St. Mary’s Hospital

“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: 45167 Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to execute and maintain an emergency preparedness plan based on an all-hazards facility-based and community-based risk assessment. Failure to complete, maintain and regularly update a facility and community based all-hazards risk assessment and then develop and regularly update an emergency preparedness plan to reflect the risks identified within the assessment can result in a facility not being prepared to address the hazards most likely to affect a patient and staff population. Findings include: A copy of St. Mary’s Hospital Emergency Preparedness Plan and all accompanying documentation and drills for calendar years 2024 and 2025 were requested. “...Carondelet Health Network Emergency Operations Plan....” was provided along with a copy of accompanying HVAs (hazard vulnerability assessments) for calendar years 2024 and 2025. In a series of interviews conducted with Employee #6 on September 8 and on September 9, Employee #6 confirmed that this was St. Mary’s Hospital’s Emergency Preparedness Plan, and that all documentation had been provided regarding the facility’s Plan. “...Carondelet Health Network Emergency Operations Plan....” indicated: “...See Individual Hospital Hazard Vulnerability Analysis within their Emergency Preparedness binders...The Hospitals have developed appropriate Emergency Response Plans based on highest scored threat on the Hazard Vulnerability Analysis within their Emergency Preparedness binders....” In an interview conducted with Employee #6 on September 9, 2025, Employee #6 confirmed there were no additional materials for emergency preparedness other than the provided Hazard Vulnerability Assessment and the Carondelet Health Network Emergency Operations Plan. Although general information was provided regarding hospital response to various disasters, no specific emergency response plans based on the HVAs could be found in the provided material. No emergency preparedness binder as described in the Carondelet Health Network Emergency Operations Plan could be provided.”

“Laboratories CFR(s): NFPA 101 Laboratories Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected by 1-hour fire resistance-rated separation, automatic sprinkler system, and are in accordance with 8.7 and with NFPA 99. Laboratories not considered a severe hazard are protected as hazardous areas (see K321). Laboratories using chemicals are in accordance with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Gas appliances are of appropriate design and installed in accordance with NFPA 54. Shutoff valves are marked to identify material they control. Devices requiring medical grade oxygen from the piped distribution system meet the requirements under 11.4.2.2 (NFPA 99). 19.3.2.2, 8.7, 8.7.4.1 (LSC) 9.3.1.2, 11.4.3.2, 15.4 (NFPA 99) This Standard is not met as evidenced by: 45167 ------------------------------------------------------CONDITION------------------------------------------------------------------------- Based on interview, review of facility documentation, and observation while on tour, it was determined the facility laboratory contained multiple unsafe conditions, including laboratory hoods that did not pass annual PM (preventative maintenance) checks and were therefore unsafe for use, a safety shower that was filled with boxes and had boxes obstructing the pathway to the safety shower, rendering it difficult or impossible to use if needed, and improper protection for operations requiring the use of pressure above or below ambient conditions, hazardous chemicals, cryogenic fluids and other operations requiring the use of a laboratory hood. Findings include: NFPA 101, 2012 Edition, Chapter 19, Section 19.3.2.2. indicated, “Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as severe hazard shall be in accordance with section 8.7 and the provisions of NFPA 99...applicable to administration, maintenance and testing.” Section 8.7.4.1 indicated, “Laboratories that use chemicals shall comply with NFPA 45....” NFPA 45, 2011 Edition, Chapter 12, Section 12.1.12.1 indicated, “All heating of flammable or combustible liquids shall be conducted so as to minimize fire hazards.” Section 12.1.3.1 indicated, “Distillation shall be conducted in equipment designed or fabricated for this use and shall be assembled with consideration being given to fire hazards from vent hazards and possible equipment breakage or failure.” 12.1.4 indicated, “Filtrations, extractions, sublimations, adsorptions, evaporations, centrifuging operations, and other separation techniques that involve flammable or combustible materials shall be protected from ignition sources and shall be provided with ventilation that prevents the accumulation of an ignitable concentration of vapors in the work area.” Section 12.1.5.1 indicated: “Mixing, grinding, stirring, and agitating operations involving flammable and combustible materials shall require the same precautions against fire as set forth in 12.1.4. Section 12.1.6.1 indicated: “Other laboratory operations, such as reactions at temperatures and pressures either above or below ambient conditions, shall be conducted in a manner that minimizes hazards.” Section 8.2.6 indicated, “The release of chemical vapors into the laboratory shall be controlled by enclosure(s) or captured to prevent any flammable and/or combustible concentrations of vapors from reaching any point of ignition.” During observation while on tour conducted on September 9, 2025, Compliance Officer observed two laboratory hoods in the cytology/histology area of the lab. Compliance Officer conducted an interview with Employee #12 on September 9, 2025 and asked Employee #12 if these laboratory hoods were operational because they did not appear to be functional. Employee #12 stated that they were not