dignity, and safety of restraint application, removal, or re-application.
c. The RN determines if the current restraint should be continued, if less restrictive methods could be used or if restraints could be discontinued based on monitoring data.
Procedure: (page eight of 12) - guidelines for restraint application are required for each restraint episode for non-violent and violent/self-destructive behavior.
Non-Violent Behavior Restraints
For current Inpatients
Initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints Maximum duration: seven calendar days following the calendar day order was obtained (order day plus seven).
ORDERS must include:
The ordering practitioner must complete their part of the assessment attending to any nursing findings and new findings related to the restraint use, type of restraint to be used, and criteria for release.
Review and revise the patient's care plan to add individualized interventions to address the patient's care plan while in restraints
Ongoing Assessment (at least daily) by an RN of the patient's behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met.
Ongoing Safety Checks and Monitoring (at least every two hours or as noted on the designated forms) by the patient's clinical team of the patient's response to the restraint, including any condition changes.
" Visually observe the patient at least every 2 hours for safety needs
" All documentation of patient status should be in real time.

B. During a review of Patient 13's "History and Physical (H&P)," dated 1/14/2024, the H&P indicated, Patient 13 admitted to the facility on 1/14/2025 for respiratory failure (inability to breathe sufficiently on one' own). Patient 13 had a past medical history of pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and cardiopulmonary arrest (the sudden and unexpected cessation of effective heart and lung function).
During a concurrent interview and record review on 7/22/25 at 12:00 PM with the Education Manager (EM), the "Nutrition Nurse Notes," (use to document patient oral intake) dated multiple dates were reviewed. The "Nutrition Nurse Notes," indicated:
" On 6/27/204, only dinner was documented as being offered and accepted
" On 6/28/2024, no meal was documented to be offered nor accepted
" On 6/29/2024, no meal was documented to be offered nor accepted
" On 6/30/2024, breakfast and lunch were offered and accepted; dinner was not documented to be offered
" On 7/3/2024, no meal was documented to be offered nor accepted
" On 7/4/2024, breakfast and dinner were offered and accepted; lunch was not documented to be offered
" On 7/5/2025, breakfast and lunch were offered and accepted; dinner was not documented to be offered.
"
The EM stated Nutritional Nursing Assessments should be documented by nurses every shift for each patient for breakfast, lunch and dinner to know what the patient is consuming every day and to be able to make adjustments in their care if necessary. The EM stated nutritional intake is important for healing, overall health and success during a patient's stay.
During a review of the facility's policy and procedure (P&P) titled, "CORE: Nutrition Care Process - Identifying Nutrition Diagnosis and Responding to Significant Change," dated 06/2023, indicated, "The policy is to ensure" . . . "Through ongoing monitoring, nutrition interventions are evaluated for effectiveness i.e. [that is], food intake" . . . [and] "Documentation of assessments, care plan updates, nutrition interventions, nutrition education, and discharged planning is completed in the medical record."

C. During a review of Patient 14's "History and Physical (H&P)," dated 6/21/2025, the H&P indicated, Patient 14 admitted to the facility on 6/21/2025 for management of respiratory failure (inability to breathe sufficiently on one' own). Patient 14 had a past medical history of stage IV (the most advanced stage of cancer where the cancer cells have spread from their original location to other parts of the body) lymphoma (a type of cancer that affects the body's immune system), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and prior stroke (a medical condition that occurs when blood flow to the brain is interrupted, causing brain cells to die) with residual right sided weakness.
During a review of Patient 14's Wound Care Order for Sacrum (triangular bone at the base of the spine), dated 7/1/2025, the order indicated for sacrum wound, to cleanse wound and soak in Vashe (wound cleansing solution) for 3-5 minutes, apply protective skin barrier, apply Therahoney (medical-grade honey used to promote wound healing) to wound bed with foam dressing. Dressing to be done once daily.
During a review of Patient 14's wound care order for left lateral(side) thigh (the part of the human leg between the hip and the knee), dated 7/1/2025, the order indicated for left lateral thigh, to cleanse wound with Vashe for 3-5 minutes, apply protective skin barrier. Dressing to be done once daily.
During a review of Patient 14's wound care order for right ischium (a paired bone forming the lower and back part of the hip bone), dated 7/3/2025, the order indicated for right ischium, to cleanse wound with normal saline (wound cleansing solution), apply protective skin barrier, apply Triad (type of dressing), large foam dressing. Dressing to be done once daily.
During a review of Patient 14's wound care order for right ischium, dated 7/7/2025, the order indicated the discontinuation of wound care orders for right ischium on 7/7/25.
During a review of Patient 14's wound care order for right ischial tuberosity (sit bone) dated 7/7/2025, the order indicated for the right ischial tuberosity, to cleanse wound with normal saline, apply protective skin barrier, apply Therahoney and cover with foam daily.
During a concurrent record review and interview on 7/22/2025 at 3:30 PM with the Education Manager (EM), Patient 14's wound care assessments, dated multiple dates were reviewed. The assessments indicated:
" On 7/3/2025, wound care was completed on Patient 14's right ischium (not completed for sacrum, and left lateral thigh)
" On 7/4/2025, wound care was completed on Patient 14's right ischium (not completed for sacrum, and left lateral thigh)
" On 7/5/2025, wound care was completed on Patient 14's right ischium (not completed for sacrum and left lateral thigh).
The EM stated all wound care orders should be followed and executed as ordered to ensure all wounds are being treated appropriately with the necessary adjustments in the care depending on the wound's condition.
During a review of the facility's policy and procedure (P&P) titled, "CORE: Clinical Guidelines for Pressure Injury," dated 06/2022, indicated, "The frequency of wound dressing change is depending upon various clinical indicators. Examples include but are not limited to: a. Physician order b. Dressing integrity c. Skin integrity d. incontinence."




