Fairbanks Memorial Hospital

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 40259 . Based on record review, policy review, and interview, the facility failed to ensure its Food and Dietetic Services were organized, directed, and implemented in accordance with 42 CFR 482.28. Specifically, the facility failed to maintain a dietary services program that consistently provided therapeutic diets in accordance with physician orders, recognized dietary practices, and the facility’s approved Nutrition Care Manual. The facility knowingly continued preparing texture-modified diets using obsolete National Dysphagia Diet (NDD) standards after adopting the International Dysphagia Diet Standardisation Initiative (IDDSI) framework as its approved dietary standard, resulting in a systemic disconnect between Speech Language Pathology recommendations, physician dietary orders, and meals prepared by the dietary department. These failures resulted in Patient #3 receiving a meal inconsistent with the ordered texture modification, contributing to an aspiration event that resulted in death, and placed additional patients receiving therapeutic diets at risk of receiving meals inconsistent with their swallowing recommendations. Collectively, these systemic failures demonstrate the facility did not maintain compliance with the Condition of Participation for Food and Dietetic Services. Findings: The facility failed to ensure menus met the needs of 1 patient (#3), out of one patient reviewed for dietary restrictions. Specifically, the facility failed to meet the individual patient’s nutritional needs in accordance with recognized dietary practices by continuing to prepare therapeutic diets using obsolete National Dysphagia Diet (NDD) standards after the facility adopted the International Dysphagia Diet Standardisation Initiative (IDDSI) framework as its approved dietary standard. This systemic failure resulted in Patient #3 receiving a meal inconsistent with the ordered texture modification and contributed to the aspiration event that resulted in death. (Refer to A-629.) .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure was 1 patient (#3), out of 20 patients reviewed, was free from all forms of abuse, to include neglect from staff. Specifically, the facility failed to provide care and services necessary to ensure Patient #3 received nutrition consistent with his/her assessed swallowing ability and physician-ordered therapeutic diet. Leadership knowingly failed to implement the facility’s approved Nutrition Care Manual after it transitioned from the National Dysphagia Diet (NDD) to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework in October 2021. As a result, Patient #3 received a meal that was inconsistent with the ordered texture modification, contributing to an aspiration event resulting in death. This failure constituted neglect by failing to provide necessary care and services to avoid physical harm. Findings: During an interview on 6/15/26 at 12:16 PM, Speech Language Pathologist (SLP) #9 stated he/she used IDDSI standards in his/her swallow assessment evaluations for patients who may have swallowing difficulties and for recommendations for diet orders, while the hospital kitchen used NDD standards when cooking meals for patients. Dietary Standards A review of the differences between IDDSI and NDD definitions of therapeutic diet textures, and “soft texture,” revealed IDDSI was more restrictive and measurable than NDD: 1. IDDSI Standard - A review of the IDDSI Standard Diet levels, at https://thegeriatricdietitian.com/iddsi/, dated 11/3/20, revealed there were 8 different consistency levels for drink and food: - Level 0: Thin drinks (e.g., water) - Level 1: Slightly thick drinks (e.g., nectar) - Level 2: Mildly thick drinks (e.g., honey) - Level 3: Moderately thick drinks/liquidised foods (e.g., can be eaten with a spoon, not a fork) - Level 4: Extremely thick drinks/Pureed foods (e.g., smooth pudding-like, no lumps) - Level 5: Minced and moist foods (e.g., very soft, small moist lumps) - Level 6: Soft and bite-sized foods (e.g., tender, moist throughout) - Level 7: Easy to Chew/Regular foods (e.g., normal everyday foods) In the IDDSI framework, the “Soft and Bite-sized,” level 6, was a diet that corresponded to a “soft” texture. It was designed for foods that were tender, moist, and easy to chew, but still require some biting and chewing ability: - Size: Pieces no larger than 1.5 cm x 1.5 cm for adults; 8 cm x 8 cm for babies or children; - Texture: Soft, tender, and moist throughout, no thin liquid should leak or drip from food; - Fork Test: When pushed down with a fork, the pieces should squash completely and not regain their shape; - Chewing ability: Some chewing ability was required - it was not fully pureed or liquidized - Purpose: Suitable for patients with a mild to moderate chewing difficulties who could still handle small, soft pieces. Examples of soft foods under IDDSI standards level 6 was soft-cooked vegetables (like carrots, zucchini, or peas), mashed potatoes, soft bread, soft fruits (like banana, or ripe peaches), and slow-cooked or shredded chicken, turkey, beef, or pork, and flaky fish cut into the appropriate sized pieces. 2. NDD Standards - A review of the NDD Standard Diet levels, from the National Dysphagia Diet: Standardization for Optimal Care American Dietetic Association, dated 2002, revealed there were 4 levels of different consistencies for food and four levels of different levels of drink: Foods: - Level 1: Dysphagia Pureed (e.g., smooth, no lumps) - Level 2: Dysphagia Mechanically Altered or Ground (e.g., moist, soft-texture, ground up) - Level 3: Dysphagia Advanced/Chopped (e.g., moist, bite-sized) - Level 4: Regular Drinks: - Thin Liquids (e.g., water) - Nectar thick liquids - Honey thick liquids - Pudding thick liquids In the NDD framework, the “Dysphagia Advanced/Chopped,” level 3, would have been the closest comparison to “soft” foods however the language was broader and stated foods consisted of “nearly regular textures” with the exception of very hard, sticky, or crunchy foods. The foods still needed to be moist and bite-sized, however there was no consistent measurement listed as to what “bite sized” should look like. It required “adequate dentition and mastication” (chewing) and was a transition to regular diet. By NDD definition soft texture was food that could be “cut” with a fork. Examples of food under NDD standards level 3 was all-cooked, tender vegetables, but not “non-tender” or “rubbery” vegetables, fried potatoes, soft breads, soft and peeled fresh fruits (like peaches, cantaloupe, honeydew), and cut-up meats into small bite size pieces. The survey identified a disconnect between the clinical evaluation of swallowing function and the hospital’s dietary production system. Speech Language Pathology conducted swallowing evaluations and recommended texture modified diets using the IDDSI framework. Those recommendations were incorporated into physician dietary orders entered into the electronic health record. Dietary orders were electronically transmitted to the CBORD food service system, which continued to generate menus using obsolete NDD standards. Consequently, meals prepared by the kitchen did not consistently reflect the texture definitions used by Speech Language Pathology when evaluating patients and recommending therapeutic diets. This resulted in patients receiving foods prepared under a different therapeutic diet framework than the one used to establish their swallowing safety recommendations. Dietary Standard Implementation During an interview on 6/17/26 at 12:00 PM, the Clinical Nutrition Senior Manager (CNSM) stated the kitchen used the Nutrition Care Manual (NCM) for diet standards and that standard’s guidance when preparing menus for patients. The CNSM stated that in October 2021 the NCM went from NDD standards to IDDSI standards, but the kitchen still used NDD for now. The CNSM stated there was a goal to move towards IDDSI standards “but we just aren’t there yet.” The CNSM stated the use of the 2026 NCM was approved by her and the medical staff, through the “Nutrition Care Manual” policy, which was approved for use in February 2026. Review of the NCM Manual, edition 2021, revealed: “NCM Transition to IDDSI Framework: As of October 2021, IDDSI is the only texture-modified diet recognized by the... NCM. The National Dysphagia Diet (NDD) and associated resources have been removed from the NCM.” Review of the facility-provided policy “Nutrition Care Manual,” dated 2/27/26, revealed: “Nutrition Care Manual ... Purpose/Expected Outcome: To have current, standardized diet and nutrition information available for Registered Dietitian Nutritionists, Nutrition Services staff, and other healthcare staff ... Policy: The AND [Academy of Nutrition and Dietetics] online Nutrition Care Manual is the approved adult and pediatric diet manual for Foundation Health Partners. The NCM serves as references for: Nutrition therapy, menu development, as a resource for patient/resident education, and more ... Therapeutic and modified diets not included in the NCM must be approved by the CNM [Clinical Nutrition Manager] or RDN [Registered Dietitian Nutritionist]. Procedure/Interventions: The NCM is: Updated annually by AND ... Reviewed every five years by Medical Staff, CNM, or RDN ... Procedural Documentation: Nutrition Care Manual Institutional Approval Form ... References: Academy of Nutrition and Dietetics. Nutrition Care Manual, 2026 ...” During an interview on 6/25/26 at 10:32 AM, the Culinary Director stated his role was to oversee the culinary department which included making menus for patients with the approval of dietitians. When asked what therapeutic diet standards were used in the kitchen to make the menus, the Culinary Director stated their diets were made based on guidance from the dietitians and he relied on the dietitians to approve all therapeutic menus. When asked if there was a manual currently being used, the Culinary Director stated he didn’t know because dietitians handled that. When asked if he was aware that the NCM changed the dietary standards from NDD to IDDSI back in 2021, the Culinary Director stated he was not aware. The Culinary Director stated the dietitians worked within the NCM and gave dietary staff guidance based on that manual. The Culinary Director stated he was never informed by the dietitians that the NCM went to the IDDSI standards in 2021. During an interview on 6/25/26 at 1:00 PM, when asked how the 5-year review was completed for the NCM, the CNSM stated she did oversee the NCM, was usually alerted to updates via email because she was a member and shared any changes with the Culinary Director and others. When asked when the last 5-year review occurred, the CNSM stated in 2023. When asked how that was documented, the CNSM stated there was a signature page that was signed. When asked when she became aware that the NCM moved from NDD to IDDSI, the CNSM stated, “a few years back, around COVID, so 2020 or 2021.” When asked what she did when she learned of that change, the CNSM stated she discussed it with speech therapy and verbally told the Culinary Director. It was discussed to make it an annual goal to change the kitchen’s standards to IDDSI for meal planning, but that project just hasn’t happened. The CNSM stated the NCM recognized IDDSI as best practice, but she didn’t know it was mandatory. When asked, based on the essential functions of her job description, what planning had occurred to establish changes to IDDSI within the Nutrition Services staff’s functions of planning menus and serving food based on those standards, the CNSM stated they talked about listing this on the facility’s Wildly Important Goals list, “but we haven’t done this planning” and the last time this was discussed was about 18 months ago. The CNSM stated she didn’t interpret her role as overseeing the kitchen and she relied on speech therapy to do that. The CNSM stated it was up to the kitchen to modify their diets and change to IDDSI so patients were safe. Review of the “Nutritional Care Manual Institutional Approval Form,” revealed the CNSM signed for the NCM’s approval for use on 11/23/21 (right after the NCM moved to IDDSI in October 2021) and again on 8/24/23. Job Descriptions Review of the facility-provided position description for “Clinical Nutrition Senior Manager,” undated, revealed the position summary included: 1) “This position exists to manage and coordinate all activities of clinical nutrition programs ...” and 2) “Provides development of systems and employees who provide clinical nutritional care to all age groups for all types of care ...” Essential functions of this position included: - “Plans, directs and provides effective leadership of the clinical nutrition programs and staff providing for nutrition screening, assessment, monitoring and education according to established departmental and System policies/protocols. Provides guidance and direction to other nutrition services staff in all areas related to clinical nutrition care; - Provides effective patient nutrition care through the effective design, management and delivery of patient and staff nutrition education materials and programs; - Provides and directs staff in patient nutrition care planning to meet patient nutrition goals. Establishes patient nutrition care standards and audit systems to ensure optimum outcomes and compliance with internal processes and regulatory agencies; and - Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day. Further review of the position description revealed the “scope and complexity” of this position included: “Facility responsibility for clinical nutrition programs/services provided to patients in scope of responsibility. Internal customers: facility management and staff, medical staff and other health care providers interfacing with clinical nutrition care for the purpose of integrating services, improving patient care, ensuring effective communication and facilitating decision making. External customers: Patients and families regarding clinical nutrition patient care; physicians regarding nutrition care and program development ...” The “Supervisory Responsibilities” of the CNSM included: “Matrix or Indirect Reporting: Provides indirect reporting, guidance and supervision of food service support staff regarding clinical nutrition care ...” Further review revealed the CNSM signed this position description on 8/25/20. Review of the facility-provided position description for “Culinary Director,” undated, revealed the position summary included: 1) “This position provides direction, planning and supervision of food services to ensure that the department provides efficient, high quality meal service and nutritional care to patient and customer,” and 2) “ ... The position provides strategic direction to ensure the department goals are