able to be used and presently, there was not a laboratory hood that was able to be used by Employee #12 and Employee #12’s colleague. Compliance Officer asked how they were able to conduct their laboratory work. Employee #12 pointed to an open vent located just above a countertop and stated that this was a negative pressure vent. Employee #12 stated that they were “expected” to conduct their lab work in front of this negative pressure vent in the hope that this would contain any vapors. Section 8.13.1 indicated, “When installed or modified and at least annually thereafter, chemical fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems, shall be inspected and tested as applicable...” Section 8.13.2 indicated, “Deficiencies in hood performance shall be corrected, or one of the following shall apply: 1) The activity within the hood shall be restricted to the capability of the hood; 2) The hood shall not be used.” PM (Preventative Maintenance) reports were requested for calendar years 2024 and 2025 for laboratory hoods located in the laboratory. A PM report dated 12/16/2024 was provided. Six laboratory hoods were identified in this report. One laboratory hood, SWV-001, passed according to manufacturer’s specifications. But this hood still had low exhaust readings. Three hoods had a “low pass-poor” rating with comments. SMH-02 had below range exhaust flow. SWV-003 had a “low pass-poor” rating with comments. It had low airflow indicating exhaust air fan issues. 60114 failed. The unit only had inward airflow and had no exhaust capacity. Microbiology hood also failed due to poor inflow and filtration that was not appropriate for the lab environment. Documentation of correction of the deficiencies for the lab hoods was requested but could not be provided. Section 6.6.3.1(5) indicated, “Plans for laboratory emergencies shall be developed, which shall include...non-fire hazards.” “Carondelet Health Network” Emergency Operations Plan Code Orange-Hazard Materials Spills Plan indicated, “Wash hands, face, and other exposed parts of your body that may have been contaminated....” During observation conducted while on tour on September 9, 2025 in the laboratory, a safety shower was observed in the laboratory. A metal shelf was obstructing the pathway to the safety shower that was covered in boxes. Some items appeared to be stored within the safety shower, including a telephone.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 45167 Based on record review, the facility failed to provide documented evidence that the kitchen hood system was cleaned and inspected semi-annually in accordance with NFPA 96. Failing to inspect and clean the kitchen hood and vents semi-annually will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire Extinguishing Systems. Section 11.4 Inspection for grease buildup. The entire exhaust system shall be inspected for grease buildup by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction and in accordance with Table 11.4. Systems serving moderate-volume cooking operations. Inspection frequency semi-annually.” Findings include: Documentation of semi-annual kitchen hood system cleaning and inspection was requested for calendar years 2024 and 2025. A kitchen hood inspection conducted by Hiller on 03/21/2025 and a cleaning conducted by Sun Devil Hoods on 07/30/2025 was provided. No services conducted in 2024 could be found or were provided regarding semi-annual inspection and cleaning of the kitchen hoods.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 45167 _______________________________________CONDITIONAL__________________________________________ Based on observation and interview, the facility failed to ensure that all exposed electrical wiring was protected. Failure to ensure exposed wiring could cause accidental damage or possibly a fire, which could cause harm to patients and staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, “Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, “Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, “National Electrical Code.” NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage.” In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. NFPA 70, 2011 Edition Chapter 1 General “110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface.” Findings include: During observation while on tour conducted on September 8 and September 9, 2025, the following was observed: -A thermostat cover missing in 35ED (emergency department) leaving wiring exposed -A communications panel with a cover that could not be closed in an electrical room that entered through the exterior of the facility leaving wiring exposed -A communications panel on the 4th floor with a broken cover that could not be closed leaving wiring exposed -Exposed wiring hanging from the wall in the clean utility room about 1 (one) foot from the floor in the DOC (Department of Corrections) area -An electrical panel with no cover in the electrical storage room near the mobile CT (computed tomography) area -An open junction box near the chillers -An open junction box in the interstitial space on the second floor of the west building -A second open junction box in the interstitial space on the second floor of the west building with the cover hanging adjacent to it; this junction box was nestled amidst a large quantity of insulation in the ceiling -An open junction box with the cover hanging off the bottom of it in the ATS (automatic transfer switch) room -An open junction box in the elevator room -Exposed wiring in the mechanical room on the 2nd floor. -Hanging wires in 5807 Employees #2, 5, 6 & 11 participated in the tour and were able to observe and acknowledge the deficiencies at the time they were found. During an exit interview conducted on September 9, 2025, administrative staff acknowledged the deficiencies.