Dale Medical Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 41623 Based on observations and interviews with staff during a tour of the hospital and off site locations by Life Safety Code surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this hospital. Findings include: Refer to tags: K-0211, K-0226, K-0325, K-0351, K-0353, and K-0923.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 49797 Based on Medical Record (MR) review, hospital policy and procedure, and staff interview it was determined the hospital failed to follow the hospital’s occurrence report policy and document all grievances reported to the staff. This deficient practice did affect MR # 19 and had the potential to affect all patients and families served by this hospital. Findings include: Hospital Policy: Occurrence Report- Quality Assurance Policy number: 1863931 Revision date: 8/2025 Purpose: Quality Assurance (QA) Occurrence Reporting contributes to the maintance of a safe environment. Documented occurrences are reviewed and analyzed for development of loss prevention measures and process improvement action under the aspects of QA Laws of the State of Alabama. Definitions: An Event or Occurrence is: Any happening which is not consistent with the routine operation of the hospital or the routine care of a particular patient... 2. Any unexpected or untoward event. It is any event or situation, which may or may not result in damage of property or illness/injury to a patient, visitor, or employee... Objectives: 1. To document all occurrences involving patients, visitors, employees, property damage and/or loss... Policy/Procedure: 1. The report must be completed as soon after the occurrence as possible, but no later than the end of the shift in which the occurrence happened or was discovered. 2. The report is a factual description of the occurrence... 4. The person first on the scene, observing, discovering, or directly involved shall complete the QA occurrence report. 1. PI # 19 was admitted to the hospital on 6/28/25 with diagnoses including Acute Appendicitis and Congestive Heart Failure. A review of the MR revealed the staff documented in the Patient Progress Notes dated 7/3/25 “...Pt’s son [Name] came in unit requesting for his father to be transferred. States “My attorney informed me to get him out of here” Mr [Name] complaints of previous care. Feels could have been prevented if someone had came in to his room. Supervisor present and talking with him. Dr [Name] informed also...” A review of the Compliant and Grievance log revealed no documentation of this occurrence. An interview was conducted on 9/25/25 at 3:11 PM with Employee Indentifer # 11, Intensive Care Unit Nurse Manager, who confirmed there was no documentation the grievance was investigated and the patient/caregiver notified of the results of the investigation..”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 41623 Based on review of the hospital QAPI (Quality Assurance and Performance Improvement) program documentation, hospital policy and interviews, it was determined the facility QAPI program failed to include reporting data for each department of the facility. This deficient practice had the potential to affect all patients admitted to this hospital. Findings include: Hospital Policy: Dale Medical Center Quality/Performance Improvement (PI) Plan 2025 Policy Number: Not Listed Approved: 2/19/25 ... The purpose of Performance Improvement is to ensure that patients are provided high quality care in an environment with minimal risk that focuses on patient safety... The leaders will set priorities for organization wide performance improvement activities... I. Departmental/Services: 1. Every department/service at Dale Medical Center is included in the Performance Improvement Program... 1. A review of the QAPI data for the year 2024 and 2025 revealed no documentation of data collection and no documentation of QAPI participation from each hospital department, including Dietary, Maintenance, Physical Therapy, and Emergency Preparedness. An interview was conducted on 9/25/25 at 1:10 PM with Employee Identifier # 1, Director of Quality and Risk Management, who confirmed there was no documentation of participation in the QAPI program from each hospital department.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41623 Based on medical record (MR) review, hospital policy and procedure, observations, and interviews with staff, it was determined the hospital failed to ensure: 1. Wound care was provided as ordered. 2. Wounds were assessed and measured per hospital policy. 3. Physician’s orders were complete with the wound care to be performed. 4. Vital Signs (VS) were assessed as ordered by the physician. This deficient practice affected six of 20 inpatient MR reviewed including Patient Identifier (PI) # 6, PI # 10, PI # 4, PI # 12, PI # 5, and PI # 19, and had the potential to negatively affect all patients admitted to this hospital. Findings include: Hospital Policy: Wound Care - Orders, Treatment, Frequency and Wound Type Policy Number: 14715662 Revised: 12/2023 Policy: Dressings for patient wound care will be managed according to physician order. A physician’s order shall be obtained prior to changing dressings. The order shall include: Kind of dressing Wound cleansing agent Medication or solution, frequency, dosage, ... to be used... Frequency of dressing change... Assessment: Should be performed once per shift... Hospital Policy: Wound/Pressure Ulcer Measuring & Photographing Policy Number: 14715378 Revised: 12/2023 ...Policy: A Registered Nurse or Physical Therapist will measure pressure ulcers/wounds upon initial assessment...then...weekly thereafter... Facility Policy: Orders-Computerized Physician Order Entry (CPOE), Verbal, Written, PO (Phone Order). Policy number: 13586484 Revised: 5/2023 ...Written orders that have been placed in the patient chart to be acknowledged by staff, entered into the CPOE, and carried out by nursing staff. Physician orders, issued usually electronically through the CPOE system, and acknowledged by nursing staff, and carried out. 1. PI # 6 was admitted to the Swing Bed Unit on 9/9/25 with a diagnosis of Small Bowel Obstruction. Review of the physician’s order dated 9/9/25 revealed orders for “Wound care.” The order did not include a location of the wound, what wound was to be cleaned with, what dressing was to be used and no documentation of the frequency the wound care was to be performed. Review of the Multi-Disciplinary Assessment dated 9/12/25 revealed the nurse documented the presence of a Stage 2 pressure injury to lower left buttock measuring 1 centimeter (cm) in length, 1 cm in width, and 0.1 cm in depth. Review