D. During a review of Patient 30's "History and Physical (H&P, a document containing a patient's medical information), dated 2/12/2025, the H&P indicated Patient 30 was admitted for sepsis (a life-threatening blood infection).

During an observation on 7/23/2025 at 4:10 pm with License Vocational Nurse (LVN 1) inside Patient 30's room, Patient 30 was observed with right soft wrist restraints.

During an interview, and record review on 7/24/2025 at 11:25 a.m., with Registered Nurse (RN 8), RN 8 stated Patient 30 was assigned to his care. RN 8 stated that he had missed Patient 30's documentation regarding right soft wrist restraint for 7/24/2025 at 8:00 a.m. and 7/24/2025 at 10:00 a.m. RN 8 stated is important to document the safety checks and monitoring (to assess range of motion, comfort, manage safety) at least every 2 hours.

During a concurrent interview and record review on 7/24/2025 at 11:46 a.m., with Chief Compliance Officer (CCO), the CCO verified, Patient 30's "Restraint Care Plan" dated 7/15/2025, indicated mitten restraint order for left and right hand to be applied 7/15/2025 at 06:30 a.m.

The CCO verified Patient 30's "Restraint Care Plan," dated 7/15/2025 indicated the following:

-On 7/15/2025 at 07:00 a.m. (Patient 30 was missing the 30-minute post restrain application safety check)

The CCO verified Patient 30's "Restraint monitoring" dated 7/16/2025 through 7/17/2025 indicated the following:

-On 7/16/2025 at no time indicated, Patient 30's RN missing initials and missing daily assessment to determine need for restraints.

-On 7/17/2025 at 8:00 a.m. indicated, Patient 30's RN missing initials and missing daily assessment to determine need for restraints.


During a concurrent interview and record review on 7/24/2025 at 11:46 a.m., with Chief Compliance Officer (CCO), the CCO verified, Patient 30's "Restraint Care Plan" dated 7/20/2025, indicated mitten restraint order for left wrist and right hand to be applied 7/20/2025 at 02:00 a.m.

The CCO verified Patient 30's "Restraint monitoring" dated 7/21/2025 through 7/22/2025 indicated the following:

-On 7/21/2025 at 8:00 a.m. indicated, Patient 30's RN missing daily assessment to determine need for restraints.

-On 7/22/2025 at 8:00 a.m. indicated, Patient 30's RN missing daily assessment to determine need for restraints.

During a concurrent interview and record review on 7/24/2025 at 11:46 a.m., with Chief Compliance Officer (CCO), the CCO stated the registered nurses were to document the restraint assessment and determine the need for restraints at the end of shift.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," dated 06/2023, indicated "A Registered Nurse (RN) will perform assessment/reassessment at established intervals and as needed, obtain physician orders, facilitate communication and document assessments in the patient's medical record according to policy."
During a review of the facility's Policy and Procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Reassessment," dated 06/2023, indicated, "Patients are re-evaluated by a licensed nurse (RN [registered nurse], LPN[licensed practical nurse]/LVN [licensed vocational nurse] - according to state specific practice acts) at a minimum every 12 hour shift-based on level of care and patient care needs." The P&P also indicated "all nursing assessment(s)/reassessments are recorded in the patient medical record by a licensed nurse."