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 45167 ______________________________CONDITIONAL_________________________________________________ Based on observation while on tour, review of facility documentation and interview, the Department has determined the Administrator failed to ensure that the hospital HVAC systems were maintained in working order. Failure to ensure that the HVAC system is maintained in working order can result in discomfort for staff and patients and can result in adverse outcomes for patients. Findings include: NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, “Heating Ventilating and Air Conditioning.” Section 19.5.2.1 “Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture’s specifications” Section 9.2.1 “ Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment.” Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 91. NFPA 91 Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, Chapter 10, Maintenance Program, Section 10.6.1 indicated, “....All system components shall be maintained in good operating condition....” Section 10.6.5 indicated: “...Serious deficiencies shall require immediate attention....” During observation while on tour conducted on September 8, 2025, Compliance Officers observed standing water pooled on the floor around an air handler unit on the second floor identified in an interview conducted on September 8, 2025 by Employee #8 as SB-002. In an interview conducted with Employee #5 on September 8, 2025, Employee #5 stated the cause of the water pooled on the floor around SB-002 was likely to be condensation from the Air Handler Unit. Employee #5 asserted that personnel conducted daily walkthroughs of the hospital which included a visual inspection of Air Handler Units. During observation while on tour conducted on September 9, 2025, Compliance Officers observed standing water pooled on the floor around an air handler unit located in Room #1278 located near biohazard storage identified as NB-005. In an interview conducted with Employee #5 on September 9, 2025, Employee #5 stated the cause of the water pooled on the floor around NB-005 was likely caused by condensation from the Air Handler Unit. According to an interview conducted with Employee #8 on September 8, 2025, St. Mary’s Hospital has 41 Air Handler Units. An observation tour was conducted of Air Handler Units by Compliance Officers on September 8 and September 9, 2025. No other Air Handler Units were observed to have condensation in the form of pools of water surrounding the Air Handler Units. HVAC 1 Work Orders” and “HVAC 2 Work Orders” revealed 221 (two hundred and twenty-one) work orders submitted regarding temperature and humidity issues in surgery and operating rooms between April 1, 2024 and January 25, 2025. In an interview conducted with Employee #5 on September 8, 2025, Employee #5 explained that work orders are typically addressed as they are received and employees are provided an email confirming a work order has been addressed once the work order is closed; however, during observation while on tour conducted on September 8, 2025, Employee #5 stated that dehumidifiers were installed “about two weeks ago” to address the humidity issues in the operating room and surgery area. Temperature and humidity logs for operating and surgery areas were requested and were provided for January 1, 2025 to present.\ Each day, temperature and humidity was measured in 24 (twenty-four) areas. 864 (eight hundred and sixty-four) temperature and humidity readings were reviewed from random sample sheets taken from March, May, June, and July 2025. Of these, 334 readings (three-hundred and thirty-four) were out of range, approximately one-third of readings taken. Documentation was requested but not provided regarding the installation of dehumidifiers; however, documentation was provided regarding thermostat calibration issues for the operating and surgical rooms with emails beginning on August 25, 2025 and ending on September 4, 2025 that indicated adjustments are still ongoing. HVAC 1 Work Orders” and “HVAC 2 Work Orders” revealed 73 (seventy-three) complaints of the air conditioner not working or of rooms being too hot on the 4th floor of the hospital between June 1, 2024 and September 1, 2025 with an additional 8 (eight) complaints regarding thermostats not working. 7 (seven) of these complaints were regarding medication room 4513 or 4W that were submitted between Mary 23, 2025 and July 11, 2025. During observation while on tour conducted on September 9, 2025 of the 4th floor of the hospital, Compliance Officer observed a medication room in an area of the hospital undergoing renovation. This medication room was in a patient care area of the hospital containing the room number previously known as 4513. Upon entering the medication room, Compliance Officer noted the room seemed hotter than the corridor. A thermostat on the wall indicated the temperature of the room was 80 degrees. Medical supplies and oxygen canisters were stored within the room. A check of the ambient temperature of the room indicated the ambient air temperature to be 82 degrees. HVAC 1 Work Orders” and “HVAC 2 Work Orders” revealed 53 (fifty-three) complaints of the air conditioner not working or of rooms being too hot on the 3rd floor of the hospital between March 1, 2024 and September 1, 2025 with an additional 3 (three) complaints regarding thermostats not working. Of these complaints, 9 (nine) were regarding medication rooms being too hot. Repair orders were requested for all HVAC systems. Other than repairs to chillers, no repairs were found that would have affected the operating room areas or 4th floor areas. One repair was found relevant to the 3rd floor. The following repairs were made during this timeframe: On August 22, 2024, an issue with the chiller 2 valve was reported. The issue was temporarily addressed, but not resolved. A plastic water bottle was placed over the chill water