consistent with organizational objectives ...” Essential functions of this position included: - “1. Provides required leadership, planning, and direction to create and deliver high quality food and nutrition services. Oversees menu planning and recipe development, food production, procurement and storage of food and nutritional supplies and equipment, retail operations, and patient food services; - Plans and directs the implementation of information systems for the department. Works with organization and vendor resources to implement and manage systems for patient menus and ordering, the management of food production; - Supports staff training and development to motivate staff to provide highest level of service and to remain current on industry trends. Establishes and communicates team goals and provides feedback and recommendations for improvement; - Manages quality, safety and compliance for all facility culinary services. Creates and administers measures and benchmarks for all required outcomes in product and service quality, regulatory compliance, customer satisfaction ...; and - Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.” Further review of the position description revealed the “scope and complexity” of this position included: “ ... This position is responsible for all aspects of retail and patient food and nutrition services on a 24-hour basis. The position plans and provides systems to support customer needs and evaluate service levels. Position organizes, directs and modifies food service activities to ensure high quality, cost-effective, and efficient operations. The position develops budgets, goals, and objectives for the department and is responsible quality assurance. Further review revealed the Culinary Director signed this position description on 10/21/20. Review of the facility-provided position description for “Speech Pathologist,” undated, revealed the position summary included: “This position provides screening, evaluation, and rehabilitation services for patients with speech and language disorders related to speech, language, cognitive-communication, voice, swallowing, and fluency. This position plans and carries out specialized treatment programs, documents treatment, and maintains data regarding patient care ...” Essential functions of this position included: - “Evaluates patients’ functional abilities and limitations to determine appropriate intervention; - Develops a plan of care and treatment goals, as ordered by physician or other referral source; - Implements individualized treatment plans that consider patients’ physical, social, spiritual, cultural, educational, and age-specific needs. Ensure that treatment plans are supported by standard practices and/or current literature. Re-evaluates treatment plans, as needed, to ensure maximum patient benefit; and - Educates patients, family, and other care providers to promote patient participation and attainment of therapeutic program goals.” Further review revealed the Speech Pathologists functions and responsibilities did not include organizing, directing, guiding dietary standard implementation within the kitchen, updating systems utilized in the kitchen to provide meal menus, or directing staff within dietary services of the kitchen for implementation of NCM dietary standards. Patient #3 Record review on 6/11-26/26 revealed Patient #3 was brought to the facility’s Emergency Department (E.D.) from his/her assisted living facility, with concerns of a witnessed seizure and decreased responsiveness while eating lunch. Review of Patient #3’s ED Record note, dated 3/26/26, revealed: “ ... Visit Reason - Seizures ... Patient was reportedly in [his/her] usual state of health, and was eating lunch when [he/she] ‘slumped forward and started shaking’ ... Medical Decision Making ... prior history of ischemic stroke and resultant cognitive impairment, presenting by way of EMS (ambulance) status post witnessed episode of decreased responsiveness/possible first-time seizure, while eating lunch. Patient with gradual and progressive development of hypoxic respiratory failure ... During [his/her] initial evaluation, patient does have an episode of vomiting/expectoration of an effectively ... unchewed meatball - high concern for aspiration event ... will admit to hospital service for continued evaluation and care ...” Further review of Patient #3’s medical record revealed he/she was placed on seizure, fall, and aspiration precautions on 3/26/26. Patient #3 was also placed on NPO status (nothing by mouth) and a “Swallow Screen for Nursing” was ordered on 3/26/26 at 3:30 PM. Review of Patient #3’s Plan of Care revealed that on 3/26/26 at 6:59 PM, a Yale swallow screening (a Yale Swallow Protocol - a standardized, pass/fail swallow screening of drinking 3 oz. of water all at once) was completed and Patient #3 failed: “Pt [patient] failed Yale swallow. Oral hygiene and suctioning performed.” On 3/26/26 at 7:40 PM, an order for “SLP [speech language pathologist] Bedside Swallow Evaluation” was ordered due to “failed yale swallow with nursing.” Review of the “Speech Therapy Evaluation - Test” note, dated 3/27/26 at 11:33 AM, completed by SLP # 9, revealed: “ ... Assessment and Impression ... Pt failed Yale with RN [registered nurse] ... RN reported, while Pt in ED, [he/she] choked/spit up a meatball, unsure of where meatball came from ... Oral Prep/phase: minimal ROM [range of motion] during mastication [chewing] though mastication completed with soft textures and rather incomplete with regular textures ... Pharyngeal phase: 1x [one time] s/s [signs and symptoms] of aspiration with quick drinking otherwise without s/s of aspiration ... Assessment: Pt presented with mild oral dysphagia d/t [due to] lack of dentition [teeth] though remains functional ... Patient placed on soft textures, thin consistencies, meds [medications] whole with liquid wash. Additional sauces will be added ... Safety recommendations: upright for meals, oral cares after meals ...” Patient #3 was ordered a “Cardiac, Soft Diet” on 3/27/26 at 11:16 AM. The physician’s dietary order incorporated the Speech Language Pathologist’s recommendation for a soft texture diet based upon the IDDSI framework. Although the order identified the patient as requiring a soft diet, meals were prepared by the dietary department using National Dysphagia Diet definitions rather than the IDDSI framework used during the swallowing evaluation. As a result, the physician ordered texture modification was not implemented consistently with the therapeutic diet standard adopted by the hospital. Review of Patient #3’s discharge note, dated 3/28/26 at 11:35 PM, written my Provider #16, revealed: “Hospital Course ... [He/she] was evaluated by speech therapy which determined he was capable of swallowing thin liquids and soft diet ... While on the medical floor [he/she] was eating dinner. The nurse had left the room to deliver [his/her] medications and on upon return found [him/her] unresponsive and cyanotic [bluish or purplish color]. A rapid response was called. Team assessed the patient at the bedside and attempted to remove multiple food boluses to include sausage, broccoli. Suction returned multiple other pieces of food. Breaths were attempted by bag valve mask at bedside. Despite best efforts patient was continued to remain unresponsive and in pulseless. Time of death [6:20 PM] ...” Review of Resident #3’s “Rapid Response Team Record,” dated 3/28/26 at 6:16 PM to 6:20 PM, revealed: “Pt sitting up in bed eating dinner ... nurse came into room to give p.o. [by mouth] meds pt cyanotic, appears to have choked on food turned to rt [right] side, suctioned called RR [rapid response] ... very faint palp [palpable - felt] pulse at [6:18 PM]. Removed food bolus visible. Initiated ambu mask ventilation no resistance to ambu bagging [6:18 PM]. No palp pulse [Provider #16] ... at BS [bedside] ... Pt a DNR [do not resuscitate] [no] heartbeat heard [with] stethoscope, no palp pulse. [Provider #16] TOD [time of death] [6:20 PM] ...” Review of the “Alaska Department of Health and Social Services - Bureau of Vital Statistics Certificate of Death,” dated 4/10/26, revealed Patient #3’s immediate cause of death was “Acute Hypoxic Respiratory Failure Due to Aspiration,” with an “approximate interval: onset of death” being “minutes” and also a sequential condition that lead to the cause of death was listed as “stroke” with an “approximate interval: onset of death” being “years.” During an interview on 6/25/26 at 1:00 PM, when asked if she had completed abuse and neglect training, the CNSM stated it had been a while, but yes, she had. When asked to define neglect, the CNSM stated neglect was not taking care of patients or the wellbeing of patients and that could include not providing nutrition that they could tolerate. When ask if not changing to IDDSI standards when the NCM directed that change and she approved the NCM for use in 2021 and 2023, would be a form of neglect based on Patient #3’s outcome, the Clinical Nutrition Manager stated she honestly didn’t interpret changing to IDDSI as something they needed to move to immediately, but that maybe they should have pushed a little harder to do so. Review of the facility’s “Patient & Visitor Information” guide, dated 9/2022, that was provided to patients admitted into the hospital, revealed: “ ... Patient Rights ... You have the right to courteous treatment ... You have the right to privacy, security, and personal dignity and to be free from all forms of abuse and harassment ...” The survey determined the facility failed to provide Patient #3 with nutrition consistent with the patient’s assessed swallowing ability and physician ordered therapeutic diet after leadership knowingly failed to implement the facility’s approved dietary standards. This failure resulted in Patient #3 receiving an inappropriate meal that contributed to an aspiration event resulting in death. Review of the NCM Manual, edition 2026, revealed: - “General Guidance For Diet Manual Implementation: Adapting a new diet manual presents the opportunity to connect patient needs and evidence-based nutrition. A diet manual provides effective, consistent communication with diet order terminology and definitions and emphasizes individualization. - Diet Manual Approval: It is generally best practice to review and approve an institution’s diet manual annually. The NCM Diet Manual provides resources to simplify this process for the registered dietitian nutritionist (RDN) and foodservices staff. The diet manual approval process requires the approval committee to review and update nutrition resources and information in order to implement evidence-based nutrition care within health care settings... - Menu Planning: The NCM Diet Manual provides menu planning guidance that reflects evidence-based nutrition recommendations that can assist foodservice departments in accommodating patient preferences. RDNs and foodservice managers customize the diet manual to establish consensus on what food items are appropriate for each diet. Implementing and customizing the diet manual ensures that menu choices are accurate according to the diet orders, consistent with patient requests, and congruous with regulations. Menu planning requires determining which foods are acceptable for each diet... Communicating menu modifications to foodservice staff is essential for safe, efficient and accurate food production and meal service. Some facilities may use diet guide sheets... to communicate menu modifications to foodservice staff. These sheets provide specific guidance on food, fluid, and texture modifications for facility diets... - IDDSI Framework and Levels: The International Dysphagia Diet Standardisation (IDDSI) established a globally consistent diet terminology and definitions for dysphagia diet therapy in all settings, for all ages, and for all cultures (IDDSI, 2024). The IDDSI Framework is used to prepare, evaluate, and serve food that is safe and easily tolerated... it is critical that clinicians use the same terms, definitions, and measurable characteristics for each food and liquid texture... Derivative works beyond language translation are NOT PERMITTED... - Transitioning Texture-Modified Diet Terminology and Definitions to the IDDSI Framework: Transitioning from prescribing the National Dysphagia Diet (NDD) and other texture-modified diets to prescribing the International Dysphagia Diet Standardisation Initiative (IDDSI) levels requires careful planning. Using the IDDSI implementation resources on the IDDSI website will help you design your transition plan... it is recommended that institutions use a continuous improvement process approach during the implementation process. This approach my include adapting recipes, menus, and diet spreadsheets to the new framework... - Process for Annual Diet Manual Review and Implementation: Follow these seven steps annually to implement and customize your NCM Diet Manual: 1. Collaborate on Diet Manual Philosophy and Goals. Review and agree on diet manual philosophy and goals along with members of the health care team... 2. Identify All Diet Orders Used at Your Facility. Review NCM Diet Terminology &Definitions... Compare your facility’s current diet order terminology and definitions with the NCM Manual names (performed by clinical nutrition staff)...Identify NCM diets to be used at your facility in consultation with medical staff leadership and medical director... Review Obsolete Diets to ensure you avoid using these diet terms in your facility’s accepted diet terminology... 3. Make Changes to Facility Diets as Needed. Identify current diet names at your facility that may require a change and/or diet names that require clarification on foods served. Discuss modifications to existing diet order names with health care team and agree on final names for all diets. Document and date this discussion... Change existing diet terminology to match new, updated diet names. 4. Customize the NCM Diet Manual to Your Facility. 5. Obtain Diet Manual Approval 6. IP Authentication. Work with you facility’s IT department to set up IP authentication, which will allow users at your facility to access the NCM without a username and password... 7. Backup Diet Manual...” .”