of the physician’s order dated 9/12/25 revealed orders to “Clean and dress buttocks wounds daily.” The order did not include what the wound was to be cleaned with or what dressing was to be used. Review of the Skilled Nurse (SN) Patient Progress Notes (PPN) dated 9/13/25 and 9/14/25 revealed no documentation wound care was provided daily to the buttocks. Review of the physician’s order dated 9/15/25 revealed orders to clean reddened areas to perineum, gluteal folds and thigh folds with Chlorhexidine solution, pat dry, then apply Butt Paste with Nystatin cream, and cover with Dry Sheets twice daily. Review of the SN PPN dated 9/18/25 and 9/19/25 revealed wound care to the buttocks was performed once a day, not twice a day as ordered. Review of the SN PPN dated 9/20/25, 9/21/25, and 9/22/25 revealed no documentation wound care was provided. An interview was conducted on 9/25/25 at 2:35 PM with Employee Identifier (EI) # 10, Director of New Day, who confirmed the physician’s orders did not include the location of the wound, the care or frequency to be provided, and the staff failed to follow the physican’s orders for wound care. 2. PI # 10 was admitted on 9/22/25 with diagnoses including Abdominal Pain, Urinary Tract Infection, and Pelvic Fracture. Review of the Physician Order dated 9/23/25 at 7:48 AM revealed physician’s orders for daily wound care to pressure wound, clean with Vashe wound solution, apply Santyl to necrotic areas, then wet to dry dressing with Vashe solution and non-woven gauze, cover with abdominal (ABD) pad, and secure with Hypafix tape. Review of the SN PPN dated 9/23/25 at 7:00 PM revealed the SN documented the pressure wound was cleaned with wound cleanser and Chlorhexidine wash, Santyl ointment was applied, wound was packed with saline soaked gauze, Telfa pad was applied to the wound, covered with 4 x 4 gauze, then taped in place with paper tape. An interview was conducted on 9/25/25 at 2:20 PM with EI # 9, Medical Surgical Unit Manager, who confirmed the staff failed to follow the physician’s orders for wound care. 49894 3. PI # 4 was admitted to the New Day Behavioral Unit on 9/19/25 with a primary diagnosis of Schizoaffective Disorder, Bipolar Type. Review of Physician Entered Orders (PEO) revealed a Nursing Order (NO) dated 9/19/25 for VS every 12 hours with Oxygen Saturation (SPO2) checks. Review of the Graphic and Intake and Output (I & O) revealed VS and SPO2 were not obtained every 12 hours on 9/20/25, per the physician’s order. Further review of the Graphic and I & O revealed no Output was documented on 9/21/25. An interview was conducted on 9/25/25 at 3:08 PM with EI # 2, Chief Nursing Officer, who confirmed VS (including I & O) and SPO2 were not obtained every 12 hours per physician’s order. 4. PI # 12 was admitted to the New Day Behavioral Unit on 9/7/25 with a primary diagnosis of Schizoaffective Disorder. Review of the PEO revealed a NO dated 9/7/25 for VS every 12 hours with SPO2. Review of the Graphic and I & O revealed on 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/13/25, 9/14/25, 9/16/25, 9/17/25, and 9/18/25, VS and SPO2 were not obtained every 12 hours per the physician’s order. Further review of the Graphic and I & O revealed there was no Input documented on 9/12/25. An interview was conducted on 9/25/25 at 3:00 PM with EI # 10, who confirmed VS (including I & O) and SPO2 were not documented every 12 hours per the physician’s order. 50417 5. PI # 5 was admitted on 9/17/25 with diagnoses including Hip Fracture and Hypertensive Heart Disease with Heart Failure. Review of the Physician Order dated 9/18/25 at 11:51 AM revealed physician’s orders for daily wound care to surgical incisions times three, clean with wound cleanser, pat dry, apply Xeroform gauze, cover with non-adherent Telfa pad, then ABD pad, and secure with Hypafix tape. Review of the SN PPN dated 9/22/25 at 5:12 PM revealed the SN documented the surgical incisions were cleaned with wound cleanser, Xeroform was applied, then covered with 4 X 4 gauze and ABD pad, and secured with Hypafix tape. Review of the SN PPN dated 9/18/25 revealed no documentation wound care was provided. An interview was conducted on 9/25/25 at 2:18 PM with EI # 1, Director of Quality/Risk Management/Safety Officer who confirmed the staff failed to follow the physician’s orders for wound care. 49797 6. PI # 19 was admitted to the hospital on 6/28/25 with diagnoses including Acute Appendicitis and Congestive Heart Failure. A review of the MR revealed the patient was admitted with documented and photographed wounds on the coccyx and right foot. A review of the physician’s orders dated 6/28/25 to 7/7/25 revealed no orders for wound care for the documented wounds listed above. A review of the SN PPN dated 6/28/25 to 7/7/25 revealed no documentation of measurements of the Coccyx, and right foot wound. A review of the SN PPN wound care dated 6/29/25, 7/1/25, 7/2/25, 7/3/25, 7/5/25, and 7/7/25 revealed wound care performed to the right foot by the staff. There was no physician’s order for wound care to the right foot. An interview was conducted on 9/25/25 at 3:11 PM with EI # 11, Intensive Care Unit Nurse Manager, who confirmed the staff failed to follow the wound care policy and provided wound care to the patient without an order.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 49894 Based on review of medical records (MR), hospital policies and procedure, and staff interview, it was determined the hospital failed to ensure staff followed the hospital policy for administration of “as needed” (PRN) drugs. This deficient practice affected Patient Identifier (PI) # 4, PI # 12, and PI # 14 in three of twenty inpatient MRs reviewed and had the potential to negatively affect all patients receiving PRN medications. Findings include: Hospital Policy: Medication Administration Policy Number: 18458034 Revised: 7/2025 ...C. Medication Administration ...2. Prepare the medication: ...j. document administration of medication k. Reassess the patient to evaluate response and any adverse side effects. Hospital Policy: Pain Assessment, Reassessment, and Management Policy Number: 17105609 Revised: 12/2024 ...Procedure... Any patient care provider...that has implemented a pain control mechanism, will reassess the patient within one hour to determine amount of pain control or relief achieved. 