flow switch to prevent water dripping on the switch. Subsequent service calls for chiller 2 were made on September 15 and September 19, 2024. During observation while on tour conducted on September 8, 2025, the water bottle was observed to still be in place over the water flow switch on chiller 2. On September 30, 2024, a repair was made to chiller 3. On October 8, 2024, a repair was made to the MRI chiller. On August 29, 2024, a fuse was replaced in an air handler unit described as the “janitorial air handler unit.” On September 6-7, 2024, service was provided for an air handler unit described as being on the third floor. On September 20, 2024, a rooftop air handler unit was replaced described as being in the MRI area. On October 8, 2024, an air handler unit was replaced described as Kitchen AHU-32. Maintenance records for air handler units were entered in as work orders. In order to evaluate frequency of air handler unit servicing, two air handler units were selected--AHU #4033 (039434) designated as servicing the hallway going to 4700, and AHU WB-23 (02296) designated as servicing operating rooms 8 and 9. #4033(039434) 02/05/2024-Air Induction Unit 04/29/2024-Air Induction Unit 08/05/2024-Air Induction Unit 11/04/2024-Air Induction Unit 05/05/2025-Air Induction Unit 06/30/2025-Air Induction Unit WB-23(02296) 05/27/2024-Exhaust Fan 05/27/2024-Exhaust Fan (It should be noted that two lists of work orders were provided, HVAC 1 and HVAC 2, which were for two separate technicians. These two entried were both timed for 11:11 p.m. on the same date and indicated one hour of work). 08/26/2024-Exhaust Fan 08/25/2025-Exhaust Fan These maintenance entries do not indicate a regular maintenance schedule. In interviews conducted with Employees #5 and 8, Employees #5 and 8 stated on September 8 that regular maintenance was performed on air handler units in the facility.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Operations Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers. 5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour and review of facility policy and procedure, it has been determined the facility failed to ensure that positive-pressure gases are properly and securely stored. Failure to securely and properly store positive-pressure gases can result in a fire, leading to potential harm to patients or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) indicated: “.Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:..They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty....” Findings include: Facility policy titled, “Compressed Gas Cylinder Management” indicated: “Cylinders...shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full or empty...Oxidizing gases...shall not be stored with any flammable gas, liquid or vapor.” During observation while on tour conducted on September 9, 2025, in the medical gas storage room, a large medical nitrogen canister that was on top of a wheeling platform was observed to be chained to 13 (thirteen) other canisters of assorted medical gases with one single chain, including carbon dioxide, nitrous oxide, oxygen and one canister of gas of an unknown type in a red canister.”

“Features of Fire Protection - Other CFR(s): NFPA 101 Features of Fire Protection - Other List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 15 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to ensure that flammable and/or combustible liquids were safely stored to prevent the likelihood of fire. Failure to ensure flammable and/or combustible liquids are safely stored can increase the likelihood of a fire event, leading to injury or death of patients and/or staff. NFPA 99 (2012), Chapter 15, Section 15.3.1, “The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards...NFPA 30, Flammable and Combustible Liquids.” Section 14.4.1 indicated, “The design and construction of a locker shall...be subject to the approval of the authority having jurisdiction.” Section 14.5.1 indicated, “Lockers shall be located on a designated approved site on the property.” Section 14.5.2 indicated, “The designated site shall be arranged to provide minimum separation distances specified in Table 14.5.2...from locker to important buildings on the same property...Area of Designated site...[less than or equal to] 100 ft [squared]...From Locker to Important Buildings on the Same Property...5 feet....” Section 14.6.5 indicated, “Miscellaneous combustible materials, including but not limited to idle pallets, excessive vegetation and packing materials shall not be permitted within 5 ft. of the designated site approved for lockers. Section 14.6.6 indicated: “Warning signs for lockers shall be in accordance with local, state, and federal regulations or with NFPA 704....” Findings include: During observation while on tour conducted on September 9, 2025, a hazardous material locker was observed outside the back of the hospital roughly across from the cooling tower. The locker was positioned in close proximity to the hospital main building. The locker was rusted with faded signs. Although it did have papers contained within transparent sleeves, it did not bear a visible 704 diamond. There was vegetation growing up above the height of the bottom of the door frame. In an interview conducted on September 9, 2025, Employee #6 stated the hazardous material locker contained Xylene. At the request of the Compliance Officer, the locker was opened. Inside were 9 (nine) large containers of violet hued liquid, one yellow barrel, one orange barrel, one large white barrel with a red top and numerous cardboard boxes. The containers of violet liquid were leaking inside the locker. On September 10, 2025, Compliance Officer contacted the Tucson Fire Department. According to the Tucson Fire Department, they were not notified about the installation of the hazardous material locker and did not approve its placement.”