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 40259 . Based on record review and interview, failed to ensure menus met the needs of 1 patient (#3), out of one patient reviewed for dietary restrictions. Specifically, the facility failed to ensure physician ordered therapeutic diets were implemented in accordance with its approved Nutrition Care Manual and recognized dietary practices after continuing to prepare texture modified meals using obsolete National Dysphagia Diet (NDD) standards rather than the International Dysphagia Diet Standardisation Initiative (IDDSI) framework adopted by the facility in October 2021. This systemic failure resulted in Patient #3 receiving a meal inconsistent with the ordered texture modification, contributing to an aspiration event that resulted in death and constituted Immediate Jeopardy at CFR 482.28(b)(1). A determination was made that the facility’s noncompliance with A-0692, Menus Meet the Needs of Patients, placed 18 current patients admitted on therapeutic diets, in Immediate Jeopardy beginning in October 2021. This situation was brought to the attention of the facility’s administration on 6/18/26 at 4:32 PM, at which time the facility was notified of the identified immediate jeopardy. The facility submitted an acceptable immediacy removal plan on 6/20/26 at 9:36 AM. The State Agency verified, onsite, that the immediacy was removed on 6/22/26 at 3:30 PM. Following the removal of the immediacy, noncompliance remained with actual harm that was not immediate jeopardy. Findings: Patient #3 Record review on 6/11-26/26 revealed Patient #3 was brought to the facility’s Emergency Department (E.D.) from his/her assisted living facility, with concerns of a witnessed seizure and decreased responsiveness while eating lunch. Review of Patient #3’s ED Record note, dated 3/26/26, revealed: “ ... Visit Reason - Seizures ... Patient was reportedly in [his/her] usual state of health, and was eating lunch when [he/she] ‘slumped forward and started shaking’ ... Medical Decision Making ... prior history of ischemic stroke and resultant cognitive impairment, presenting by way of EMS (ambulance) status post witnessed episode of decreased responsiveness/possible first-time seizure, while eating lunch. Patient with gradual and progressive development of hypoxic respiratory failure ... During [his/her] initial evaluation, patient does have an episode of vomiting/expectoration of an effectively ... unchewed meatball - high concern for aspiration event ... will admit to hospital service for continued evaluation and care ...” Further review of Patient #3’s medical record revealed he/she was placed on seizure, fall, and aspiration precautions on 3/26/26. Patient #3 was also placed on NPO status (nothing by mouth) and a “Swallow Screen for Nursing” was ordered on 3/26/26 at 3:30 PM. Review of Patient #3’s Plan of Care revealed that on 3/26/26 at 6:59 PM, a Yale swallow screening (a Yale Swallow Protocol - a standardized, pass/fail swallow screening) was completed and Patient #3 failed: “Pt [patient] failed Yale swallow. Oral hygiene and suctioning performed.” On 3/26/26 at 7:40 PM, an order for “SLP [speech language pathology] Bedside Swallow Evaluation” was ordered due to “failed yale swallow with nursing.” Review of the “Speech Therapy Evaluation - Test” note, dated 3/27/26 at 11:33 AM, completed by Speech Language Pathologist(SLP) # 9, revealed: “ ... Assessment and Impression ... Pt failed Yale with RN [registered nurse] ... RN reported, while Pt in ED, [he/she] choked/spit up a meatball, unsure of where meatball came from ... Oral Prep/phase: minimal ROM [range of motion] during mastication [chewing] though mastication completed with soft textures and rather incomplete with regular textures ... Pharyngeal phase: 1x [one time] s/s [signs and symptoms] of aspiration with quick drinking otherwise without s/s of aspiration ... Assessment: Pt presented with mild oral dysphagia d/t [due to] lack of dentition [teeth] though remains functional ... Patient placed on soft textures, thin consistencies, meds [medications] whole with liquid wash. Additional sauces will be added ... Safety recommendations: upright for meals, oral cares after meals ...” Patient #3 was ordered a “Cardiac, Soft Diet” on 3/27/26 at 11:16 AM. Review of Patient #3’s discharge note, dated 3/28/26 at 11:35 PM, written my Provider #16, revealed: “Hospital Course ... [He/she] was evaluated by speech therapy which determined [he/she] was capable of swallowing thin liquids and soft diet ... While on the medical floor [he/she] was eating dinner. The nurse had left the room to deliver [his/her] medications and on upon return found [him/her] unresponsive and cyanotic [bluish or purplish color]. A rapid response was called. Team assessed the patient at the bedside and attempted to remove multiple food boluses to include sausage, broccoli. Suction returned multiple other pieces of food. Breaths were attempted by bag valve mask at bedside. Despite best efforts patient was continued to remain unresponsive and in pulseless. Time of death [6:20 PM] ...” Review of Resident #3’s “Rapid Response Team Record,” dated 3/28/26 at 6:16 PM to 6:20 PM, revealed: “Pt sitting up in bed eating dinner ... nurse came into room to give p.o. [by mouth] meds pt cyanotic, appears to have choked on food turned to rt [right] side, suctioned called RR [rapid response] ... very faint palp [palpable - felt] pulse at [6:18 PM]. Removed food bolus visible. Initiated ambu mask ventilation no resistance to ambu bagging [6:18 PM]. No palp pulse [Provider #16] ... at BS [bedside] ... Pt a DNR [do not resuscitate] [no] heartbeat heard [with] stethoscope, no palp pulse. [Provider #16] TOD [time of death] [6:20 PM] ...” During an interview on 6/18/26 at 9:00 AM, Provider #16 stated he/she had seen Patient #3 on the morning of 3/28/26 and the patient was alert and oriented to himself/herself. Provider #16 stated Patient #3 participated with staff’s efforts and care and was on the road to recovery. That day, Patient #3 stepped down from the ICU to a medical/surgical floor identified as 2South. When asked about the Rapid Response for Patient #3, Provider #16 stated he/she did respond and assist with that response. Provider #16 stated when he/she entered the room Patient #3 was cyanotic, unresponsive, and pulseless. Staff worked to clear Patient #3’s airway and they pulled food items from his/her airway. When asked to describe the food, Provider #16 stated that they were “pretty sizable chucks,” probably the size of the tip of a finger, and the food consisted of sausage and broccoli that was hard at that time. When asked if a patient was ordered a cardiac soft diet, what food consistency would a provider expect to be served to a patient, Provider #16 stated, “I would expect it to be soft.” Provider #16 did add, however, that he/she was not exactly sure about the nuances of what constituted “soft.” During an interview on 6/18/26 at 1:30 PM, Nurse #5 stated he/she was the nurse on 2South that received Patient #3 on 3/28/26. Nurse #5 stated Patient #3 came to 2South just after lunch. When asked what information was received about Patient #3, Nurse #5 stated Patient #3 had come to the E.D. because of an aspiration problem, and he/she was evaluated by speech therapy. Patient #3 was on aspiration precautions, and he/she was to have a soft diet for meals. Nurse #5 stated he/she set up a suction machine prior to Patient #3 coming to the room. When asked to describe what occurred on 3/28/26, Nurse #5 stated meal trays came to the unit between 5:45 PM and 6:00 PM for dinner, however there was no documentation as to when Patient #3 received his/her dinner tray. Nurse #5 stated he/she ensured that Patient #3’s bed was in an upright position, the patient was given his/her dinner tray by another staff member. Nurse #5 couldn’t say how long it was between when the patient received the tray and when he/she entered the room to give Patient #3 his/her medications, but when he/she entered the room he/she found Patient #3 cyanotic and unresponsive. Nurse #5 stated he/she called for a rapid response and staff tried to clear his/her airway with suction. Nurse #5 stated when staff opened his/her mouth, there were food particles in his/her mouth. Suction was resistive and staff manually extracted food from Patient #3’s airway. When asked to describe what food was removed, Nurse #5 stated they removed mashed potatoes, broccoli, and meat. When asked how staff on the floor ensured patients received the appropriate food based on provider orders, Nurse #5 stated there was a printed ticket on the tray that came with the meals. Staff would ensure they checked that the patient’s name was on the ticket and the diet order was also on the ticket. Nurse #5 stated Patient #3’s ticket did say “soft diet.” Review of the “Alaska Department of Health and Social Services - Bureau of Vital Statistics Certificate of Death,” dated 4/10/26, revealed Patient #3’s immediate cause of death was “Acute Hypoxic Respiratory Failure Due to Aspiration,” with an “approximate interval: onset of death” being “minutes” and also a sequential condition that lead to the cause of death was listed as “stroke” with an “approximate interval: onset of death” being “years.” Aspiration Precautions and Yale Swallow Assessment During an interview on 6/17/26 at 2:00 PM, with ICU Charge Nurse #3 and the ICU Manager, ICU Charge Nurse #3 stated he/she was the Charge Nurse when Patient #3 was admitted to the ICU on 3/26/26. When asked about the admission process, ICU Charge Nurse #3 stated the ICU would receive notification of admission, the charge nurse would assign a nurse to the patient, the nurse would review the SBAR (notes from the E.D.) and what orders were put in place from the provider. The nurse would meet the patient, settle them into a room, and implement the orders as written. When asked what precautions Patient #3 was admitted on, ICU Charge Nurse #3 stated Patient #3 was on seizure, fall, and aspiration precautions. When asked what interventions were implemented for aspiration precautions, ICU Charge Nurse #3 stated the nurse would set up a suction machine at the bedside, and the patient’s airway and ability to swallow would be monitored. They would also ensure patients were sitting up when eating. The ICU Manager stated that the hospital used Lippincott standards when implementing aspiration precautions. When asked to describe how nurses implemented a “swallow screening for nursing” order, ICU Charge Nurse #3 stated a nurse performed a Yale test that would consist of a cognitive assessment (orientation questions, simple commands) and a facial symmetry assessment that consisted of asking the patient to puff their cheeks out and checking oral mechanics which included of asking the patient to move their tongue (to assess for range of motion). The patient would be then given 3 oz of water to drink all at once. The nurse would observe for any difficulties swallowing the water. If they could swallow the water without difficulty, they passed. If not, they failed. When asked what happened if a patient failed the test, the ICU Charge Nurse #3 stated an SLP assessment would be ordered. A review of “Lippincott Nursing Procedures,” Ninth edition dated 2023, revealed: “ ... Impaired Swallowing and Aspiration Precautions. Patients may experience impaired swallowing as a result of several specific reasons. The first of these - oropharyngeal dysphagia - is impaired swallowing associated with deficits in oral and pharyngeal [mouth and upper throat] structure or function. Patients with oropharyngeal dysphagia are at especially high risk for aspiration ... Patient at risk for oropharyngeal dysphagia include those with nervous system damage, such as from stroke ... A swallowing evaluation using a facility-approved assessment tool such as the Yale Swallow Protocol, can determine if the patient is at risk for aspiration. Managing impaired swallowing due to oropharyngeal dysphagia ... develop a multidisciplinary management plan that includes common swallow strategies ... Have suction equipment available at bedside. Verify the patient’s diet modification, as ordered. Place the patient in an upright position at a 90-degree angle during meals to decrease the risk of aspiration. Otherwise, maintain the head of the patient’s bed at 30 to 45 degrees ... Assist with or perform oral care using appropriate oral care supplies before and after meals, and check for food residue ... Avoid mixed consistencies of food ... If applicable, ensure that the temperature, consistency, and amount of foods and liquids are appropriate ...” SLP Swallow Assessment During an interview on 6/15/26 at 12:16 PM, when asked to describe how a swallow evaluation was conducted, SLP #9 stated the evaluation was completed in person, and prior to seeing the patient completed a thorough medical record review, talked with nurses and the providers about the patient, and attended unit huddles or meetings to get a report on the patient. Once he/she was ready to conduct the evaluation, SLP #9 entered the patient’s room and conversed with the patient to gain insight into his/her speech and cognition and conducted a thorough interview looking for consistencies, or inconsistencies, to their own perception of their ability to swallow. SLP #9 stated he/she did the same thing every time with each evaluation. He/she also always completed a cranial [head] nerve exam, and a sensation/motor exam. Once these were completed, SLP #9 moved on to testing liquid and food items with the patient to see how they handled chewing and swallowing different levels of food textures, as well as how well they handled swallowing water. SLP #9 stated he/she usually started with ice chips, but this could be skipped if applicable. For liquids, water was used. With the water, he/she had the patient sip from a cup, then use a straw, and then had the patient drink 3oz of water to see how the patient tolerated all these steps. SLP #9 stated he/she usually used applesauce or pudding for a puree food texture test. For a soft food texture test, SLP #9 used a fruit cup of peaches or mixed fruit and for a regular texture test, SLP #9 used pineapple, pretzels or crackers. All food tests were conducted with drinks of water mixed in between. Some patients didn’t get to every food texture test level if it was not safe to do so. Then SLP #9 observed a medications administration with a nurse to determine if the patient could swallow whole pills safely. SLP #9 stated he/she was the SLP who conducted Patient #3’s swallow evaluation on 3/27/26 at 11:33 AM. SLP #9 stated after his/her interview and exam, he/she had used ice chips and water, and SLP #9 used applesauce for a puree food texture test, a fruit cup of peaches for a soft food texture test, and a fruit cup of pineapple and crackers for a regular food texture test. When asked if he/she used any meat during his/her assessment, SLP #9 stated, “no,” and that they were not provided meat as an option for use, so meat was not used. When asked what dietary standard SLP #9 used when conducting swallow evaluations, SLP #9 stated he/she used the IDDSI standards and that standard’s food texture definitions. When asked to define soft foods, SLP #9 stated IDDSI defined “soft” textured foods as ones that could be squished easily with a fork or pressure with say your thumb. When asked about the results of Patient #3’s swallow evaluation, SLP #9 stated Patient #3 failed to pass the regular texture portion of the