1. PI # 4 was admitted to the facility on 9/19/25 with a diagnosis of Schizoaffective Disorder, Bipolar Type. Review of the Physician Entered Orders (PEO) revealed an order dated 9/20/25 for Vistaril (Hydroxizine Pamoate) 50 milligrams (mg) by mouth every six hours PRN. Orders did not state the reason for the PRN medication. Review of the Medication Record revealed PRN Vistaril was administered on 9/20/25, 9/21/25, and 9/22/25. There was no documentation the PRN Vistaril was reassessed after administration. An interview was conducted on 9/25/25 at 3:08 PM with EI # 2, Chief Nursing Officer, who confirmed PRN medications were not reassessed after administration per the hospital policy. 2. PI # 12 was admitted to the facility on 9/7/25 with a primary diagnosis of Schizoaffective Disorder. Review of the PEO revealed the following medication orders: Geodon (Ziprasidone) 20 mg injection every eight hours PRN dated 9/9/25. Orders did not state the reason for the PRN medication. Benadryl (Diphenhydramine) 50 mg injection every eight hours PRN dated 9/9/25. Orders did not state the reason for the PRN medication. Review of the Medication Record revealed the following: PRN Geodon was administered on 9/10/25, 9/15/25, and 9/17/25. There was no documentation the PRN Geodon was reassessed after administration. PRN Benadryl was administered on 9/14/25 and 9/15/25. There was no documentation PRN Benadryl was reassessed after administration. An interview was conducted on 9/25/25 at 3:00 PM with EI # 10, Director of New Day Behavioral Unit, who confirmed PRN medications were not reassessed after administration per the hospital policy. 3. PI # 14 was admitted to the facility on 7/1/25 with a diagnoses including Closed Head Injury, Blunt Abdominal Trauma, Supraventricular Tachycardia, and Urinary Retention. Review of the PEO revealed orders for the following: Zofran (Ondansetron Hydrochloride) 4 mg Intavenous Push every four hours PRN nausea dated 7/1/25. Norco (Hydrocodone/Acetaminophen) 5 mg by mouth every 4 hours PRN pain dated 7/2/25. Review of the Medication Record revealed the following: PRN Zofran was administered on 7/1/25. There was no documentation the PRN Zofran was reassessed after administration. PRN Norco was administered on 7/3/25. There was no documentation the PRN Norco was reassessed within one hour after administration. An interview was conducted on 9/25/25 at 3:06 PM with EI # 1, Director of Quality/Risk Management/Patient Safety Officer, who confirmed staff failed to reassess the patient within one hour after PRN medication administration per the hospital policy.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 49797 Based on a Dietary manual review, and staff interview it was determined the hospital failed to maintain a current dietary manual approved by the dietitian and medical staff. This deficient practice had the potential to affect all patients served by the hospital’s dietary service. Findings include: A review of the dietary manual revealed the published date of 2014 and no current signature of the dietician or evidence of approval by medical staff. An interview was conducted on 9/25/25 at 2:14 PM with Employee Indentifer # 13, Facilities Director, who confirmed the Dietary Manual date of 2014 and no documented signature of the dietician or approval of medical staff.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49894 Based on observations, hospital policy, and staff interview, it was determined the hospital failed to ensure staff performed hand hygiene per the facility policy. This affected Patient Identifier (PI) # 10 , PI # 9, PI # 7, PI # 18, PI # 6, PI # 33, and one unsampled patient in seven of nine observations of patient care on the medical surgical unit and one of one observation in the surgical unit, and had the potential to negatively affect all patients receiving patient care in this hospital. Findings include: Hospital Policy: Hand Hygiene Policy Number: 12610377 Revised: 01/2020 Policy: All staff should use the hand hygiene techniques, ... Before coming on duty, when hands are soiled, before each patient encounter, ...before applying gloves..., after coming in contact with patient’s intact skin, after working on a contaminated body site and then moving to a clean body site of the same patient, after coming in contact with bodily fluids, dressings, mucous membranes...and hands are not visibly soiled, after contact with medical equipment/supplies in patient areas, always after removing gloves or facemasks, ... 1. An observation was conducted on 9/23/25 at 2:38 PM with Employee Identifier (EI) # 3, Registered Nurse, administering an intravenous (IV) antibiotic to PI # 10. After documenting in the electronic health record (EHR) and scanning the patient’s wrist band and medications, EI # 3 failed to change gloves and perform hand hygiene before accessing the bag of IV antibiotic and connecting it to the patient’s indwelling IV catheter. EI # 3, failed to perform hand hygiene one time before donning gloves and one time after removing gloves during the medication administration. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, Director of Quality/Risk Management/Patient Safety Officer, who confirmed staff failed to perform hand hygiene per hospital policy. 2. An observation was conducted on 9/24/25 at 8:20 AM with EI # 3 administering oral medications to PI # 9. After documenting in the EHR, scanning the medications and the patient’s wrist band, EI # 3 failed to change gloves and perform hand hygiene before opening and administering the patient’s oral medications. After administering the patient’s medications, EI # 3 failed to remove his/her gloves and perform hand hygiene before documenting in the EHR. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 3. An observation was conducted on 9/24/25 at 8:35 AM with EI # 3 changing the IV access site for PI # 9. After documenting in the EHR, EI # 3 failed to perform hand hygiene before donning gloves. EI # 3 failed to change gloves and perform hand hygiene after he/she removed the dressing from the old IV site and discontinued the IV and before preparation and insertion of the new IV site. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 4. An observation was conducted on 9/24/25 at 9:45 AM with EI # 4, Licensed Practical Nurse (LPN), administering oral medications and an IV antibiotic to PI # 7, who was on isolation precautions due to having COVID. EI # 4 failed to perform hand hygiene prior to donning his/her personal protective equipment. EI # 4 scanned the medications and failed to perform hand hygiene before donning gloves and administering the oral medications. EI # 4 failed to don gloves before connecting the IV tubing to the antibiotics and accessing the patient’s indwelling IV catheter. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 5. An observation was conducted on 9/24/25 at 10:20 AM with EI # 12, Patient Care Technician, obtaining a blood glucose level for PI # 18. EI # 12 failed to perform hand hygiene before donning gloves one time during the observation. EI # 12 failed to perform hand hygiene after removing gloves at the completion of the blood glucose check. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 6. An observation was conducted on 9/24/25 at 10:30 AM with EI # 5, LPN, performing wound care for PI # 6. EI # 5 removed his/her gloves five times, and without performing hand hygiene, donned new gloves. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 7. An observation was conducted on 9/24/25 at 11:03 AM of a Left Shoulder Arthroscopy for PI # 33. EI # 7, Certified Registered Nurse Anesthetist, performed hand hygiene, donned gloves, administered Xyocaine 2% intravenous (IV), Ropivaccaine 0.5% IV, then removed gloves, and donned sterile gloves. EI # 7 failed to perform hand hygiene after removing gloves and prior to donning sterile gloves. An interview was conducted on 9/25/25 at 2:18 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 8. An observation was conducted on 9/24/25 at 2:55 PM with EI # 6, Respiratory Therapist, administering a nebulizer treatment (inhaled medication), to an unsampled patient. EI # 6 failed to perform hand hygiene three times during the nebulizer treatment. An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy. 50417”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49797 Based on observation, hospital policy and procedure, and staff interview it was determined the hospital failed to ensure the staff followed the Hand Hygiene policy and procedure. This deficient practice had the potential to affect all patients, visitors, and employees served by the dietary department. Findings include: Hospital Policy: Hand Hygiene Policy number: 12610377 Revision date: 11/2022 Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs,and infections and for maintaining patient and healthcare personnel safety... Policy: All staff should use the hand-hygiene techniques, as set forth in the following procedure... * Before coming on duty. * When hands are soiled... * Always after removing gloves or facemask... 1. An observation was performed in the kitchen on 9/24/25 at 11:25 AM during the plating of the patient dietary trays. The five staff members observed were changing gloves frequently and not performing hand hygiene before putting on clean gloves, during the plating of patient dietary trays. An interview was conducted on 9/25/25 at 1:45 PM with Employee Identifier # 14, Infection Prevention Nurse, who confirmed the staff did not follow the hospital policy regarding hand hygiene.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s Emergency Preparedness plan, and staff interview, it was determined the hospital failed to update and or review the hospital’s emergency preparedness plan every two years. This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital. Findings include: A review of the emergency preparedness plan revealed the last documented review of the plan was performed in September of 2022. An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan had not been reviewed or updated since September 2022.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s All Hazards Risk Assessment and staff interview, it was determined the hospital failed to fully complete a hospital-based and community-based risk assessment, utilizing an all-hazards approach. This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital. Findings include: A review of the all-hazards risk assessment revealed the assessment included a cyber attack, transportation failure, and a snow storm. No date was listed on the form for the assessment. An interview was completed on 9/25/25 at 2:20 PM with Employee Identifier # 2, Chief Nursing Officer, who confirmed the all hazards risk assessment presented to the surveyor included all hazards that were assessed for this hospital. The hospital failed to complete an assessment to include all hazards likely to affect this hospital.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s emergency preparedness plan, and staff interview, it was determined the hospital failed to have a system to track the location of on-duty staff and sheltered patients in the care of the hospital during an emergency. This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital. Findings include: A review of the emergency preparedness plan revealed no documentation of a system to track on-duty staff and sheltered patients in the care of the hospital during an emergency. An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan did not have a system to track on-duty staff and sheltered patients in the care of the hospital during an emergency.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s emergency preparedness plan, and staff interview, it was determined the hospital failed to develop arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients. This deficient practice had the potential to affect all patients, staff, and vistors served by this hospital. Findings include: A review of the emergency preparedness plan revealed no documentation of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients. An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan did not have arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s emergency preparedness plan, and staff interview, it was determined the hospital failed to develop a communication plan, and update it and or review it at least every two years. This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital. Findings include: A review of the emergency preparedness plan revealed no documentation of a communication plan. An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan failed to include a communication plan.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 49797 Based on a review of the hospital’s emergency preparedness plan, and staff interview, it was determined the hospital failed to have a tabletop exercise or record an actual event during the 2024 year. This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital. Findings include: A review of the emergency preparedness plan revealed no documentation of a tabletop exercise or actual event during the 2024 year. An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the hospital failed to have a tabletop exercise or actual event during the 2024 year.”