“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: 37489 Based on review of policies and procedures, hospital documents, clinical records, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR §489.20 and 42 CFR §489.24, responsibilities of Medicare participating hospitals in emergency cases. Findings include: 1. The policy titled “ St Mary’s Hospital, Triage, Assessment and RE-Assessment, Effective date 5/22/03, Last review date 8/2021 “ requires: “ ... ’ Quick Look ’ and comprehensive triage are assessments that include a rapid and systematic collection of data relevant to each patient ’ s chief complaint, age, cognitive level, and social situation. The assessment is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychosocial needs ... Triage facilitates the flow of patients through the emergency care system, ensuring a timely evaluation and plan of care based on the health care needs of the patient ...Based on EMTALA policy, all patients who come to the ED seeking health care will be: ...Offered a Medical Screening Exam (MSE) ...Registered into the CHN System ...Triage ...Every patient will be sorted and classified according to urgency of condition or complaint. Triage is the first decision point in the care of the emergency patient ...a) Quick-Look Triage: refers to a rapid assessment that assures ABCs are intact and the patient does not have a life-threatening or potentially life- threatening illness or injury ...b) Comprehensive Triage: refers to a focused assessment based on chief complaint and presenting signs and symptoms and urgency of care needed ...The triage assessment is done by a registered nurse (RN). All other members of the health care team will contribute to the gathering of information and formulation of the plan of care. Review of Patients #1 - 25’s ED medical records revealed that the facility failed to provide either a “quick look” or comprehensive RN triage assessment for (11) of (25) patients (Patients #1, 3, 9, 10, 11, 12, 13, 16, 17, 19, and 20) that presented to the ED seeking care for an emergency medical condition. Employees #2 and 6 confirmed on 08/12/2024 that the staff did not follow facility policy for providing nursing “quick look” and/or comprehensive triage assessments for the 11 aforementioned patients. 2. The policy titled “Carondelet Health Network, Emergency Medical Treatment and Labor Act of 1986 (EMTALA), Effective Date: 12/13/2021” requires: “...Purpose: To ensure individuals presenting to [Carondelet Hospital ’ s] emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment or an appropriate transfer in accordance with and that requests for transfer to [Carondelet Hospitals] are accepted or declined in accordance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ... III. Definitions: ... Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs ...Medical Screening Examination (MSE): Screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist ...A.[Carondelet Hospitals] will provide an appropriate MSE within the capability of Carondelet Hospital] to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists ...B. Subject to the patient ’ s right to refuse treatment, [Carondelet Hospitals] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care .... “ Review of Patients #1 - 25’s ED medical records revealed that the facility failed to provide MSE’s for Employees #2 and 6 confirmed on 08/12/2024 that providers did not conduct an MSE for (18) of (25) patients (Patients #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 22, 23 and 25) that presented to the ED for examination and treatment. 3. The policy titled “St. Mary’s Hospital, Leaving Against medical Advice, Effective date November 2003, Last review Dec 2018” requires: “ ...Against Medical Advice, (AMA). The self-discharge of a patient from a health care facility, contrary to what the patient ’ s physician(s) perceive to be in the patient ’ s best interests after assessment and treatment has been recommended. The patient is asked to sign a form, acknowledging that they are aware of the risks associated with leaving the medical facility before treatment has been completed. Elopement is a term used when a patient leaves the treatment setting without notification to the nursing unit or before the Medical Screening Exam (MSE) in the Emergency Department. See related policy on Emergency Medical Treatment and Active Labor Act (EMTALA). Left without being seen or left without treatment is a term used to describe a situation in the Emergency Department when the patient voluntarily left without being triaged and/or receiving a medical screening examination ... Documentation of AMA and elopement situations is the responsibility of the physicians and nursing staff ...ELOPEMENT: If it is determined that a Category #1 Patient left the medical facility without notifying anyone (see definition of “ Elopement “ above), this should be recorded in the medical record and the patient ’ s physician must be notified. (See the EMTALA policy for guidelines on how to document if a patient leaves the Emergency Department prior to receiving a Medical Screening Exam or prior to being seen.) ...The following information should be documented in the medical record: 1. Time/location patient found missing or left AMA. 2. Steps taken, if applicable, to locate the patient, including who was notified and when and where search was conducted. 3. If patient is found, where found and patient ’ s condition. 4. Any follow-up care for a patient that is found and who was notified .... “ Review of Patients #1 - 25’s ED medical records revealed that the facility failed to ensure appropriate information was documented by staff in (18) of (25) patients’ medical records (Patients #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, and 22) as required by policy for leaving without treatment. Additionally, the policy titled “St. Mary’s Hospital, Leaving Against medical Advice, Effective date November 2003, Last review Dec 2018” referenced guidelines to be found in the EMTALA policy for documentation of AMA and elopement; however, the EMTALA policy did not include guidelines for the documentation requirements. Employee #2 confirmed on 02/12/2024 that facility staff and providers did not document as required patients’ that eloped or left without treatment.”