During a review of the facility's Registered Nurse job description, dated 1/27/2025, the job description indicated, an essential function of a Registered Nurse is "performs assessment on all patients on admission and reassessments as per policy" . . . "receives physician's orders, ensures transcription is accurate and documents completion."


E 1. During a record review of Patient 20's History and Physical (H&P, a formal and complete assessment of the patient and the problem) was admitted on 12/24/2024 for hypertension (high blood pressure), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a slow progressive narrowing of the blood blow to the arms and legs), peripheral polyneuropathy (a disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), right foot transmetatarsal amputation (surgical removal of the foot at the area between the ankle and toes), left foot gangrene (an area where the tissue dies due to a lack of blood supply), and dementia (a progressive state of decline in mental abilities).

During a record review of a physician order dated 12/25/2024 (time unnoted), the physician's order indicated: Reposition Left and Right only. Start 12/25/2024 6:00p.m., every 2 hours, (0 2 4 . . . 22), stop after 45 days.

During a concurrent interview and record review on 07/23/2025 at 2:30 p.m. with the Director of Respiratory and Radiology (DRR), Patient 20's electronic medical record for turning and repositioning schedule, dated 1/06/2025 to1/10/2025, indicated there were times when Patient 20 was not turned and repositioned every 2 hours. The DRR stated the gaps in turning and repositioning can cause a lot of harm, not just to the skin, but other body systems also. The turning and repositioning schedule for Patient 20 for 1/06/2025 to 1/1020/25 indicated the following gaps in turning:
1. 1/06/2025: 6:46 p.m., turned to left side, 10:00 p.m. turned to right side (Patient 20 was not turned or repositioned for a total of 3 hours 14 minutes).
2. 1/07/2025: 7:53 a.m., turned to left side, 11:01 a.m. turned to right side (Patient 20 was not turned or repositioned for a total of 3 hours 8 minutes).
3. 1/09/2025: 11:06 a.m., turned to left side, 9:48 p.m. turned to right side (Patient 20 was not turned or repositioned for a total of 10 hours 42 minutes, excluding a 2 minute repositioning to right side from 2:29 p.m. to 2:41 p.m.).
4. 1/10/2025: 5:06 a.m., turned to right side, 10:28 turned to left side (Patient 20 was not turned or repositioned for a total of 5 hours and 22 minutes).

During a review of Patient 20's Patient Wound Images dated 01/10/2025, the Patient Wound Images indicated a Pressure Injury (PI) to the left hip that was not present on admission.

During a review of Patient 20's Physician Progress Note dated 01/10/2025, the Progress Note indicated a left hip/buttock unstageable pressure injury observed not present on admission.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Clinical Guidelines for Pressure Injury," dated 6/2022, the policy and procedure ( P&P) indicated, " Standard interventions for all patients can include but are not limited to: ...c. Repositioning orders (minimum every 2 hour turns) ...i. Consider turning schedule of every 1 hour if patient is unable to tum and reposition self, has poor nutrition, multiple wounds..."

2. During a record review of Patient 21's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 06/28/2025, indicated Patient 21 was admitted on 06/28/2025 for pneumonia (an infection that inflames [a normal part of the body's response to injury or infection] air sacs [small sacs off the larger breathing tubes in the lungs] in one or both lungs) , congestion (an abnormal accumulation of fluid in a specific area of the body), dysphagia (difficulty swallowing), cardiac arrest (a sudden and unexpected stopping of the heart's pumping action), metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying chemical disturbance), bed bound (being confined to bed, usually due to an illness, injury, or physical limitation that restricts the ability to move), and on a ventilator (a medical device to help support or replace breathing).

During a record review of a physician order dated 6/28/2025 at 4:03 p.m., the physician's order indicated: Repositioning: Start 06/28/2025 at 6:00p.m., every 2 hours, (0 2 4 . . . 22), stop after 45 days.