“. K3 Building: 0203 K6 Plan Approval: 1998 K7 Survey Under: 2012 Existing K8 BUSINESS Generator: None FACP: None Locking Devices: None Smoke Detection: None Census: 90 per month Type of Structure: 1998 single story unprotected noncombustible, Type II(000). This building does not have an automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were met as evidenced by the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 21.2.1, and 7.2.1.9.1.3 This deficiency affects 1 set of powered egress doors. Findings include: During a tour of the facility, the surveyor observed the power-assisted manually operated powered egress cross-corridor doors between the Endoscopy Area and the Boiler Room Corridor did not have a sign on the egress side that read: “IN EMERGENCY, PUSH TO OPEN”. A member of the maintenance staff was present when this deficiency was identified. .”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a horizontal fire barrier exit per the requirements of: 2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1 This deficiency affects one horizontal fire barrier exit. Findings include: During a tour of the facility, the surveyor observed penetrations of multiple conduits and cables in the horizontal fire barrier exit, above the ceiling, over the fire barrier cross corridor doors (between the Ultra-sound Waiting area and Room 100) sealed with an unapproved expanding foam sealant. A member of the maintenance staff was present when this deficiency was identified. .”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to store Alcohol-Based Hand-Rub (ABHR) solution per the requirements of: 2012 NFPA 101, 19.3.2.6 (7) This deficiency affects 1 of 8 smoke compartments. Findings include: During a tour of the facility, the surveyor observed 6.9 gallons of ABHR solution stored in the Basement Purchasing and Receiving Room (one smoke compartment) and did not meet the requirements of NFPA 30 (Flammable and Combustible Liquids Code). A member of maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following: (1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet (4) Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 41792 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.6, and 5.2.1.1.2(5) This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the following: 1. The facility failed to provide documentation that the (11) dry sprinklers installed in 2014, located in the walk-in cooler and freezer, Front Entrance Vestibule, the Loading Dock, and at the Outside Medical Gas Storage Areas had been replaced or a representative sample tested within 10 years of installation 2. A sprinkler located in the 2nd Floor DRG Room was loaded (had excessive dust insulating the bulb of the sprinkler), this may delay the activation of the sprinkler 3. A representative sample of 4 sprinklers from the first floor where tested. One sprinkler failed to meet the test requirements. The facility must test another sprinkler from the Lobby or replace all the sprinklers within the area represented by the failed sample sprinkler. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the oxygen cylinders in the Respiratory Storage Room per the requirements of: 2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3, 11.3.4.1, and 11.3.4.2 This deficiency affects 1 of 8 smoke compartments. Findings include: During a tour of the facility, the surveyor observed the following in the Respiratory Storage Room: 1. Eight 24 cu. ft. oxygen cylinders: a. Laying in carts on their sides, unsecured b. Located within 3’ of combustibles (wooden shelving, cardboard boxes, etc.) 2. There was not a precautionary sign displayed on the door of the room that included the following: “Caution: Oxidizing Gas(es) Stored Within No Smoking” A member of the maintenance staff was present when this deficiency was identified.”

“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: 40119 Based on review of hospital A’s (Dale Medical Center) policies and procedures, Medical Records (MR), transfer request log, New Day Behavioral Health (hospital A’s psychiatric unit) Adult Unit Bed Census, New Day Behavioral Health Master Staffing Grid, on-call physician calendar, Hospital B (Referring Hospital number one) Emergency Department (ED) MR, Hospital C (Referring Hospital number two) ED MR, Transfer Center Call Summary, and staff interviews, it was determined the hospital failed to: 1. Place a patient who presented to the Emergency Department (ED) with symptoms of psychiatric disturbances on an involuntary hold for the completion of the Medical Screening Exam (MSE) and mental health screening exam. 2. Reassess a patient for the mental competency to make the decision to leave the facility Against Medical Advice (AMA) by a physician prior to the patient’s discharge from the ED. 3. Provide an appropriate MSE, mental health screening exam, that was within the capability of the hospital’s emergency department including ancillary services (on-call psychiatrist) routinely available to the emergency department whether or not an emergency medical exited, and failed deter and/or prevent a patient from leaving the ED prior to the completion of the MSE who was experiencing auditory hallucinations, unclear thinking, and confusion. 4. Accept from Hospital B and Hospital C, a referring hospital within the boundaries of the United States, an appropriate transfer of an individual who required such specialized capabilities or facilities when Hospital A had the capability and capacity to treat the patient who had an emergency psychiatric condition. This deficient practice affected one of one psychiatric MRs reviewed who left AMA, including Patient Identifier (PI) # 2, and one of one psychiatric MRs reviewed who Left Without Being Seen, including PI # 16, two of two denied transfer requests reviewed, including PI # 23 and PI # 24, and had the potential to affect all patients served by the hospital ED with a psychiatric problem or requiring transfer to the hospital. Findings Include: Refer to Tags- A 2406, and A 2411 for findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 40119 Based on review of the hospital policies and procedures, Medical Records (MR), Hospital Psychiatric On-call physician calendar, and interviews with staff it was determined the hospital failed to: 1. Place a patient who presented to the Emergency Department (ED) with symptoms of psychiatric disturbances on an involuntary hold for the completion of the Medical Screening Exam (MSE) and mental health screening exam. 2. Reassess a patient for the mental competency to make the decision to leave the facility Against Medical Advice (AMA) by a physician prior to the patient’s discharge from the ED. 3. Provide an appropriate MSE, mental health screening exam, that was within the capability of the hospital’s emergency department including ancillary services (on-call psychiatrist) routinely available to the emergency department whether or not an emergency medical exited, and failed deter and/or prevent a patient from leaving the ED prior to the completion of the MSE who was experiencing auditory hallucinations, unclear