evaluation, but was able to tolerate soft foods, therefore a Cardiac Soft Diet was ordered. When asked if sausage links and broccoli were considered “soft,” SLP #9 stated by IDDSI definitions, these foods were considered regular textured foods. Under the IDDSI framework, a Level 6 Soft and Bite Sized diet required foods to be tender, moist, and easily squashed completely with the pressure of a fork. Sausage links and broccoli, as served to Patient #3, were identified by SLP #9 as Level 7 Regular texture foods because they required greater chewing ability than permitted under the ordered soft texture diet. As a result, the foods served were inconsistent with the texture recommendations established during the patient’s swallowing evaluation. SLP #9 further stated that while he/she used IDDSI standards in his/her evaluations and recommendations for diet orders, the hospital kitchen used NDD when cooking meals for patients. Dietary Standards A review of the differences between IDDSI and NDD definitions of therapeutic diet textures, and “soft texture,” revealed IDDSI was more restrictive and measurable than NDD: 1. IDDSI Standard - A review of the IDDSI Standard Diet levels, at https://thegeriatricdietitian.com/iddsi/, dated 11/3/20, revealed there were 8 different consistency levels for drink and food: - Level 0: Thin drinks (e.g., water) - Level 1: Slightly thick drinks (e.g., nectar) - Level 2: Mildly thick drinks (e.g., honey) - Level 3: Moderately thick drinks/liquidised foods (e.g., can be eaten with a spoon, not a fork) - Level 4: Extremely thick drinks/Pureed foods (e.g., smooth pudding-like, no lumps) - Level 5: Minced and moist foods (e.g., very soft, small moist lumps) - Level 6: Soft and bite-sized foods (e.g., tender, moist throughout) - Level 7: Easy to Chew/Regular foods (e.g., normal everyday foods) In the IDDSI framework, the “Soft and Bite-sized,” level 6, was a diet that corresponded to a “soft” texture. It was designed for foods that were tender, moist, and easy to chew, but still require some biting and chewing ability: - Size: Pieces no larger than 1.5 cm x 1.5 cm for adults; 8 cm x 8 cm for babies or children; - Texture: Soft, tender, and moist throughout, no thin liquid should leak or drip from food; - Fork Test: When pushed down with a fork, the pieces should squash completely and not regain their shape; - Chewing ability: Some chewing ability was required - it was not fully pureed or liquidized - Purpose: Suitable for patients with a mild to moderate chewing difficulties who could still handle small, soft pieces. Examples of soft foods under IDDSI standards level 6 was soft-cooked vegetables (like carrots, zucchini, or peas), mashed potatoes, soft bread, soft fruits (like banana, or ripe peaches), and slow-cooked or shredded chicken, turkey, beef, or pork, and flaky fish cut into the appropriate sized pieces. 2. NDD Standards - A review of the NDD Standard Diet levels, from the National Dysphagia Diet: Standardization for Optimal Care American Dietetic Association, dated 2002, revealed there were 4 levels of different consistencies for food and four levels of different levels of drink: Foods: - Level 1: Dysphagia Pureed (e.g., smooth, no lumps) - Level 2: Dysphagia Mechanically Altered or Ground (e.g., moist, soft-texture, ground up) - Level 3: Dysphagia Advanced/Chopped (e.g., moist, bite-sized) - Level 4: Regular Drinks: - Thin Liquids (e.g., water) - Nectar thick liquids - Honey thick liquids - Pudding thick liquids In the NDD framework, the “Dysphagia Advanced/Chopped,” level 3, would have been the closest comparison to “soft” foods however the language is broader and stated foods consisted of “nearly regular textures” with the exception of very hard, sticky, or crunchy foods. The foods still needed to be moist and bite-sized, however there was no consistent measurement listed as to what “bite sized” should look like. It required “adequate dentition and mastication” (chewing) and was a transition to regular diet. By NDD definition soft texture was food that could be “cut” with a fork. Examples of food under NDD standards level 3 was all-cooked, tender vegetables, but not “non-tender” or “rubbery” vegetables, fried potatoes, soft breads, soft and peeled fresh fruits (like peaches, cantaloupe, honeydew), and cut-up meats into small bite size pieces. The survey identified a disconnect between the clinical evaluation of swallowing function and the hospital’s dietary production system. Speech Language Pathology conducted swallowing evaluations and recommended texture modified diets using the IDDSI framework. Those recommendations were incorporated into physician dietary orders entered into the electronic health record. Dietary orders were electronically transmitted to the CBORD food service system, which continued to generate menus using obsolete NDD standards. Consequently, meals prepared by the kitchen did not consistently reflect the texture definitions used by Speech Language Pathology when evaluating patients and recommending therapeutic diets. This resulted in patients receiving foods prepared under a different therapeutic diet framework than the one used to establish their swallowing safety recommendations. Dietary Standard Implementation During an interview on 6/17/26 at 12:00 PM, the Clinical Nutrition Senior Manager (CNSM) stated the kitchen used the Nutrition Care Manual (NCM) for diet standards and that standard’s guidance when preparing menus for patients. The CNSM stated that in October 2021 the NCM went from NDD standards to IDDSI standards, but the kitchen still used NDD for now. The CNSM stated there was a goal to move towards IDDSI standards “but we just aren’t there yet.” The CNSM stated the use of the 2026 NCM was approved by her and the medical staff, through the “Nutrition Care Manual” policy, which was approved for use in February 2026. Review of the NCM Manual, edition 2021, revealed: “NCM Transition to IDDSI Framework: As of October 2021, IDDSI is the only texture-modified diet recognized by the... NCM. The National Dysphagia Diet (NDD) and associated resources have been removed from the NCM.” Review of the facility-provided policy “Nutrition Care Manual,” dated 2/27/26, revealed: “Nutrition Care Manual ... Purpose/Expected Outcome: To have current, standardized diet and nutrition information available for Registered Dietitian Nutritionists, Nutrition Services staff, and other healthcare staff ... Policy: The AND [Academy of Nutrition and Dietetics] online Nutrition Care Manual is the approved adult and pediatric diet manual for Foundation Health Partners. The NCM serves as references for: Nutrition therapy, menu development, as a resource for patient/resident education, and more ... Therapeutic and modified diets not included in the NCM must be approved by the CNM [Clinical Nutrition Manager] or RDN [Registered Dietitian Nutritionist]. Procedure/Interventions: The NCM is: Updated annually by AND ... Reviewed every five years by Medical Staff, CNM, or RDN ... Procedural Documentation: Nutrition Care Manual Institutional Approval Form ... References: Academy of Nutrition and Dietetics. Nutrition Care Manual, 2026 ...” During an interview on 6/25/26 at 10:32 AM, the Culinary Director stated his role was to oversee the culinary department which included making menus for patients with the approval of dietitians. When asked what therapeutic diet standards were used in the kitchen to make the menus, the Culinary Director stated their diets were made based on guidance from the dietitians and he relied on the dietitians to approve all therapeutic menus. When asked if there was a manual currently being used, the Culinary Director stated he didn’t know because dietitians handled that. When asked how the kitchen cooks received diet orders and menus for those orders, the Culinary Director stated menus were produced in the facility’s software program called CBORD (a NetMenu integrated menu planning program). The Culinary Director stated he built menus, by researching recipes striving for culinary variety. Once the menus were built he would place them into CBORD for nutritional analysis, then show the menus to the dietitians for approval. The Culinary Director stated diet orders placed in the electronic health record program called Cerner would be automatically integrated into CBORD. CBORD would then create a ticket, based on that order, for each patient. This ticket would have the day’s menu listed out, and changes to the menu would be listed to ensure the appropriate level of food was serve based on the order. When asked what standards CBORD was programmed with to make the menus, the Culinary Director stated CBORD was currently using NDD standards. When asked if he was aware that the NCM changed the dietary standards from NDD to IDDSI back in 2021, the Culinary Director stated he was not aware. The Culinary Director stated the dietitians worked within the NCM and gave dietary staff guidance based on that manual. The Culinary Director stated he was never informed by the dietitians that the NCM went to the IDDSI standards in 2021. When asked if there were any policies used to assist cooks in making therapeutic meals, the Culinary Director stated cooks used the “Mechanically Altered Foods” policy to ensure the consistency of the meals were appropriate and that the policy was based on referencing the NCM. Review of the facility-provided policy “Mechanically Altered Food,” dated 6/12/25, revealed: “ ... Purpose: to establish guidelines for preparing, identifying, and serving mechanically altered foods.” Further review of this policy revealed the policy provided guidance for the use of NDD standards despite being approved in 2025, four years after NCM moved to IDDSI standards: “ ... Dysphagia Chopped (Level 3) ... Food is cut into approximately 1/4 [inch] by 1/4 [inch] pieces ... Tough meats and hard fruits not allowed. Foods still need to be moist and should be in ‘bite-size’ pieces at the oral phase to swallow. Foods must be moist and liquids (gravy, sauce, milk, etc) may be added to get the desired consistency ... See attachment #3 for clarification ... Appendix #3 Chopped Dysphagia Chopped ...Refer to current, prescribed therapeutic diet plan as a guide when planning the menu ... fruits ... any allowed by prescribed diet ... Vegetables ... any allowed by prescribed diet ... Meat/Protein ... any allowed by prescribed diet. Hot dogs/kielbasa/sausage - remove casing ...” Further review of the policy revealed no guidance for a “soft” diet. The references for this policy included an older edition of the NCM: “References: American Dietetic Association. ‘Nutrition Care Manual - Level 1 Nutrition Therapy for Dysphagia: Pureed Foods; Level 2 Nutrition Therapy for Dysphasia: Mechanically Altered Foods; Level 3 Nutrition Therapy for Dysphagia: Advanced Foods.” American Dietetic Association, 2011 ...” Review of the facility-provided policy “Interpretation of Diet Orders,” dated 9/11/24, revealed the purpose of this policy was “to provide an interpretation of diet orders.” Further review revealed this policy still referenced NDD standards: “ ... Diets will be interpreted as follows ... Texture Modified Diets ... Soft Foods ... Soft Texture, easy to cut with a fork ...” Further review of this policy revealed it referenced the “Academy of Nutrition and Dietetics. Nutrition Care Manual, 2024” and did not reference any NDD standards. Related policies associated with this policy was the “Mechanically Altered Food” policy. During an interview on 6/25/26 at 1:00 PM, when asked how the 5-year review was completed for the NCM, the CNSM stated she did oversee the NCM, was usually alerted to updates via email because she was a member and shared any changes with the Culinary Director and others. When asked when the last 5-year review occurred, the CNSM stated in 2023. When asked how that was documented, the CNSM stated there was a signature page that was signed. When asked when she became aware that the NCM moved from NDD to IDDSI, the CNSM stated, “a few years back, around COVID, so 2020 or 2021.” When asked what she did when she learned of that change, the CNSM stated she discussed it with speech therapy and verbally told the Culinary Director. It was discussed to make it an annual goal to change the kitchen’s standards to IDDSI for meal planning, but that project just hasn’t happened. The CNSM stated the NCM recognized IDDSI as best practice, but she didn’t know it was mandatory. When asked, based on the essential functions of her job description, what planning had occurred to establish changes to IDDSI within the Nutrition Services staff’s functions of planning menus and serving food based on those standards, the CNSM stated they talked about listing this on the facility’s Wildly Important Goals list, “but we haven’t done this planning” and the last time this was discussed was about 18 months ago. The CNSM stated she didn’t interpret her role as overseeing the kitchen and she relied on speech therapy to do that. The CNSM stated it was up to the kitchen to modify their diets and change to IDDSI so patients were safe. When asked to review the “Mechanically Altered Food” policy, which was approved for use on 6/12/25 and to explain why NDD standards and an older edition of the NCM was used as a reference despite knowing the NCM went to IDDSU, the CNSM stated she was aware the 2011 NCM was kept as a reference and the NDD standards were kept in the policy when it was approved because the kitchen staff still used NDD to make menu meals for patients. When asked to review the “Interpretation of Diet Orders,” dated 9/11/24, which was approved by the CNSM and to explain why NDD standards were still used despite referencing the 2024 edition of NCM, after the NCM changed to IDDSI standards, the CNSM stated the policy kept NDD terms because the kitchen staff still used NDD standards. Review of the “Nutritional Care Manual Institutional Approval Form, revealed the CNSM signed for the NCM’s approval for use on 11/23/21 (right after the NCM moved to IDDSI in October 2021) and again on 8/24/23. Job Descriptions Review of the facility-provided position description for “Clinical Nutrition Senior Manager,” undated, revealed the position summary included: 1) “This position exists to manage and coordinate all activities of clinical nutrition programs ...” and 2) “Provides development of systems and employees who provide clinical nutritional care to all age groups for all types of care ...” Essential functions of this position included: - “Plans, directs and provides effective leadership of the clinical nutrition programs and staff providing for nutrition screening, assessment, monitoring and education according to established departmental and System policies/protocols. Provides guidance and direction to other nutrition services staff in all areas related to clinical nutrition care; - Provides