During a concurrent interview and record review on 07/23/2025 at 2:30 p.m. with the Director of Respiratory and Radiology (DRR), the electronic medical record for turning and repositioning schedule, dated 6/30/2025 to 7/06/2025, indicated there were times when Patient 21 was not turned and repositioned every 2 hours. The DRR stated the gaps in turning and repositioning can cause a lot of harm, not just to the skin, but other body systems also. The turning and repositioning schedule for 6/30/2025 to 7/06/2025 indicated the following gaps in turning:
1. 6/30/2025: 12:15 a.m., Patient 21 was turned to right side and at 6:50 a.m. Patient 21 was turned to left side (Patient 21 was not turned and repositioned for a total of 6 hours 35 minutes).
2. 7/03/2025: 6:00 a.m., Patient 21 was turned to the supine (lying on one's back with the face and body facing upwards) position and at 9:41 a.m. Patient 21 was turned to right side (Patient 21 was not turned and repositioned for a total of 3 hours 41 minutes).
3. 7/03/2025: 12:45 p.m., Patient 21 was turned to the supine position and at 5:01 p.m. Patient 21 was turned to right side (Patient 21 was not turned and repositioned for a total of 4 hours 44 minutes).
4. 7/06/2025: 10:15 a.m., Patient 21 was turned to supine position and at 2:35 p.m. Patient 21 was turned to right side (Patient 21 was not turned and repositioned for a total of 4 hours and 20 minutes).

During a review of the facility's policy and procedure (P&P) titled, "CORE: Clinical Guidelines for Pressure Injury," dated 6/2022, the P&P indicated, " Standard interventions for all patients can include but are not limited to: ...c. Repositioning orders (minimum every 2 hour turns) ...i. Consider turning schedule of every 1 hour if patient is unable to tum and reposition self, has poor nutrition, multiple wounds..."

3. During a review of Patient 25's "History and Physical (H&P, a formal and complete
assessment of the patient and the problem)," dated 12/03/2024, the H&P indicated,
Patient 25 was admitted to the facility on 12/03/2024 at 8:05 p.m. with a diagnosis of respiratory failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood). Patient 25's skin assessment included PI to the sacrum (buttock [butt] area), PI to the left ear, and ecchymosis (bruises) to both arms and hands.

During a concurrent interview and record review, on 7/23/2025 at 10:40 a.m. with the Market Clinical Analyst Administrator (MCA), the MCA verified Patient 25's "Nurses notes," dated 1/17/2025, indicated Patient 25 had an Unstageable pressure injury (a full-thickness skin and tissue loss where the depth of the wound bed is obscured by slough-dead cells, debris and bacteria) on bilateral ischium (sit bone) measuring (length x width) left ischium 5 centimeters (cm, unit of measurement) x (by) 3 cm and right ischium 4 cm x (by) 3 cm.

During concurrent interview and record review on 7/23/2025 at 11:35 a.m. with the MCA, the MCA verified, Patient 25's "Reposition Orders," dated 12/25/2024, indicated Patient 25 to be reposition left and right only every two hours.

The MCA verified Patient 25's "Chronological Retrieval for Reposition data," dated 1/13/2025 through 1/17/2025 indicated the following:

-On 1/13/2025 at 05:35 a.m., Patient 25 was repositioned to right side. Patient 25 was next repositioned to left side on 1/13/2025 at 10:00 a.m. (Patient 25 was not turned and repositioned for a total of 4 hours and 25 minutes).

-On 1/15/2025 at 05:36 a.m., Patient 25 was repositioned to left side. Patient 25 was next repositioned to the right side on 1/15/2025 at 12:33 p.m. (Patient 25 was not turned and repositioned for a total of 6 hours and 57 minutes).

- On 1/17/2025 at 08:29 a.m., Patient 25 was repositioned to left side. Patient 25 was next repositioned to the right side on 1/17/2025 at 2:00 p.m. (Patient 25 was not turned and repositioned for a total of 5 hours and 31 minutes).

The MCA stated Patient 25's Chronological Retrieval for Reposition record indicated there were gaps in Patient 25's turning and repositioning. The MCA stated the patient should be repositioned every two hours to prevent pressure injury (PI).

During a review of the facility's policy and procedure (P&P) titled, "CORE: Clinical Guidelines for Pressure Injury," dated 6/2022, the P&P indicated, " Standard interventions for all patients can include but are not limited to: ...c. Repositioning orders (minimum every 2 hour turns) ...i. Consider turning schedule of every 1 hour if patient is unable to tum and reposition self, has poor nutrition, multiple wounds..."

F. During a review of Patient 11's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/14/2025, the H&P indicated Patient 9's was admitted on 7/14/2025 due to abdominal pan (pain at abdominal area), small bowel obstruction (SBO - condition where the passage of food and fluids through the small intestine is blocked), and Acute Kidney Injury (AKI - sudden decline in kidney function that can lead to a buildup of waste products in the blood and other complications).