thinking, and confusion. This deficient practice affected one of one psychiatric MRs reviewed who left AMA, including Patient Identifier (PI) # 2, and one of one psychiatric MRs reviewed who LWBS (left without being seen), including PI # 16, and had the potential to affect all patients served by the hospital ED with a psychiatric problem. Findings include: Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy Policy Number: 16429730 Revised Date: 8/24 1. EMTALA Compliance Policy. ...1.2. General Policy Statement... It is the policy of this hospital that all persons presenting for unscheduled procedures or evaluation...shall receive a MSE within the capabilities of the ED and the ancillary services routinely available to the emergency services of the hospital, including examination...and the services of appropriate on-call physicians where indicated... Procedure: 1.5 Capabilities: Capabilities encompass... privileged medical staff and technical staff of this hospital as it pertains to the nature, scope, and degree of services that can be provided by this hospital... 2. Areas of Practice: ...Psychiatry... 9. Psychiatric Assessment: A. Patients presenting with symptoms of psychiatric disturbances are considered to have an Emergency Medical Condition (EMC) under federal law. They shall receive a MSE and mental health assessment... B. The patient may be involuntarily held until a complete MSE and mental health screening exam are completed and a determination is made by the ED physician or authorized physician that the patient’s condition has stabilized or improved and no longer represents an EMC... D. Indications for mental health screening include, but are not limited to, primary complaints or secondary observations of: ...g. Flat affect. h. Manic status. i. Altered mental state. j. Documented inability to maintain nutrition or safety. Hospital Policy: Prescreen of Psychiatric Patients in the ED Policy Number: 16834018 Revised Date: 10/24 ...Procedure: For patients...are a danger to themselves or others, or lack capacity to give informed consent, Emergency Detention/commitment procedures may be instituted. 1. PI # 2 presented to the hospital ED on 5/14/24 at 4:44 AM via ambulance with a chief complaint of psychiatric problem. Review of the Triage Assessment dated 5/14/24 at 4:45 AM revealed the patient was experiencing auditory hallucinations which were saying they were going to harm the patient, was unable to sleep due to the hallucinations, the patient had a history of anxiety, depression, and Schizophrenia. Review of the ED Physician Note dated 5/14/24 at 4:53 AM revealed the patient was experiencing auditory hallucinations, was unable to care for self, was unable to control self, had unclear delusional thinking, and bizarre behavior. The ED Physician documented an impression of Manic Episode, Severe with Psychotic Symptoms. Review of the ED nursing note dated 5/14/24 at 6:24 AM revealed the hospital psychiatric unit (New Day Behavioral Health) was notified of the need for an evaluation on the patient. Review of the ED nursing note dated 5/14/24 at 6:46 AM revealed the patient requested to leave the hospital ED AMA. The ED physician was notified and stated the patient was not on a psychiatric hold but is advised to stay for the psychiatric evaluation (mental health screening exam). The nurse documented speaking with the patient who agreed to wait a little longer for the psychiatric evaluation. Review of the ED disposition note dated 5/14/24 at 7:01 AM revealed the patient left the ED AMA. Review of the MR revealed no documentation of a mental health screening exam and and no documentation the ED physician reexamined/reevaluated the patient’s competency to make the decision to leave AMA. Review of the hospital Psychiatric On-call physician calendar dated 5/14/24 revealed the hospital did have a Psychiatrist on call. The hospital had the capability to provide a psychiatric evaluation for Patient #2 on 5/14/2024. An interview was conducted on 11/6/24 at 10:47 AM with Employee Identifier (EI) # 1, Director of Quality/Risk Management who confirmed there was no documentation of a mental health screening exam, no documentation the patient was placed on an involuntary hold for the completion of the MSE and mental health screening exam, and no documentation the ED Physician reexamined/reevaluated the patient’s competency to make the decision to leave the hospital AMA prior to the patient leaving the hospital ED AMA. EI # 1 confirmed the hospital did have a Psychiatrist on call on 5/14/24. An interview was conducted on 11/6/24 at 2:43 PM with EI # 9, Interim Medical Director of Hospital A. EI # 9 verbalized if a patient presented to the ED and was a danger to self, danger to others, or they had severe psychosis, the physician would contact the psychiatrist. If a psychiatrist was not available, then two physicians would review, and the patient would be placed on a 72-hour hold. 2. PI # 16 presented to the hospital ED on 10/8/24 at 8:34 PM with a chief complaint of psychiatric problem. Review of the ED Triage Assessment dated 10/8/24 at 8:48 PM, by EI # 3, ED Registered Nurse (RN), revealed the patient was experiencing auditory hallucinations, unclear thinking, and confusion. The patient’s family stated the patient was wandering around the neighborhood. The patient claimed someone had called him/her to come down the street. Review of the ED nursing assessment dated 10/8/24 at 9:02 PM, by EI # 3, revealed the patient had a flat affect, was experiencing weakness, slurred speech, and had a history of Bipolar Disorder in addition to the Triage Assessment findings. Review of the ED disposition note dated 10/9/24 at 12:37 AM revealed the patient left the ED without being seen (LWBS). Review of the MR revealed no documentation of a MSE, mental health screening exam, or the patient was deterred and/or prevented from leaving the ED prior to the completion of the MSE. Review of the hospital Psychiatric On-call physician calendar dated 10/8/24 revealed the hospital did have a Psychiatrist on call. The hospital the capability to provide a Psychiatric examination for patient #16 on 10/8/24. Review of EI # 3’s personnel file on 11/6/24 revealed EI # 3’s date of hire as 3/24/22. Further review of EI # 3’s personnel file revealed no documentation EI # 3 had been provided education on EMTALA. An interview conducted on 11/6/24 at 10:57 AM with EI # 1 and EI # 2, Chief Nursing Officer, who confirmed there was no documentation of a MSE, mental health screening exam, or the patient was deterred and/or prevented from leaving the ED prior to the completion of the MSE. An interview conducted on 11/6/24 at 1:56 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 3 had been provided education on EMTALA. An interview conducted on 11/6/24 at 2:43 PM with EI # 9, who verbalized when a patient comes into the ED with a psychiatric problem the patient would need to be evaluated for suicidal ideation, homicidal ideation, delusions, and psychosis to see if the patient is a danger to self or others. EI # 9 verbalized if the patient was a danger to self or others or they had severe psychosis, the physician would contact the psychiatrist. If a psychiatrist was not available, then two physicians would review, and the patient would be placed on a 72-hour hold. The facility failed to ensure that their own policy and procedure was fallowed as evidenced by failing to place Patient #2 and Patient #16 on voluntary hold until the medical screening examinations and mental health examinations were completed as stated in the facility’s policy.”