effective patient nutrition care through the effective design, management and delivery of patient and staff nutrition education materials and programs; - Provides and directs staff in patient nutrition care planning to meet patient nutrition goals. Establishes patient nutrition care standards and audit systems to ensure optimum outcomes and compliance with internal processes and regulatory agencies; and - Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day. Further review of the position description revealed the “scope and complexity” of this position included: “Facility responsibility for clinical nutrition programs/services provided to patients in scope of responsibility. Internal customers: facility management and staff, medical staff and other health care providers interfacing with clinical nutrition care for the purpose of integrating services, improving patient care, ensuring effective communication and facilitating decision making. External customers: Patients and families regarding clinical nutrition patient care; physicians regarding nutrition care and program development ...” The “Supervisory Responsibilities” of the CNSM included: “Matrix or Indirect Reporting: Provides indirect reporting, guidance and supervision of food service support staff regarding clinical nutrition care ...” Further review revealed the CNSM signed this position description on 8/25/20. Review of the facility-provided position description for “Culinary Director,” undated, revealed the position summary included: 1) “This position provides direction, planning and supervision of food services to ensure that the department provides efficient, high quality meal service and nutritional care to patient and customer,” and 2) “ ... The position provides strategic direction to ensure the department goals are consistent with organizational objectives ...” Essential functions of this position included: - “1. Provides required leadership, planning, and direction to create and deliver high quality food and nutrition services. Oversees menu planning and recipe development, food production, procurement and storage of food and nutritional supplies and equipment, retail operations, and patient food services; - Plans and directs the implementation of information systems for the department. Works with organization and vendor resources to implement and manage systems for patient menus and ordering, the management of food production; - Supports staff training and development to motivate staff to provide highest level of service and to remain current on industry trends. Establishes and communicates team goals and provides feedback and recommendations for improvement; - Manages quality, safety and compliance for all facility culinary services. Creates and administers measures and benchmarks for all required outcomes in product and service quality, regulatory compliance, customer satisfaction ...; and - Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.” Further review of the position description revealed the “scope and complexity” of this position included: “ ... This position is responsible for all aspects of retail and patient food and nutrition services on a 24-hour basis. The position plans and provides systems to support customer needs and evaluate service levels. Position organizes, directs and modifies food service activities to ensure high quality, cost-effective, and efficient operations. The position develops budgets, goals, and objectives for the department and is responsible quality assurance. Further review revealed the Culinary Director signed this position description on 10/21/20. Review of the facility-provided position description for “Speech Pathologist,” undated, revealed the position summary included: “This position provides screening, evaluation, and rehabilitation services for patients with speech and language disorders related to speech, language, cognitive-communication, voice, swallowing, and fluency. This position plans and carries out specialized treatment programs, documents treatment, and maintains data regarding patient care ...” Essential functions of this position included: - “Evaluates patients’ functional abilities and limitations to determine appropriate intervention; - Develops a plan of care and treatment goals, as ordered by physician or other referral source; - Implements individualized treatment plans that consider patients’ physical, social, spiritual, cultural, educational, and age-specific needs. Ensure that treatment plans are supported by standard practices and/or current literature. Re-evaluates treatment plans, as needed, to ensure maximum patient benefit; and - Educates patients, family, and other care providers to promote patient participation and attainment of therapeutic program goals.” Further review revealed the Speech Pathologists functions and responsibilities did not include organizing, directing, guiding dietary standard implementation within the kitchen, updating systems utilized in the kitchen to provide meal menus, or directing staff within dietary services of the kitchen for implementation of NCM dietary standards. Review of the NCM Manual, edition 2026, revealed: - “General Guidance For Diet Manual Implementation: Adapting a new diet manual presents the opportunity to connect patient needs and evidence-based nutrition. A diet manual provides effective, consistent communication with diet order terminology and definitions and emphasizes individualization. - Diet Manual Approval: It is generally best practice to review and approve an institution’s diet manual annually. The NCM Diet Manual provides resources to simplify this process for the registered dietitian nutritionist (RDN) and foodservices staff. The diet manual approval process requires the approval committee to review and update nutrition resources and information in order to implement evidence-based nutrition care within health care settings... - Menu Planning: The NCM Diet Manual provides menu planning guidance that reflects evidence-based nutrition recommendations that can assist foodservice departments in accommodating patient preferences. RDNs and foodservice managers customize the diet manual to establish consensus on what food items are appropriate for each diet. Implementing and customizing the diet manual ensures that menu choices are accurate according to the diet orders, consistent with patient requests, and congruous with regulations. Menu planning requires determining which foods are acceptable for each diet... Communicating menu modifications to foodservice staff is essential for safe, efficient and accurate food production and meal service. Some facilities may use diet guide sheets... to communicate menu modifications to foodservice staff. These sheets provide specific guidance on food, fluid, and texture modifications for facility diets... - IDDSI Framework and Levels: The International Dysphagia Diet Standardisation (IDDSI) established a globally consistent diet terminology and definitions for dysphagia diet therapy in all settings, for all ages, and for all cultures (IDDSI, 2024). The IDDSI Framework is used to prepare, evaluate, and serve food that is safe and easily tolerated... it is critical that clinicians use the same terms, definitions, and measurable characteristics for each food and liquid texture... Derivative works beyond language translation are NOT PERMITTED... - Transitioning Texture-Modified Diet Terminology and Definitions to the IDDSI Framework: Transitioning from prescribing the National Dyshgagia Diet (NDD) and other texture-modified diets to prescribing the International Dysphagia Diet Standardisation Initiative (IDDSI) levels requires careful planning. Using the IDDSI implementation resources on the IDDSI website will help you design your transition plan... it is recommended that institutions use a continuous improvement process approach during the implementation process. This approach my include adapting recipes, menus, and diet spreadsheets to the new framework... - Process for Annual Diet Manual Review and Implementation: Follow these seven steps annually to implement and customize your NCM Diet Manual: 1. Collaborate on Diet Manual Philosophy and Goals. Review and agree on diet manual philosophy and goals along with members of the health care team... 2. Identify All Diet Orders Used at Your Facility. Review NCM Diet Terminology &Definitions... Compare your facility’s current diet order terminology and definitions with the NCM Manual names (performed by clinical nutrition staff)...Identify NCM diets to be used at your facility in consultation with medical staff leadership and medical director... Review Obsolete Diets to ensure you avoid using these diet terms in your facility’s accepted diet terminology... 3. Make Changes to Facility Diets as Needed. Identify current diet names at your facility that may require a change and/or diet names that require clarification on foods served. Discuss modifications to existing diet order names with health care team and agree on final names for all diets. Document and date this discussion... Change existing diet terminology to match new, updated diet names. 4. Customize the NCM Diet Manual to Your Facility. 5. Obtain Diet Manual Approval 6. IP Authentication. Work with you facility’s IT department to set up IP authentication, which will allow users at your facility to access the NCM without a username and password... 7. Backup Diet Manual...” .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33393 . Based on record review and interview, the facility failed to meet the Condition of Participation of Patient Right’s according to CFR 482.13. The facility failed to protect and promote patient’s rights to be free from abuse and neglect. Findings: The facility failed to ensure 76 staff were adequately screened for abuse and neglect, as well as maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Specifically, the facility failed to: 1) an employee (Staff #1) had a valid background check while working at the facility over a four-year period; and 2) 75 active employees (Staff #s 2 through 76) had continuous background check clearance during employment. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 33393 . Based on record review and interviews, the facility failed to ensure 76 staff were adequately screened for abuse and neglect, as well as maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Specifically, the facility failed to: 1) an employee (Staff #1) had a valid background check while working at the facility over a four-year period; and 2) 75 active employees (Staff #s 2 through 76) had continuous background check clearance during employment. This failed practice placed all patients at risk for abuse, neglect, and/or misappropriation. Furthermore, these failed practices resulted in lack of oversight from the Department of Health Background Check Unit due to failure to ensure employees were appropriately screened and maintained valid background check status. Findings: Lack of Background Checks Record review of the New Alaska Background Check System (NABCS) on 4/25/25 revealed Staff #1 had a valid background check from 11/28/14 through 4/14/21. NABCS automatically closed the background application when the eligibility expired on 4/14/21. As a result, the Staff #1 did not have a valid background check from 4/5/21 to 4/19/25. Record review of the New Alaska Background Check System (NABCS) on 4/25/25 revealed that a background application was entered and paid for by the facility on 4/16/21. On 4/28-30/21 the Background Check Unit (BCU) identified a barrier crime, but did not make a final determination until a fingerprint card was received. On 7/31/22, the application was incomplete and closed due to the lack of submission of a fingerprint card. Record review of Staff #1 timesheets, dated 4/1/21 through 4/19/25, revealed the Staff #1 worked a cumulative 7,772.29 hours at the facility. During an interview on 4/24/25, Human Resources (HR) Staff #1 stated there were some inconsistencies in the background check process prior to his/her team taking on the responsibilities of background checks in December 2024. HR Staff #1 further stated the facility became aware of background check issues after receiving a letter from the State in March of 2025. Record review of the facility’s job description for “Certified Phlebotomist ...Job Code: 3372,” undated, revealed job duties included “Performs specimen collection and patient preparation, ensuring correct patient and specimen identification and specimen integrity by using appropriate techniques as required. May perform assigned patient testing. May perform collections for drug and alcohol screening, following chain of custody protocols. May transport patient specimens and/or patients, per guidelines ... Performs registration processes including collecting insurance information, verifying coverage of Advanced Beneficiary Notices, obtain authorizations and signatures. Verifies patient demographics, insurance, and diagnostic test information, and accurately enters data into appropriate systems to ensure accurate documentation and billing.” Gaps in Background Check Clearance Record review on 4/25/25 of the facility’s active employee list, dated 4/24/25, in conjunction with Alaska Background Check System (NABCS) revealed the following employees were actively employed by the facility with gaps in background check clearance during the following dates: Staff #2 - No clearance 1/10/22-12/2/24 Staff #3 - No clearance 1/16/23-1/22/23 & 3/25/23-8/11/24 Staff #4 - No clearance 1/27/23-12/22/24 Staff #5 - No clearance 1/3/25-3/23/25 Staff #6 - No clearance 1/3/25-4/6/25 Staff #7 - No clearance 1/6/14-3/12/14 & 12/28/18-10/2/20 Staff #8 - No clearance 10/05/23-current Staff #9 - No clearance 10/1/18-12/15/19 Staff #10 - No clearance 10/11/21-12/21/21 Staff #11 - No clearance 10/18/21-11/15/21 Staff #12 - No clearance 10/18/21-11/15/21 Staff #13 - No clearance 10/18/21-11/16/21 Staff #14 - No clearance 10/20/14-11/23/14 & 4/3/19-2/5/20 Staff #15 - No clearance 10/22/17-9/1/20 Staff #16 - No clearance 10/22/20-6/6/21 Staff #17 - No clearance 10/23/18-11/23/20 Staff #18 - No clearance 10/24/16-4/26/18 Staff #19 - No clearance 10/3/20-3/17/21 Staff #20 - No clearance 10/30/23-1/7/24 Staff #21 -No clearance 10/4/21-10/27/21 Staff #22 - No clearance 10/5/20-11/7/22 & 9/2/23-9/17/23 Staff #23 - No clearance 10/7/21-4/21/24 Staff #24 - No clearance 10/9/19-10/10/19 & 5/16/20-8/1/23 Staff #25 - No clearance 11/1/21-11/16/21 Staff #26 - No clearance 11/1/21-11/23/21 Staff #27 - No clearance 11/11/19-3/4/20 Staff #28 - No clearance 11/15/21-12/12/21 Staff #29 - No clearance 11/18/21-11/15/21 Staff #30 - No clearance 11/23/21-12/12/21 Staff #31 - No clearance 11/24/21-12/12/21 & 9/9/22-6/18/23 Staff #32 - No clearance 11/25/20-12/9/20, 7/23/22-1/8/23 & 6/10/23-1/22/25 Staff #33 - No clearance 11/27/23-1/7/24 Staff #34 - No clearance 11/29/21-12/20/21 Staff #35 - No clearance 11/7/21-11/23/21 Staff #36 - No clearance 11/7/21-12/2/21 Staff #37 - No clearance 11/8/21-11/23/21 Staff #38 - No clearance 11/8/21-11/25/21 Staff #39 - No clearance 12/11/20-1/10/21 Staff #40 - No clearance 12/11/23-1/7/24 Staff #41 - No clearance 12/12/21-12/21/21 Staff #42 - No clearance 12/13/21-12/29/21 Staff #43 - No clearance 12/16/19-1/8/20 Staff #44 - No clearance 12/19/22-1/8/23 Staff #45 - No clearance 12/19/24-current Staff #46 - No clearance 12/2/21-2/20/22 Staff #47 - No clearance 12/20/20-9/28/22 Staff #48 - No clearance 12/28/19-11/11/24 Staff #49 - No clearance 12/31/22-9/10/23 Staff #50 - No clearance 12/9/20-10/28/21 Staff #51 - No clearance 2/14/20-6/17/20 Staff #52 - No clearance 2/15/21-12/31/24 Staff #53 - No clearance 2/2/15-10/28/21 & 10/17/23-6/23/24 Staff #54 - No clearance 2/20/25-4/13/25 Staff #55 - No clearance 2/23/20-3/17/24 Staff #56 - No clearance 2/9/20-9/22/24 Staff #57 - No clearance 3/16/20-9/29/20 Staff #58 - No clearance 3/2/19-9/29/20 Staff #59 - No clearance 3/21/11-7/4/16 & 5/8/18-10/31/20 Staff #60 - No clearance 3/27/20-3/30/20 & 4/3/21-1/10/22 Staff #61 - No clearance 3/27/22-3/28/22 & 4/5/22-11/12/23 Staff #62 - No clearance 3/30/22-2/5/23 Staff #63 - No clearance 3/5/20-10/31/20 Staff #64 - No clearance 3/6/20-10/31/20 Staff #65 - No clearance 4/19/16-1/8/17 & 10/15/20-10/20/20 Staff #66 - No clearance 4/2/21-7/18/22 Staff #67 - No clearance 4/23/20-5/10/20 & 6/28/20-9/7/20 Staff #68 - No clearance 5/19/22-5/30/22 & 8/13/22-7/14/24 Staff #69 - No clearance 5/21/23 & 5/13/24-6/17/24 Staff #70 - No clearance 6/19/20-10/1/20 & 4/5/21-4/7/21 Staff #71 - No clearance 6/21/21-10/20/21; 11/13/21-6/18/23 Staff #72 - No clearance 6/5/22-6/14/22 & 8/3/23-3/24/24 Staff #73 - No clearance 7/19/21-current Staff #74 - No clearance 8/18/23-9/24/23 & 4/17/25-4/21/25 Staff #75 - No clearance 8/19/19-11/15/21 Staff #76 - No clearance 8/24/20-9/1/20 & 1/7/23-6/4/23 Review of the facility provided document “State Background Check - HR process, undated, revealed “Employees, Students and Volunteers are required to renew their Alaska Background Checks every five years. This is coordinated by the HR Coordinator, Talent Development Coordinator, Voluntary Services Coordinator. The background check renewal process begins 60 days from the expiration date. An email is sent to the employee and their leader within FHP. The employee is required to fill out the renewal application and submit that to the HR Coordinator. Once the HR Coordinator receives the application it is entered into the State of Alaska Database. After the application is finalized, the employee will then have their fingerprints taken with the Security Badging office. HR will mail fingerprints and applications the next business day via FedEx. It has been FHP’s philosophy to put every position through the background check process to ensure 100% compliance.” .”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to follow the provider’s agreement to comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to: 1) ensure the facility had an EMTALA (Emergency Medical Treatment and Labor Act) orientation and training program designed to prepare all medical staff of the hospital’s responsibilities of Medicare participating hospitals in emergency cases; 2) ensure the facility had proof of official administrative monitoring and oversight of EMTALA cases, in the form of documented meeting minutes of any Leadership group; and 3) provide available stabilizing treatment prior to transfer to a higher level of care for 1 patient (#25), out of 2 transfers reviewed. Specifically, the facility failed to control active bleeding, that required multiple transfusions, prior to transferring. These failed practices had the potential to: 1) affect emergency department (ED) patient care and treatment; 2) place patients having an emergency medical condition (EMC) at risk for inconsistent or inappropriate transfers, and/or delay in life saving care and treatment; and 3) placed Patient #25 at risk for the inability to supply blood to major organs, which could have caused organ failure and/or death, before reaching the receiving hospital for treatment. Findings: EMTALA Training Review of the facility’s “Bylaws of the Medical Staff of Fairbanks Memorial Hospital,” dated 10/24/23, revealed: “. . . Basic Responsibilities and Requirements. As a condition of initial appointment and reappointment and as an ongoing condition of being a Member of the Medical Staff and/or holding Clinical Privileges and Scope of Practice, each member agrees to: Abide by the Bylaws, Rule and Regulations, and other policies of the Medical Staff and Hospital . . .” Review of the facility’s policies revealed they had an established policy entitled “EMTALA: Medical Screening Examination and Stabilizing Treatment,” dated 8/7/24. Further review revealed: “. . . Applicability. This policy applies to Foundation Health and the applicable campus . . .” During an interview on 1/9/25 at 1:56 PM, when asked to describe the EMTALA training medical staff receive at the facility, the Chief Medical Officer stated there was no mandatory EMTALA training and no annual EMTALA training at the facility. Administrative Oversight of EMTALA During an interview on 1/9/25 at 8:09 AM, when asked if there were any formal leadership meetings at the facility where EMTALA cases, or concerns about potential EMTALA violations, were discussed, the Chief Quality Officer stated EMTALA cases were verbally discussed but could not provide documented proof of any leadership meeting where meeting minutes would reflect EMTALA cases, or concerns about potential EMTALA violations. During an interview on 1/9/25 at 1:56 PM, when asked if he was aware of any leadership meetings where EMTALA cases were discussed, the Chief Medical Officer stated he knew EMTALA cases are verbally discussed but couldn’t recall a leadership meeting where the minutes would reflect discussions about EMTALA cases. Patient #25 Incident on 12/5/24 Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transported to the facility by ambulance for treatment. Further review revealed: - 6:07 PM: Patient #25 arrived at the facility; at which time a full trauma code was called due to the extent of his/her injuries. - 6:08 PM: A medical screening examination was initiated to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CAT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head. Further review of x-ray and CAT scans revealed Patient #25 sustained: 1) a rupture of his/her diaphragm (the primary muscle of breathing at the base of chest cavity and separates the abdomen from the chest) that caused the stomach and omentum (fatty tissue that secured and protected abdomen organs) to enter the chest cavity; 2) extensive pelvic fractures and a displaced femur fracture (where the bone ends were not aligned); 3) multiple rib fractures; and 4) flattening of the inferior vena cava (largest vein of the body which carried unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body. Blood Transfusion Record Review of Patient #25’s Transfusion Summary report from the ED record, dated 12/5/24, revealed the ED transfused a total of eight units of PRBCs as follows - 6:49 PM: Patient #25 received two units of packed red blood cells (prbcs) due to loss of blood from his/her injuries. - 7:56 PM: Patient #25 received an additional two units of prbcs. - 8:01 PM: Patient #25 received two more units of prbcs. - 8:38 PM: Patient #25 received an additional two units of prbcs. Further review of the physician’s note, dated 12/5/24, revealed: “. . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . . We have given life med [emergency helicopter transport] 3 units of blood to go with . . .” Decision to Transfer Review of Patient #25’s “Patient Transfer Orders” from the medical record, dated 12/5/24, revealed: “Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient’s best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual’s health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . .” During an interview on 1/8/25 at 5:40 PM, when asked what the main decision was to transfer Patient #25 to another hospital, Physician #2 stated that during examination and treatment, Patient #25 was actively bleeding, requiring transfusions, and needed immediate treatment from a higher level of care to surgically repair injuries sustained in the accident. During an interview on 1/9/25 at 1:56 PM, when asked to describe the facility’s emergency department (ED) and trauma capabilities, the Chief Medical Officer stated the facility was a level 4 trauma center, where the facility did not have to do definitive care of anything but must stabilize beyond what a normal ED would do, which was called “trauma stabilization.” When asked what the expectations were when a full trauma code was called in the ED, the Chief Medical Officer stated when an ED doctor called a full trauma code, all available resources would be activated to include: a general surgeon would come to the bedside, the Charge Nurse would be notified, the blood bank would be alerted for blood products, and a life flight would be placed on standby. Review of Patient #25’s “Trauma Flowsheet” from the medical records, dated 12/5/24, revealed no consults from other facility providers, like a general surgeon, was documented. During an interview on 1/9/25 at 2:30 PM, when asked what occurred when a physician called a full trauma code, Physician #2 stated a general surgeon would come to the bedside, nurses would be alerted, blood bank would be alerted, and a life flight would be placed on standby. When asked if a general surgeon came to the bedside on 12/5/24 when Physician #2 called the full trauma code for Patient #25, Physician #2 stated they did not. When asked why they did not come, Physician #2 stated, “I don’t know.” When asked if it was possible that the facility could have performed surgery for Patient #25’s injuries, Physician #2 stated it was not possible because the facility did not have Interventional Radiology (IR - medical specialty that uses minimally invasive procedures to diagnose and treat diseases. Guided surgery through medical imaging) capabilities in the operating room. When asked if Physician #2 consulted with a specialty physician at the facility prior to transfer, Physician #2 stated he/she consulted with a facility general surgeon, Physician #7, by phone. Record review of the facility’s ED call log, dated 12/5/24, revealed Physician #7 was called at 6:34 PM. Further review revealed this call was made prior to the initiation of Patient #25’s blood transfusions, which started at 6:49 PM. The facility confirmed there were no other calls made to Physician #7 prior to Patient #25’s transfer. During an interview on 1/9/25 at 3:02 PM, Physician #7 (who was a general surgeon) stated the facility did not have IR capability in the OR setting and anyone requiring this for surgery would be transferred to another facility for treatment. When asked about trauma stabilization capabilities at the facility for a patient who was losing blood volume that required transfusions, Physician #7 stated the overall goal would have been to stabilize prior to transport by packing off the wounds to slow bleeding. When asked about Patient #25’s condition of active bleeding that required multiple transfusions and the decision to transport, Physician #7 stated Patient #25’s level of instability was not relayed to him/her during the consultation over the phone on 12/5/24 and he/she would have never recommended transport for someone who had that degree of blood loss. Review of the facility’s policy “Trauma Activation Roles and Responsibilities Guidelines,” dated 6/24/24, revealed: “During the stabilization and resuscitation phase, members of the trauma team will follow the guidelines of their respective roles as listed herein. All trauma team members are required to respond to the trauma room immediately upon receipt of the activation page . . .” Review of the list of trauma team responders for a full trauma activation included the ED physician. Further review of the policy revealed no roles and responsibilities listed for the ED physician. A general surgeon was not listed as being required to respond to the bedside upon activation of a full trauma code and there were no roles and responsibilities for the general surgeon. Review of the facility’s policy “Inter-Facility Trauma Transfer Guidelines,” dated 2/2/24, revealed: “. . . Trauma transfers out of Fairbanks Memorial Hospital are managed by the patient’s attending physician, including ER [Emergency Room] physician, surgeons, neurosurgeons and orthopedists, in conjunction with the AC [Administrative Coordinator] . . . physician judgement is the deciding factor in transfer. If resources are not available and it is in the best interest of the patient, then transfer to a higher-level Trauma Center should be considered . . .” Review of the facility’s on-call schedule, dated 12/5/24, revealed Physician # 7 was available during this emergency for “Surgery - 24 [hour] shift - change [at] [7:00 AM]. Review of the facility policy “EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination and Stabilizing Treatment,” dated 8/7/24, revealed: “. . . Transfer Requirements for the Patient. Transfer of a Patient may be considered under the following circumstances . . . The Patient may be transferred to another hospital if . . . The physician in attendance or QMP [Qualified Medical Professional] in consultation with the physician determines that the benefits of Transfer outweigh the risks; or the Hospital is unable to stabilize the Patient within its capacity . . .” .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to provide available stabilizing treatment prior to transfer to a higher level of care for 1 patient (#25), out of 2 transfers reviewed. Specifically, the facility failed to control active bleeding, that required multiple transfusions, prior to transferring. This failed practice placed the patient at risk for the inability to supply blood to major organs, which could have caused organ failure and/or death, before reaching the receiving hospital for treatment. Findings: Incident on 12/5/24 Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transported to the facility by ambulance for treatment. Further review revealed: - 6:07 PM: Patient #25 arrived at the facility; at which time a full trauma code was called due to the extent of his/her injuries. - 6:08 PM: A medical screening examination was initiated to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CAT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head. Further review of x-ray and CAT scans revealed Patient #25 sustained: 1) a rupture of his/her diaphragm (the primary muscle of breathing at the base of chest cavity and separates the abdomen from the chest) that caused the stomach and omentum (fatty tissue that secured and protected abdomen organs) to enter the chest cavity; 2) extensive pelvic fractures and a displaced femur fracture (where the bone ends were not aligned); 3) multiple rib fractures; and 4) flattening of the inferior vena cava (largest vein of the body which carried unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body. Blood Transfusion Record Review of Patient #25’s Transfusion Summary report from the ED record, dated 12/5/24, revealed the ED transfused a total of eight units of PRBCs as follows: - 6:49 PM: Patient #25 received two units of packed red blood cells (prbcs) due to loss of blood from his/her injuries. - 7:56 PM: Patient #25 received an additional two units of prbcs. - 8:01 PM: Patient #25 received two more units of prbcs. - 8:38 PM: Patient #25 received an additional two units of prbcs. Further review of the physician’s note, dated 12/5/24, revealed: “. . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . . We have given life med [emergency helicopter transport] 3 units of blood to go with . . .” Decision to Transfer Review of Patient #25’s “Patient Transfer Orders” from the medical record, dated 12/5/24, revealed: “Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient’s best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual’s health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . .” During an interview on 1/8/25 at 5:40 PM, when asked what the main decision was to transfer Patient #25 to another hospital, Physician #2 stated that during examination and treatment, Patient #25 was actively bleeding, requiring transfusions, and needed immediate higher level of care treatment to surgically repair injuries sustained in the accident. During an interview on 1/9/25 at 1:56 PM, when asked to describe the facility’s emergency department (ED) and trauma capabilities, the Chief Medical Officer stated the facility was a level 4 trauma center, where the facility did not have to do definitive care of anything but must stabilize beyond what a normal ED would do, which was called “trauma stabilization.” When asked what the expectations were when a full trauma code was called in the ED, the Chief Medical Officer stated when an ED doctor called a full trauma code, all available resources would be activated to include: a general surgeon would come to the bedside, the Charge Nurse would be notified, the blood bank would be alerted for blood products, and life flight would be placed on standby. Review of Patient #25’s “Trauma Flowsheet” from the medical records, dated 12/5/24, revealed no consults from other facility providers, like a general surgeon, were documented. During an interview on 1/9/25 at 2:30 PM, when asked what occurred when a physician called a full trauma code, Physician #2 stated a general surgeon would come to the bedside, nurses would be alerted, blood bank would be alerted, and a life flight would be placed on standby. When asked if a general surgeon came to the bedside on 12/5/24 when Physician #2 called the full trauma code for Patient #25, Physician #2 stated they did not. When asked why they did not come, Physician #2 stated, “I don’t know.” When asked if it was possible that the facility could have performed surgery for Patient #25’s injuries, Physician #2 stated it was not possible because the facility did not have Interventional Radiology (IR - medical specialty that uses minimally invasive procedures to diagnose and treat diseases. Guided surgery through medical imaging) capabilities in the operating room. When asked if Physician #2 consulted with a specialty physician at the facility prior to transfer, Physician #2 stated he/she consulted with a facility general surgeon, Physician #7, by phone. Record review of the facility’s ED call log, revealed on 12/5/24 Physician #7 was called at 6:34 PM. Further review revealed this call was made prior to the initiation of Patient #25’s blood transfusions, which started at 6:49 PM. The facility confirmed there were no other calls made to Physician #7 prior to Patient #25’s transfer. During an interview on 1/9/25 at 3:02 PM, Physician #7 (who was a general surgeon) stated the facility did not have IR capability in the OR setting and anyone requiring this for surgery would be transferred to another facility for treatment. When asked about trauma stabilization capabilities at the facility for a patient who was losing blood volume that required transfusions, Physician #7 stated the overall goal would have been to stabilize prior to transport by packing off the wounds to slow bleeding. When asked about Patient #25’s condition of active bleeding that required multiple transfusions and the decision to transport, Physician #7 stated Patient #25’s level of instability was not relayed to him/her during the consultation over the phone on 12/5/24 and he/she would have never recommended transport for someone who had that degree of blood loss. Review of the facility’s policy “Trauma Activation Roles and Responsibilities Guidelines,” dated 6/24/24, revealed: “During the stabilization and resuscitation phase, members of the trauma team will follow the guidelines of their respective roles as listed herein. All trauma team members are required to respond to the trauma room immediately upon receipt of the activation page . . .” Review of the list of trauma team responders for a full trauma activation included the ED physician. Further review of the policy revealed no roles and responsibilities listed for the ED physician. A general surgeon was not listed as being required to respond to the bedside upon activation of a full trauma code and there were no roles and responsibilities for the general surgeon. Review of the facility’s policy “Inter-Facility Trauma Transfer Guidelines,” dated 2/2/24, revealed: “. . . Trauma transfers out of Fairbanks Memorial Hospital are managed by the patient’s attending physician, including ER [Emergency Room] physician, surgeons, neurosurgeons and orthopedists, in conjunction with the AC [Administrative Coordinator] . . . physician judgement is the deciding factor in transfer. If resources are not available and it is in the best interest of the patient, then transfer to a higher-level Trauma Center should be considered . . .” Review of the facility’s on-call schedule, dated 12/5/24, revealed Physician # 7 was available during this emergency for “Surgery - 24 [hour] shift - change [at] [7:00 AM]. Review of the facility policy “EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination and Stabilizing Treatment,” dated 8/7/24, revealed: “. . . Transfer Requirements for the Patient. Transfer of a Patient may be considered under the following circumstances . . . The Patient may be transferred to another hospital if . . . The physician in attendance or QMP [Qualified Medical Professional] in consultation with the physician determines that the benefits of Transfer outweigh the risks; or the Hospital is unable to stabilize the Patient within its capacity . . .” .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure: 1) all available medical records related to the emergency medical condition (EMC) were sent to the receiving hospital for 1 transferred patient (#25), out of 2 transfers reviewed; and 2) “Patient Transfer Orders” and “Physician’s Certificate of Transfer and Patient Consent” paperwork of transferred patients was complete and accurate for 4 patients (#’s 4, 52, 64, and 77), out of 9 records of transferred patients reviewed. These failed practices placed the patients at risk for incomplete medical records and delay in treatment which had the potential to affect their overall outcome and well-being. Findings: Medical Records for Transfers During an interview on 1/9/25 at 8:33 AM, the Senior Manager for the Emergency Department (ED) stated when a physician order for transfer was received, the Desk Tech (technician) would be responsible to gather all related medical records and send them to the receiving hospital by two methods: 1) a transfer packet, which contained all available medical records pertaining to the EMC, would be given to the transfer team to accompany the patient, and 2) the Desk Tech would also fax the documents to the receiving hospital. Patient #25 Incident on 12/5/24 Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transport to the facility by ambulance for treatment. Further review revealed: - 6:07 PM: Patient #25 arrived at the facility at which time a full trauma code was called due to the extent of his/her injuries. - 6:08 PM: A medical screening examination was started to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head. Further review of x-ray and CT scans revealed Patient #25 sustained: 1) a rupture of his/her diaphragm (muscle between chest cavity and stomach/intestines) causing the stomach and omentum (fatty tissue that secures and protects organs) to enter the chest cavity; 2) extensive pelvic fractures and a femur fracture that was not aligned; 3) multiple rib fractures; and 4) flattening of the inferior vena cava (largest vein which carries unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body. Further review of the physician’s note, dated 12/5/24, revealed: “. . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . .” Review of Patient #25’s “Patient Transfer Orders,” dated 12/5/24, revealed: “Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient’s best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual’s health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . .” Further review revealed order instruction #2 “. . . copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient” was left blank. Review of the receiving hospital report of Patient #25 on 12/5/24 revealed the patient arrived without a provider history and physical report or labs. Review of Patient #25’s medical record, dated 12/5/24, revealed the physician documented he/she shared the results of the CT scans with the receiving hospital. Further review revealed no documentation to reflect what other items of the medical record were sent to the receiving hospital. During an interview on 1/9/25 at 8:33 AM, when asked how the facility could prove what medical records were sent and/or faxed, and when, to a receiving hospital, the Senior Manager for the ED stated the facility identified a gap in their processes concerning this about two weeks ago. The Senior Manager of the ED stated the facility could show when a fax was sent, but not what was faxed. Because of this gap, a new fax coversheet was created to document which items from the medical record were sent. Record review of the facility’s fax log, dated 12/5/24, revealed no fax was logged to show medical records were sent to the receiving hospital for Patient #25. Record review of the facility’s print log (what items were printed) revealed items from Patient #25’s medical record were printed on 12/5/24 at 7:23 PM, however could not identify what items from the medical records were printed or why they were printed. Review of the facility’s policy “EMTALA: Medical Screening Examination and Stabilizing Treatment,” dated 8/7/24, revealed: “. . . Transfer of the Patient who is not Stable for Transfer is accomplished as follows . . . Copies of all medical records related to the EMC [emergency medical condition] are sent with the Patient to the accepting facility. Other records, including test results, not available at the time of Transfer must be sent as soon as practicable after Transfer . . .” Complete and Accurate Medical Records Patient #4 Record review on 1/8-9/24 revealed Patient #4 was seen in the ED on 11/3/24: “. . . [Patient #4] presents via EMS [emergency medical services - ambulance] for worsening generalized fatigue, severe skin ulcers/rash, worsening generalized edema and deconditioning. . .” Further review revealed Patient #4 was diagnosed with acute renal failure, hyperkalemia (high potassium levels), acute CHF (congestive heart failure) exacerbation, pulmonary edema, pericardial effusion (the buildup of too much fluid around the heart), soft tissue infection, and sepsis (a serious condition which the body responds improperly to infection). The decision was made to transfer Patient #4 to a higher level of care where dialysis could be provided. An order for transfer was made. Review of Patient #4’s “Patient Transfer Orders,” dated 11/3/24, revealed the following order instructions were left blank: “Reason for Patient Transfer” and #2, “copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient”. Review of Patient #4’s “Physician’s Certificate of Transfer and Patient Consent,” dated 11/3/24, revealed section C, “Transport,” was left blank. Patient #52 Record review on 1/8-9/24 revealed Patient #52 was seen in the ED on 10/12/24: “. . . [Patient #52] presenting [to] emergency department for evaluation of straddle injury [genital trauma]. Patient’s presentation is concerning for pelvic fracture, urethral injury, testicular injury . . .” Further review revealed Patient #52 was diagnosed with an inferior pubic rami fracture (a pelvic bone near the bottom of the pelvis) and perineal trauma (genital region injury). The decision was made to transfer Patient #52 to a higher level of care where urology (specialty focused on diagnosing and treating conditions the urinary tract and male reproductive organs) was available. An order for transfer was made. Review of Patient #52’s “Patient Transfer Orders,” dated 10/12/24, revealed the following order instructions were left blank: #2 “copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient;” #3 “Mode of transfer;” #4 “Escort requirements/equipment or life support services required to accompany patient;” and #5 “Special transport orders.” Further review revealed the physician’s signature was not dated or timed. Review of Patient #52’s “Physician’s Certificate of Transfer and Patient Consent,” dated 10/12/24, revealed section C, “Transport (Do Both),” was left blank. Under section D “Analysis of Risks and Benefits of Transfer,” neither “Worsening the condition or death if the patient stays here” and/or “Obtain level of care not available at this facility” were marked. Patient #64 Record review on 1/8-9/24 revealed Patient #64 was seen in the ED on 10/9/24: “This is [Patient #64] with likely recurrent right hip dislocation . . .” Further review revealed the patient had a history of a hip replacement and through the examination on 10/9/24 discovered the patient’s hip prosthesis was disarticulated from itself (separated at the prosthesis’s joint). The decision was made to transfer Patient #64 to a higher level of care for prosthesis repair. An order for transfer was made. Review of Patient #64’s “Patient Transfer Orders,” dated 10/9/24, revealed the following order instructions were left blank: #2 “copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient;” #3 “Mode of transfer;” #4 “Escort requirements/equipment or life support services required to accompany patient;” and #5 “Special transport orders.” Review of Patient #64’s “Physician’s Certificate of Transfer and Patient Consent,” dated 10/9/24, revealed section C, “Transport (Do Both),” was left blank. Patient #77 Record review on 1/8-9/24 revealed Patient #77 was seen in the ED on 9/20/24 due to preterm labor at 29 weeks gestation. The decision was made to transfer Patient #77 to a higher level of care were NICU (Neonatal Intensive Care Unit) capabilities were available if labor could not be stopped. An order for transfer was made. Review of Patient #77’s “Patient Transfer Orders,” dated 9/20/24, revealed order instruction #2, “copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient” was left blank. Review of the facility policy “Inter-Facility Trauma Transfer Guidelines,” dated 2/2/24, revealed: “. . . Procedural Documentation. Patient Transfer Orders form is completed by the transferring physician and RN [registered nurse]. Physician’s certificate of transfer and patient consent form is completed by the transferring physician . . .” Review of the facility’s policy “EMTALA: Medical Screening Examination and Stabilizing Treatment,” dated 8/7/24, revealed: “. . . Transfer of the Patient who is not Stable for Transfer is accomplished as follows. The form “Request for Transfer/Consent to Transfer/Certification for Transfer” is required and fully completed for Patients . . .” .”