During a review of Patient 11's Physician Order dated 7/15/24 at 0:06 a.m., hydromorphone (Dilaudid - is a powerful opioid analgesic used to treat moderate to severe pain) was ordered intravenous (IV) ( method use to administer fluids or medication directly into the vein) push 1 milligram (mg-unit of measurement) every 4 hours as needed for moderate pain (subjective experience that doctors often rate on a pain scale of 1 to 10, with 5-6 considered moderate).
During a concurrent interview and record review on 7/23/2025 at 2:55 p.m., with Clinical Supervisor (CS2), Patient 11's Medication Administration Record (MAR-use to document what medication administered to a patient) was reviewed and patient was complaining abdominal pain 6/10 (pain scale is a numerical scale used to assess pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable) on 7/19/25 at 1:19 a.m. Pain medication hydromorphone 1 mg IV was given at that time. Concurrently, no pain reassessment was documented in the MAR after the pain medication was administered to Patient 11. CS2 stated that the nurse should reassess and document the pain reassessment within 30 minutes if pain medication is administered via IV.

During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed date 6/2023, indicated " Reassessment of pain relief interventions vary according to patient level of pain and patient status ... Recommended timeframes for reassessment of ef

Based on observation, interview and record review, the facility failed to ensure pain medication was administered correctly per physician order for three of 30 sampled patients (Patient 14, Patient 27, and Patient 29).

This failure resulted in Patient 14 ' s safety being at risk due to higher drug levels being administered than originally ordered, which could have led to respiratory failure or even death. And had the potential for Patients 27 and Patient 29 ' s medical condition to not be managed and had the potential to cause adverse health outcomes which could negatively affect the patients' health and safety due to unsafe medication administration and may lead to prolonged hospitalization.

Findings:

1.During a review of Patient 14's "History and Physical (H&P)," dated 6/21/2025, the H&P indicated, Patient 14 admitted to the facility on 6/21/2025 for management of respiratory failure (inability to breathe sufficiently on one' own). Patient 14 had a past medical history of stage IV (the most advanced stage of cancer where the cancer cells have spread from their original location to other parts of the body) lymphoma (a type of cancer that affects the body's immune system), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and prior stroke (a medical condition that occurs when blood flow to the brain is interrupted, causing brain cells to die) with residual right sided weakness.

During a review of Patient 14's medication order for hydromorphone (pain medication), dated 6/24/2025, indicated hydromorphone was ordered as 1 milligram (mg-unit of weight), intravenous (within blood vessels called veins) push, every 3 hours as needed for severe pain of 7 to 10 out of 10 on pain scale (pain scale is a numerical scale used to assess pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable).

During a concurrent record review and interview on 7/22/2025 at 4:00 PM with the Education Manager (EM), Patient 14's Medication Administration Record (use to document medication administered to a patient), dated 6/25/2025 was reviewed. The record indicated on 6/25/2025:
" At 2:43 PM, hydromorphone 1mg was administered for 7 of 10 generalized pain
" At 4:10 PM, hydromorphone 1mg was administered for 10 of 10 chest pain.
The EM stated the second hydromorphone dose at 4:10 PM was not given appropriately because three hours had not passed since the time of the first dose at 2:43 PM. The EM stated this could be dangerous due to drug levels being higher than ordered, which could risk patient safety.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Administration of Medications via Injection," dated 06/2022, indicated, "The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation."

2. During a review of Patient 27's "History & (and) Physical (H&P)," dated 5/28/2025, the H&P indicated Patient 27 was admitted to the facility for respiratory failure (inability to breathe sufficiently on one's own) and myelofibrosis (a rare bone marrow [soft matter inside the bones] blood cancer).

During a concurrent observation and interview, on 7/21/25 at 3:51 p.m., with Registered Nurse (RN) 7, Patient 27 was observed in bed, awake and able to communicate with his pen and notebook. Patient 27 wrote in his notebook that he needed pain medication for his lower back pain.


During a review of a Patient 27's "Medication Administration Record (MAR- use to document medication administered to a patient)," dated 7/23/2025, the MAR indicated a physician's order for Patient 27 to receive the following:

- Hydrocodone/Acetaminophen (narcotic pain medication) 5-325 mg (mg-a unit of measurement) per feeding tube (a device to allow feedings and medications to be administered directly to the stomach common for people with swallowing problems) every 4 hours as needed (PRN) for moderate pain (pain score of 5-6 is moderate pain), with a start date of 5/29/25; and,

- Morphine (narcotic pain medication) 2 mg intravenous (IV- in the vein) push every 4 hours PRN for moderate pain (pain score 5-6 is moderate pain), with a start date of 5/29/2025.