“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: 40119 Based on review of hospital A’s (Dale Medical Center) policies and procedure, medical records (MR), transfer request log, New Day Behavioral Health (hospital A’s psychiatric unit) Adult Unit Bed Census, New Day Behavioral Health Master Staffing Grid, on-call physician calendar, Hospital B (Referring Hospital number one) Emergency Department (ED) MR, Hospital C (Referring Hospital number two) ED MR, Transfer Center Call Summary, and staff interviews, it was determined Hospital A refused to accept from Hospital B and Hospital C, a referring hospital within the boundaries of the United States, an appropriate transfer of a patients who required such specialized capabilities or facilities when Hospital A had the capability and capacity to treat the patients who had an emergency psychiatric condition. This did affect Patient Identifier (PI) # 23 and PI # 24, two of two denied transfer requests reviewed, and had the potential to affect all patients requiring transfer to the hospital. Findings Include: Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy Policy Number: 16429730 Revised Date: 8/24 1. EMTALA Compliance Policy. Procedure: 1.5 Capabilities: Capabilities encompass... privileged medical staff and technical staff of this hospital as it pertains to the nature, scope, and degree of services that can be provided by this hospital... 2. Areas of Practice: ...Psychiatry... 3. Capacity: ...physical ability of the facility to accommodate the patient, including bed availability, staff ability, or availability... A hospital has the capacity to accommodate a patient if it has previously accommodated more patients using reassignment of beds, early discharge, staff call-backs, and use of other areas of the facility... Hospital Policy: Pre-Admission Psychiatric Assessment for the Behavioral Health Units Policy Number: 16524097 Revised Date: 10/24 Purpose: The pre-admission assessment is designed to gather critical information from prospective patient to assess their eligibility for acute in-patient psychiatric services. Criteria for Admission ...The patient is 19 years or older... The patient must meet one or more of the following criteria: ...Has been physically assaultive to a degree...that threatens the life or safety of other persons. ...Acute deterioration of the patient’s behavior, coping skills, or ability to care for self to a degree that creates a risk of harm to self or others... Medical/Condition Admission Exclusionary Criteria ...Severe or profoundly developmentally delayed individuals (IQ (intelligence Quotient- test or subset designed to assess human intelligence) of < (less than) 70) with no acute behavioral change or no known psychiatric disorder or no expectation for a positive response to treatment. Behavioral or baseline cognitive impairment to such a degree that they would be unable to benefit from the treatment interventions offered...or the patient is unable to function at a minimally acceptable level within the acute inpatient treatment program. Hospital A, Dale Medical Center, documentation: 1. Review of the hospital transfer request log revealed a request for transfer was received from Hospital B (transferring hospital) on 10/11/24 (no time documented) for PI # 23. Further review revealed PI # 23 was denied due to not meeting criteria with a comment of “mental retardation and anger.” Review of New Day Behavioral Health (hospital A’s psychiatric unit) Adult Unit Bed Census from 10/10/24 at 12:00 AM to 10/11/24 at 5:00 PM, revealed the 13-bed unit had two beds available. Further review revealed the unit was staffed with two nurses and two mental health technicians on 10/10/24 from 12:00 AM to 10/11/24 at 7:00 AM and two nurses and three mental health technicians on 10/11/24 from 7:00 AM to 5:00 PM. Review of New Day Behavioral Health Master Staffing Grid revealed the adult unit would require two nurses and two mental health technicians to be normally staffed for 11 to 13 patients on the unit. Review of the hospital on-call physician calendar revealed Employee Identifier (EI) # 5 was the on-call Psychiatrist for the hospital on 10/11/24. Hospital A had capability and capacity at the time of the transfer request from Hospital B. Review of the credentialing file for EI # 5 revealed no documentation EI # 5 was provided education on EMTALA. An interview was conducted on 11/5/24 at 2:38 PM with EI # 7, Director of Social Services, and on 11/5/24 at 3:20 PM with EI # 8, Director of New Day Behavioral Health, two of two staff who receive patient transfer request for New Day Behavioral Health. EI # 7 and EI # 8 both verbalized a patient would be denied for transfer to New Day Behavioral Health if the patient has an Intellectual disability or an IQ of less than 70, EI # 7 and EI # 8 both verbalized if the patient’s IQ was unknown then the patient ability to function would be evaluated to see if the patient would be able to participate in the groups and/or plan of care the unit offers. EI # 7 verbalized if a referral is not accepted the referral is not kept by the hospital. EI # 8 verbalized PI # 23 was automatically excluded from transfer due to the mental retardation. An interview conducted on 11/6/24 at 9:38 AM with EI # 5, On-call Psychiatrist during the referral of PI # 23. EI # 5 verbalized a patient with mental retardation/intellectual disability would be accepted at New Day Behavioral Health if the patient had other psychiatric issues going on besides the mental retardation/intellectual disability. An interview conducted on 11/6/24 at 1:59 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 5 had been provided education on EMTALA. An interview conducted on 11/6/24 at 2:05 PM with EI # 2, Chief Nursing Officer, confirmed staffing was per