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to provide proof of compliance with recipient hospital responsibilities. This failed practice placed all patients in need of emergency transport at risk for potential refusal to accept care and/or delay in care. Findings: During an interview on 1/8/25 at 1:14 PM, the Senior Manager for the ED stated calls from other facilities to request transfers were received by calling the emergency department (ED) number. These calls were handled two ways: 1) A charge nurse would take the call and take the report from the provider calling. The charge nurse could prepare for the arrival or get a facility provider to talk to the provider calling; and 2) the nursing supervisor would take the call, and they would get a facility provider who was on-call to talk to the provider calling. When asked to see the facility’s call log for calls received requesting transfer to their facility, the Senior Manager of the ED stated there was no call log. The Senior Manager of the ED further stated if a facility provider took a call and decided the patient needed to go elsewhere, there was no log or documentation to show who called, which facility provider took the call, or what was decided. .”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 40259 . Based on observation, record review, and interview, the facility failed to inform each patient of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible, for all patients in the Emergency Department (ED). This failed practice placed all patients of the ED (current census of 12) at risk for not knowing their patient rights, the grievance process, or how to contact outside resources for assistance if needed. Findings: An observation on 1/12/24 at 9:10 AM, of the ED lobby revealed the “Notice of Privacy Practices,” for medical records and patient information privacy, were posted. Further review revealed the patient rights were not posted anywhere in view. Record review medical records for patients seen in the ED, from 9/2/23 to 12/27/23, revealed no documented acknowledgement of being informed of, or provided a copy of, the patient rights for 10 out of 10 records reviewed. Record review of the facility’s consent to treat form “Authorizations and Services Terms,” dated 1/2022, revealed no documented acknowledgement of being informed of, or provided a copy of, the patient rights. During an interview on 1/12/24 at 1:49 PM, the Accreditation Program Manager stated the “Authorizations and Services Terms” form was redrafted in late 2021, to replace older forms and consolidate them into one. The Accreditation Program Manager stated this form was used as a consent to treat and was used hospital-wide, for inpatients and outpatients. The Accreditation Program Manager further stated it was only discovered, during this survey, that the documented acknowledgement for the notice of patient rights was inadvertently dropped from the new form’s verbiage when the redraft occurred. Review of the facility’s previous consent form “Consent for Health Care Services,” dated 4/2018, revealed: “ ... Acknowledgements: I acknowledge that I have been informed of ... “Patient Bill of Rights”/“Patient Rights and Responsibilities” ...” During an interview on 1/12/24 at 4:43 PM, ED Receptionist #1 stated that when a patient comes into the ED, he/she takes the patient’s name, date of birth, and why they had come to the ED. ED Receptionist #1 would then create a wrist band identifier and labels for patient paperwork. When asked if he/she offered patients the patient rights, ED Receptionist #1 stated he/she did not. When asked if he/she completed the “Authorizations and Services Terms” consent form, ED Receptionist #1 stated he/she did not, that this form was completed in the ED with Registration staff. During an interview on 1/12/24 at 4:45 PM, Registration Representative #4 stated his/her role in the ED was to verify patient identification and completed ED consents and other paperwork. When asked if he/she offered patients the patient rights, Registration Representative #4 stated he/she did not. An observation on 1/12/24 at 4:48 PM, revealed the facility’s pamphlets of patient rights “Patient Rights [and] Responsibilities,” dated 6/2019, were to the left of the ED receptionist desk, on a counter to the side of the desk that was lower and not visible from the front desk area. Further observation revealed the pamphlets were in a wire meshed file holder. The pamphlet’s title was obscured by the wire mesh. There was no signage to indicate where the patient rights were located. There was no label on the file holder to indicate patient rights were stored here. Review of the facility’s policy “Patient Rights and Responsibilities,” dated 11/10/22, revealed: “ ... A framed copy of the “Patients’ Rights and Responsibilities” statement is on display in multiple departments throughout the organization’s facilities, in each Patient and Visitor Guide, is given to each patient at time of registration, and is placed in the pre-admission packets .... Notice of Rights. The hospital will inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible ...” .”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure that arrangements from a discharge plan evaluation were made for 1 patient (#16), out of 10 patients reviewed. Specifically, the facility failed to follow the physician’s order from a discharge plan evaluation, which was to discharge Patient #16, who was intoxicated, directly to the Community Service Patrol (CSP - a service provided to take intoxicated or incapacitated people into protective custody to prevent victimization and cold-related injuries) for appropriate after care. This failed practice placed the patient at risk for the inability to care for himself/herself and exposure to cold weather which may have resulted in cold-related injuries, hypothermia, and/or death. Findings: Record review on 1/12/24 revealed Patient #16 was seen in the ED on 12/3/23 at 4:50 PM for a fall and complaints of feeling shaky and weak. Further review revealed this patient had a long history of alcohol abuse and had been seen multiple times in the ED due to alcoholism, the last time being at 1:00 AM earlier in the day. Patient #16 had also recently tested positive for COVID and was required to wear a mask. Review of Patient #16’s ED assessment, dated 12/3/23 at 4:50 PM, revealed that at 5:00 PM his/her blood alcohol concentration (BAC - the metric used to measure the amount of alcohol in a person’s bloodstream) was 0.411% (over 5 times the legal limit of 0.08%). Review of the physician’s notes, dated 12/3/23 at 5:49 PM, revealed: “ ... We observe[d] the patient for 90 minutes in the emergency department. [His/Her] alcohol level is quite elevated at 411. Patient has a long history of alcohol abuse. [He/She] is ambulatory. We will call CSP and have [him/her] discharged to their care ...” Review of Patient #16’s “Emergency Department Report for ESP [Emergency Service Patrol, also called CSP - Community Service Patrol]/Detox or Fairbanks Correctional Center” form, signed by the Physician #7 on 12/3/23 at 5:56 PM, revealed: “Diagnostic Results: etoh [alcohol] 411 [at] [5:00 PM] ... 97.6 [degrees Fahrenheit] temp ... Functional Status at Discharge: Ambulatory, tolerates PO [fluid/food by mouth] ... I certify this patient is medically stable for transport ...” During an interview on 1/12/24 at 4:30 PM, Physician #7 stated that when an intoxicated individual presented to the ED, they were assessed and then evaluated until deemed stable, which could take hours. A patient would be deemed stable to discharge once they were ambulatory. Physician #7 stated CSP would be part of the discharge plan evaluation when the hospital wanted to ensure an intoxicated patient had a safe placed to discharge to. Review of a nurse’s note, dated 12/3/23 at 5:42 PM, revealed: “Pt [patient] out of bed several times, bed alarm placed at arrival. Self discontinued prehospital IV [intravenous catheter for intravenous fluids] to right FA [forearm]. Dressed self, demanding discharge. Able to put on own boots, ambulating around room. Call to FPD [Fairbanks Police Department] for CSP transport, several calls prior. Pt discharged to lobby.” Further review revealed an addendum was added at 6:05 PM: “pt to FMH [Fairbanks Memorial Hospital] lobby with steady gait. Given ED form for CSP transport.” Review of the facility’s video recording, of the ED lobby on 12/3/23, revealed: 5:52 PM - Patient #16 observed to walk independently from ED Room 15 to the ED lobby with ED nurse. Patient #16 observed to walk to a lobby phone and make a phone call. 6:03 PM - A security guard was observed to talk to Patient #16, then point in the direction of the entrance/exit door of the ED lobby. Patient #16 was observed to leave the ED after this, walk across the ED parking lot and cross the street. Patient #16 was observed to walk down a street until he/she was no longer viewable from the camera. 6:38 PM - CSP van was observed to park in the ED parking lot. CSP employee entered the ED and walked to the ED nurse’s station to speak to staff. 6:42 PM - CSP employee walked into the lobby and talked to security. Then CSP employee left and drove away. During an interview on 1/12/24 at 5:05 PM, the Plant Operations and Safety Director stated he was able to play the audio of the 12/3/23 video recording from when the security guard interacted with Patient #16 in the ED lobby. Per the Plan Operations and Safety Director, the security guard informed Patient #16 that he/she had been asked to keep his/her mask in place while in the ED area three times. Since Patient #16 would not comply with this request, Patient #16 needed to leave the ED lobby. During an interview on 1/12/24 at 5:20 PM, the ED Director stated that it was not normal protocol to discharge an intoxicated patient, who was waiting for CSP transport, to the ED lobby. The ED Director stated the normal protocol would have been to have the patient wait in the ED until CSP arrived. CSP would enter the ED, come to the ED nurse’s desk and receive a report. The ED staff would then hand off the patient to the CSP employee for transport. The ED Director further stated she could not explain why the ED Nurse chose to discharge Patient #16 to the ED lobby on 12/3/23. Record review of the AK #4465 intake documents, dated 12/4/24, revealed that at 11:00 PM on 12/3/23 Patient #16 was found by FPD laying outside on a sidewalk near a facility that was across the street from FMH. Patient #16 was unable to ambulate independently and could barely shuffle without assistance. It was -9 degrees outside. FPD attempted to take Patient #16 to a sleep-off/detox facility, however they would not accept him/her due to his/her intoxicated state. FPD then took Patient #16 to Fairbanks Correctional Center (FCC) for assessment. At 11:00 PM, Patient #16’s BAC was 0.216%. Patient #16 was taken back to the ED for treatment. Review of Patient #16’s “ED Triage,” dated 12/3/23 at 11:55 PM, revealed: “ ...FPD picked up from outside, denied from FCC [Fairbanks Correctional Center] for inability to ambulate and intoxicated mentation ...” Further review revealed Patient #16’s temperature was 96.8 degrees Fahrenheit. Further review revealed no Physician’s note was present in Patient #16’s medical record from this visit. Review of the facility’s policy “Emergency Department Patient Standards of Care,” dated 7/11/23, revealed: “ ...Medical care is directed by the ED medical provider/designee ... Discharge. The ED Provider and/or the licensed nurse is responsible for delivering discharge instructions to the patient ... Report is given to the receiving facility or unit using SBAR [Situation, Background, Assessment, Recommendation charting] format. Patient leaves Against Medical Advice (AMA) - Patient has received medical screening exam and has refused recommended treatment. The provider is notified of the patient’s desire to leave against medial advice. Attempts are made to ascertain the reason the patient wants to leave and intervention is performed as appropriate. If the patient still desires to leave, the AMA form is signed and witnessed ... Handoff Communications: The transition of the patient (“hand off” of patient care) is communicated using SBAR, including an opportunity to ask and respond to questions from all involved parties ...” Review of information from American Addictions Centers Alcohol.org at https://alcohol.org/health-effects/blood-alcohol-concentration/ , “Blood Alcohol Concentration Levels and How They Affect the Body, dated 3/27/23, revealed: “ ... Although there is no one universally accepted standard for what is considered a “safe” level of drinking, the metric used to measure the amount of alcohol in a person’s bloodstream is called blood alcohol concentration, or BAC. Common symptoms, levels of impairment, and risks of various blood alcohol concentration (BAC) levels include ... 0.20 - 0.29%: Confusion, feeling dazed, and disorientation are common. Sensations of pain will change, so if you fall and seriously hurt yourself, you may not notice, and you are less likely to do anything about it ... 0.30 - 0.39%: At this point, you may be unconscious and your potential for death increases ... 0.40% and over: This level of BAC may put you in a coma or cause sudden death because your heart or breathing will suddenly stop. This is what is known as a lethal blood alcohol level ...” .”