During a concurrent interview and record review on 7/23/2025 at 2:21 p.m., with Market Clinical Analyst Administrator (MCA), MCA verified Patient 27's Medication Administration Record (MAR) indicated on 7/22/2025 at 06:27 a.m., Patient 27 was given Hydrocodone/Acetaminophen 5-325 mg (ordered for moderate pain) 1 tab per feeding tube. MCA verified Patient 27 corresponding pain assessment was 8 (severe pain).

During a concurrent interview and record review on 7/23/2025 at 2:21 p.m., with MCA, MCA stated it was important to give medication according to physician's orders for a safe medication administration. MCA confirmed that Patient 27's order for Hydrocodone/Acetaminophen was for moderate pain and Patient 27 had severe pain.

During a concurrent interview and record review on 7/23/2025 at 2:21 p.m., with MCA verified Patient 27's MAR indicated the following:

-On 7/18/2025 at 10:09 a.m., Patient 27 was given Morphine 2mg (ordered for moderate pain) IV. Patient 27 corresponding pain assessment was 7 (severe pain).

- On 7/19/2025 at 5:21 p.m., Patient 27 was given Morphine 2mg (ordered for moderate pain) IV. Patient 27 corresponding pain assessment was 7 (severe pain).

- On 7/23/2025 at 11:47 p.m., Patient 27 was given Morphine 2mg (ordered for moderate pain) IV. Patient 27 corresponding pain assessment was 9 (severe pain).

During a concurrent interview and record review on 7/23/2025 at 2:21 p.m., with MCA, MCA stated it is important to give medication according to physician's orders for a safe medication administration. MCA confirmed that Patient 27's order for Morphine was for moderate pain and Patient 27 had severe pain.

In the same interview on 7/23/2025 at 2:21 p.m., MCA stated Patient 27's Morphine order was ordered for moderate pain, the nurse should have contacted the physician to address Patient 27's severe pain.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Administration of Medications via Injection," dated 06/2022, the P&P indicated, "The 7 "R's" of administering medications will be followed with each medication administration:
i. "Right" patient
ii. "Right" medication
iii. "Right" dose
iv. "Right" time
v. "Right" route
vi. "Right" reason
vii. "Right" documentation ..."


3. During a review of Patient 29's "History & (and) Physical (H&P)," dated 7/18/2025, the H&P indicated Patient 29 was admitted to the facility for respiratory failure (inability to breathe sufficiently on one's own).

During a review of a Patient 29's "Medication Administration Record (MAR)," dated 7/23/2025, the MAR indicated a physician's order for Patient 29 to receive the following:

- Ipratropium Bromide/Albuterol Sulfate (open the airways of the lungs) 3mL (mL- a unit of measure capacity) inhalator (breathing in), nebulizer (help with breathing and help loosen lung secretions) solution every 4 hours, with a start date of 7/20/2025 at 08:00 p.m.

During a concurrent interview and record review on 7/23/2025 at 3:15 p.m., with Market Clinical Analyst Administrator (MCA), MCA verified Patient 29's MAR indicated on 7/21/2025 at 5:00 a.m. Patient 29 was given Ipratropium Bromide/Albuterol Sulfate 3mL inhalator, nebulizer solution and the next administration was at 9:10 p.m. (total of 16 hours and 10 minutes in between medication administration). MCA verified Patient 29 did not have any refusal documentation between 5:00 a.m. and 9:10 p.m. MCA stated it was important to give medication according to physician's orders for safe medication administration.

During a concurrent interview and record review on 7/24/2025 at 3:30 p.m., with Charge Nurse (CN) 1, CN 1 stated the importance of Ipratropium bromide/albuterol medication administration is to open airway, makes breathing easier, and relieves secretions from the airways. CN 1 stated Ipratropium bromide/albuterol medication orders if ordered every 4 hours the patient (Patient 29) must receive the medication as ordered by the physician.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Administration of Medications via Injection," dated 06/2022, the P&P indicated, "The 7 "R's" of administering medications will be followed with each medication administration:
ii. "Right" patient
iii. "Right" medication
iv. "Right" dose
v. "Right" time
vi. "Right" route
vii. "Right" reason
viii. "Right" documentation ..."