the Master Staffing Grid and beds were available on the unit at the time of the transfer request from Hospital B. Review of Hospital B ED MR revealed PI # 23 presented to the ED on 10/10/24 at 6:44 PM with a chief complaint of behavioral issues. PI # 23’s caregiver reported the patient had been attempting to bite family. Review of the ED nursing assessment dated 10/10/24 at 6:52 PM revealed the patient was alert and oriented, attention-seeking, fidgeting, and manipulative. Review of the ED Provider’s Exam note dated 10/10/24 at 7:08 PM revealed the patient had been getting more agitated and violent at home. The patient had pushed and hit family, would lock doors, steal money to buy snacks which were against the patient’s diabetic diet, and had a medical history of Mental Retardation and Attention Deficit Hyperactive Disorder with anger disorder. Further review of the ED Provider’s Exam note dated 10/10/24 at 7:08 PM revealed physical assessment findings of the patient being hard of hearing but able to talk, not currently violent, slightly agitated, and talkative but easily redirected. Further review revealed assessment findings of Oppositional Defiant Disorder (Behavior condition characterized by a persistent pattern of negative, defiant, and hostile behaviors towards peers, parents and authority figures), Agitation, and Violent Behavior with a plan to attempt to transfer to a mental health facility. Review of the ED nursing note dated 10/11/24 at 2:44 AM revealed Hospital A (Dale Medical Center) was contacted for transfer of PI # 23 to hospital A. Further review revealed Hospital A requested PI # 23’s MR be faxed to the hospital and the social worker would evaluate the MR in the morning. There was no documentation on the final decision of Hospital A. Review of the ED MR revealed no documentation of PI # 23’s IQ, or that an IQ test had been performed. Review of the nursing note dated 10/11/24 at 7:46 AM revealed after attempting to find placement at multiple inpatient facilities the patient would be discharged home with family. Review of the nursing note dated 10/11/24 at 9:02 AM revealed the patient was discharge home and the caregiver was encouraged to take the patient to “...mental health today or Monday.” Hospital A failed to ensure PI # 23, who had an identified psychiatric emergency condition and required the specialized capabilities of hospital A, was transferred when Hospital A had the capacity and specialized capabilities required to admit and treat PI # 23. 2. Review of Hospital A’s, Dale Medical Center, transfer request log revealed a request for transfer was received from Hospital C (transferring hospital) on 10/31/24 (no time documented) for PI # 24. Further review revealed PI # 24 was denied due to “intellectually disabled.” Review of the New Day Behavioral Health Adult Unit Bed Census from 10/31/24 at 9:30 AM to 10/31/24 at 1:00 PM, revealed the 13-bed unit had one beds available until 10:45 AM. Further review revealed three patients were discharged from the unit between 10:45 AM and 11:15 AM, which would have provided four total beds available on the unit. Further review of the New Day Behavioral Health Adult Unit Bed Census from 10/31/24 at 9:30 AM to 10/31/24 at 1:00 PM, revealed the unit was staffed with two nurses and one mental health technician. Review of New Day Master Staffing Grid revealed the adult unit would require one nurse and one mental health technician with a census of four to six patients and two nurses and two mental health technicians with a census of seven to be normally staffed on the unit. Review of the hospital on-call physician calendar revealed EI # 6 was the on-call Psychiatrist for the hospital on 10/31/24. Hospital A had capability and capacity prior to the denial of PI # 24’s transfer request from Hospital C. Review of the credentialing file for EI # 6 revealed no documentation EI # 6 had be provided education on EMTALA. An interview conducted on 11/6/24 at 9:54 AM with EI # 6, On-call Psychiatrist for PI # 24. EI # 6 verbalized a patient with mental retardation/intellectual disability would be accepted at New Day if the patient had other psychiatric issues going on besides the mental retardation/intellectual disability. EI # 6 also verbalized a patient with an IQ of 70 would be able to participate in the unit activities. An interview conducted on 11/6/24 at 1:59 PM with EI # 4, Nursing Administration Specialist, confirmed there was no documentation EI # 6 had been provided education on EMTALA. An interview conducted on 11/6/24 at 2:05 PM with EI # 2, Chief Nursing Officer, confirmed staffing was per the Master Staffing Grid and beds were available on the unit prior to the denial of PI # 24’s transfer request from Hospital C. Review of the Hospital C’s ED MR revealed PI # 24 presented to ED on 10/29/24 at 3:48 PM with a chief complaint per the patient’s caregiver of being delusional, shutdown, aggressive, and refusing to speak. Review of the ED Psychiatric Screening Exam dated 10/29/24 at 4:22 PM revealed the patient had a history of moderate intellectual disability and presented to the ED with complaints of the patient shutting down, being delusional, acting aggressively, making homicidal threats against other residents of the group home where the patient resides, and decreased talking. The character of the symptoms was documented as homicidal threats, periods of agitation and appeared to be shutting down and mumbling to self and others. Further review of the ED Psychiatric Screening Exam dated 10/29/24 at 4:22 PM revealed physical assessment findings of the patient being cooperative, alert, and oriented to person, place, time, and situation. Further review revealed diagnoses of Homicidal Thoughts and Acute Psychosis with an order to transfer the patient to an acute psychiatric facility. Review of Hospital C’s Transfer Center Call Summary dated 10/31/24 at 9:41 AM revealed Hospital A (Dale Medical Center) was contacted for transfer of PI # 24 to hospital A. Further review revealed PI # 24 was declined by Hospital A at 12:30 PM. Review of the ED MR revealed no documentation of PI # 24’s IQ, or that an IQ test had been performed. Review of the ED Provider note dated 11/2/24 at 2:20 AM revealed there was no accepting facility for transfer and the patient would be discharged home with caregiver. Review of the ED Discharge Information revealed the patient was discharged home on 11/2/24 at 10:30 AM. Hospital A failed to ensure PI # 24, who had an identified psychiatric emergency condition and required the specialized capabilities of hospital A, was transferred when Hospital A had the capacity and specialized capabilities required to admit and treat PI # 24.”