“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: 37489 Based on document review and interview, it was determined that the facility failed to complete a medical screening examination (MSE) to determine if an emergency medical condition existed and provide treatment and/or at a minimum provide an RN triage assessment of patients’ condition upon arrival to ensure that the patients were appropriately prioritized based on presenting condition if the provider was unable to immediately complete an appropriate examination. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided. Findings include: The policy titled “Carondelet Health Network, Emergency Medical Treatment and Labor Act of 1986 (EMTALA), Effective Date: 12/13/2021” requires: “...Purpose: To ensure individuals presenting to [Carondelet Hospital ’ s] emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment or an appropriate transfer in accordance with and that requests for transfer to [Carondelet Hospitals] are accepted or declined in accordance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ... III. Definitions: ... Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs ...Medical Screening Examination (MSE): Screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist ...A.[Carondelet Hospitals] will provide an appropriate MSE within the capability of Carondelet Hospital] to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists ...B. Subject to the patient ’ s right to refuse treatment, [Carondelet Hospitals] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care .... “ The policy titled “ St Mary’s Hospital, Triage, Assessment and RE-Assessment, Effective date 5/22/03, Last review date 8/2021 “ requires: “ ... ’ Quick Look ’ and comprehensive triage are assessments that include a rapid and systematic collection of data relevant to each patient ’ s chief complaint, age, cognitive level, and social situation. The assessment is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychosocial needs ... Triage facilitates the flow of patients through the emergency care system, ensuring a timely evaluation and plan of care based on the health care needs of the patient ...Based on EMTALA policy, all patients who come to the ED seeking health care will be: ...Offered a Medical Screening Exam (MSE) ...Registered into the CHN System ...Triage ...Every patient will be sorted and classified according to urgency of condition or complaint. Triage is the first decision point in the care of the emergency patient ...a) Quick-Look Triage: refers to a rapid assessment that assures ABCs are intact and the patient does not have a life-threatening or potentially life- threatening illness or injury ...b) Comprehensive Triage: refers to a focused assessment based on chief complaint and presenting signs and symptoms and urgency of care needed ...The triage assessment is done by a registered nurse (RN). All other members of the health care team will contribute to the gathering of information and formulation of the plan of care. The policy titled “ The policy titled “ St. Mary’s Hospital, Leaving Against medical Advice, Effective date November 2003, Last review Dec 2018 “ requires: “ ...Against Medical Advice, (AMA). The self-discharge of a patient from a health care facility, contrary to what the patient ’ s physician(s) perceive to be in the patient ’ s best interests after assessment and treatment has been recommended. The patient is asked to sign a form, acknowledging that they are aware of the risks associated with leaving the medical facility before treatment has been completed. Elopement is a term used when a patient leaves the treatment setting without notification to the nursing unit or before the Medical Screening Exam (MSE) in the Emergency Department. See related policy on Emergency Medical Treatment and Active Labor Act (EMTALA). Left without being seen or left without treatment is a term used to describe a situation in the Emergency Department when the patient voluntarily left without being triaged and/or receiving a medical screening examination ... Documentation of AMA and elopement situations is the responsibility of the physicians and nursing staff ...ELOPEMENT: If it is determined that a Category #1 Patient left the medical facility without notifying anyone (see definition of “ Elopement “ above), this should be recorded in the medical record and the patient ’ s physician must be notified. (See the EMTALA policy for guidelines on how to document if a patient leaves the Emergency Department prior to receiving a Medical Screening Exam or prior to being seen.) ...The following information should be documented in the medical record: 1. Time/location patient found missing or left AMA. 2. Steps taken, if applicable, to locate the patient, including who was notified and when and where search was conducted. 3. If patient is found, where found and patient ’ s condition. 4. Any follow-up care for a patient that is found and who was notified .... “ Patient #1 presented to an urgent care prior to seeking treatment at Hospital #1. The urgent care provider recommended the patient go to an ED for treatment after evaluating the patient. The ED log dated 01/10/2024 revealed that Patient #1 presented to Hospital #1 ’ s ED on 01/10/2024 at 1636 with dyspnea and that the patient “ left without being seen “ on 01/10/2024 at 1728. Patient #1 ’ s medical record contained a face sheet with the patient ’ s demographic information, an ED nursing note entered on 01/10/2024 at 2041 for 1728 that revealed: “ ...pt (sic) not found in lobby when called to triage. pt (sic) not seen by staff at front desk or ed (sic) leaving ... “ The provider ED note dated 01/10/2024 at 1813 revealed: “ ...This patient left prior to evaluation. I did not have the opportunity to evaluate him .... “ Patient #1 ’ s medical record from Hospital #2 revealed that the patient presented the second ED and was registered on 01/10/2024 at 1804. Patient #1 was triaged by an RN at 1811 and an MSE initiated by the provider at 2037 and diagnostic testing and treatment was initiated. Patient #1 was diagnosed with rhinovirus associated respiratory insufficiency with hypoxia and sepsis and subsequently admitted as an inpatient to Hospital #2 for treatment. Review of an additional 24 patient ED records revealed a pattern of lack of timely RN triage to determine the severity of the patients ’ presenting symptoms, ensure airway, breathing and circulation were intact, or that patients presenting with life threatening or potentially life-threatening conditions were promptly seen by a provider for an MSE and/or stabilizing treatment. Additionally, the additional 24 patient records revealed a pattern of delay in an MSE by the provider. Medical records for (17) of (24) patients (Patients #3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, and 22) revealed the following: Patient #3 - Patient registered on 01/10/2024 at 2004 with complaint of a toothache. No triage or MSE was performed for the patient and the patient left without being seen at 2030. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #5 - Patient registered on 01/01/2024 at 1558 with complaint of an allergic reaction. The RN triaged the patient at 1836 (2 hours 38 minutes after presentation to the ED). The ED provider did not conduct an MSE. The ED provider made a note on 01/02/2024 at 0711 that an MSE was not conducted because the patient left the ED. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #6 - Patient registered on 01/04/2024 at 1603 with complaint of flank pain. The RN triaged the patient at 1715 (1 hour 12 minutes after presentation to the ED). The ED provider did not conduct an MSE. The medical record revealed that the patient was missing from the ED lobby on 01/07/2024 at 0252. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #7 - Patient registered on 01/05/2024 at 1717 with complaint of abdominal pain. The RN triaged the patient at 1730. The ED provider did not conduct an MSE. There were no provider ED notes as to the reason an MSE was not conducted. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #8 - Patient registered on 01/05/20245 at 1744 with complaint of stepping on rusty nail. The RN triaged the patient at 1840 (56 minutes after presentation to the ED). The ED provider did not conduct an MSE. There were no provider ED notes as to the reason an MSE was not conducted. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #9 - Patient registered on 01/16/2024 at 1734 with complaint of abdominal pain. No triage or MSE was conducted for the patient as of 2029 when the patient was noted to be missing from the lobby by the RN attempting to triage the patient (2 hours 55 minutes after presentation to the ED). The ED log discharge disposition revealed “Left Without Being Seen.” Patient #10 - Patient registered on 01/19/2024 at 1243 with complaint of leg bleeding. The record only contained a face sheet and did not contain any progress notes. The RN did not triage the patient or enter a nursing note to document a disposition. The MD did not conduct an MSE or document why an MSE was not conducted. The patient was discharged at 1414 (1 hour 31 minutes after presenting for emergency medical care). The ED log discharge disposition revealed “Left Without Being Seen.” Patient #11 - Patient registered on 01/19/2024 at 1304 with complaint of dizziness. No triage or MSE was performed for the patient. The patient was missing form the facility when the RN went to lobby to triage at 1436 (1 hour 32 minutes after presentation to the ED). The ED log discharge disposition revealed “Left Without Being Seen.” Patient #12 - Patient registered on 01/25/2024 at 1232 with complaint of cough, wheezing. No triage or MSE was performed for the patient. The patient was found missing when the RN went to the lobby to triage the patient at 1419 (1 hour 47 minutes after presentation to the ED). The MD made a note that no MSE was done and documented a call to the patient in which the patient reported they sought treatment at another facility. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #13 - Patient registered on 02/08/2024 at 1458 with complaint of dislocated jaw. No triage or MSE was performed for the patient. The RN did not complete any notes or a reason why the patient was not triaged. The MD did not conduct an MSE and made a note that the patient left prior to triage. The patient was discharged at 1610 (1 hour 48 minutes after presentation to the ED). The ED log discharge disposition revealed “Left Without Being Seen.” Patient #15 - Patient registered on 02/20/2024 at 1403 with complaints of fever, rash, and abdominal pain. The RN triaged the patient at 1431. The RN made a note at 2048 that the patient left the ED because they were tired of waiting to see a provider for MSE. The patient was discharged at 2048 (6 hours 45 minutes after presentation to the ED). The ED log discharge disposition revealed “Left Without Being Seen.” Patient #16 - Patient registered on 02/20/2024 at 1520 with complaint of abdominal pain. No triage or MSE was performed for the patient. The RN documented a note that triage was attempted at 1655 (1 hour 35 minutes after presentation to the ED). The MD made a note that MSE was not conducted and an attempt to call the patient’s family on 02/21/2024 at 0844. The patient was discharged at 1728. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #17 - Patient registered on 02/20/2024 at 1527 with complaint of abdominal pain. No triage or MSE was performed for the patient. The RN documented that triage was not attempted until 1700 (1 hour 33 minutes after presentation to the ED). The MD did not conduct and MSE or make a note as to the patient’s disposition. The patient was discharged at 1729. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #18 - Patient registered on 02/20/2024 at 1736 with complaint of shortness of breath, cough. The RN triaged the patient at 1805. The patient was not present in the lobby when called back for MSE at 2000. The MD contacted the patient by phone who stated that they will seek treatment elsewhere. The patient was discharged at 2005. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #19 - Patient registered on 02/25/2024 at 1407 with complaint of cough. No triage or MSE done. The RN made a note when triage was attempted at 1553 (1 hour 44 minutes after patient presented to the ED) that the patient had left. The MD made a note that triage and MSE were not done and a call to the patient’s family revealed that they took the patient to another facility for treatment. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #20 - Patient registered on 12/26/2023 at 1322 with complaint of shortness of breath. The RN did not triage the patient or write a note why triage was not conducted. The MD made a not at 1733 that an MSE was not conducted because the patient had left the facility. The ED log discharge disposition revealed “Left Without Being Seen.” Patient #22 - Patient registered on 01/08/2024 at 2022 with complaints of shortness of breath and brought in by ambulance. The RN triaged the patient at 2025. The RN made a note in the record that the patient was noted as missing when passing by the patient’s room at 2148. An MSE was not conducted and the patient was discharged at 2148. The ED log discharge disposition revealed “Left Without Being Seen.” Employee #2 confirmed on 08/08/2024 and 08/12/2024 that the aforementioned patients left the ED without treatment because they did not have an RN do triage assessment and/or have a provider perform an MSE within an appropriate timeframe. Employees #2 and 6 confirmed on 08/12/2024 that the goal for the facility was to have an RN triage assessment within 15 minutes or less and an MSE by a qualified medical provider within 30 minutes or less and that this was not done for the aforementioned patients.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 37489 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for (20) of (25) patients (Patients #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 22, 23 and 25) who presented to the ED seeking medical treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient is denied necessary medical treatment. Findings include: The policy titled “Carondelet Health Network, Emergency Medical Treatment and Labor Act of 1986 (EMTALA), Effective Date: 12/13/2021” requires: “...Purpose: To ensure individuals presenting to [Carondelet Hospital ’ s] emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment or an appropriate transfer in accordance with and that requests for transfer to [Carondelet Hospitals] are accepted or declined in accordance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ... III. Definitions: ... Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs ...Medical Screening Examination (MSE): Screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist ...A.[Carondelet Hospitals] will provide an appropriate MSE within the capability of Carondelet Hospital] to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists ...B. Subject to the patient ’ s right to refuse treatment, [Carondelet Hospitals] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care .... “ The policy titled “ St Mary’s Hospital, Triage, Assessment and RE-Assessment, Effective date 5/22/03, Last review date 8/2021 “ requires: “ ... ’ Quick Look ’ and comprehensive triage are assessments that include a rapid and systematic collection of data relevant to each patient ’ s chief complaint, age, cognitive level, and social situation. The assessment is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychosocial needs ... Triage facilitates the flow of patients through the emergency care system, ensuring a timely evaluation and plan of care based on the health care needs of the patient ...Based on EMTALA policy, all patients who come to the ED seeking health care will be: ...Offered a Medical Screening Exam (MSE) ...Registered into the CHN System ...Triage ...Every patient will be sorted and classified according to urgency of condition or complaint. Triage is the first decision point in the care of the emergency patient ...a) Quick-Look Triage: refers to a rapid assessment that assures ABCs are intact and the patient does not have a life-threatening or potentially life- threatening illness or injury ...b) Comprehensive Triage: refers to a focused assessment based on chief complaint and presenting signs and symptoms and urgency of care needed ...The triage assessment is done by a registered nurse (RN). All other members of the health care team will contribute to the gathering of information and formulation of the plan of care. Patient #1 presented to an urgent care prior to seeking treatment at Hospital #1. The urgent care provider recommended the patient go to an ED for treatment after evaluating the patient. The ED log dated 01/10/2024 revealed that Patient #1 presented to Hospital #1 ’ s ED on 01/10/2024 at 1636 with dyspnea and that the patient “ left without being seen “ on 01/10/2024 at 1728. Patient #1 ’ s medical record contained a face sheet with the patient ’ s demographic information, an ED nursing note entered on 01/10/2024 at 2041 for 1728 that revealed: “ ...pt (sic) not found in lobby when called to triage. pt (sic) not seen by staff at front desk or ed (sic) leaving ... “ The provider ED note dated 01/10/2024 at 1813 revealed: “ ...This patient left prior to evaluation. I did not have the opportunity to evaluate him .... “ The RN did not attempt to triage Patient #1 until 1728 (52 minutes after the patient’s arrival at the ED seeking treatment). Patient #1 ’ s medical record from Hospital #2 revealed that the patient presented the second ED and was registered on 01/10/2024 at 1804. Patient #1 was triaged by an RN at 1811 and an MSE initiated by the provider at 2037 and diagnostic testing and treatment was initiated. Patient #1 was diagnosed with rhinovirus associated respiratory insufficiency with hypoxia and sepsis and subsequently admitted as an inpatient to Hospital #2 for treatment. Review of an additional 24 patient ED records revealed a pattern of lack of timely RN triage to determine the severity of the patients ’ presenting symptoms, ensure airway, breathing and circulation were intact, or that patients presenting with life threatening or potentially life-threatening conditions were promptly seen by a provider for an MSE and/or stabilizing treatment. Additionally, the additional 24 patient records revealed a pattern of delay in an MSE by the provider. Medical records for (17) of (24) patients (Patients #3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, and 22) revealed the following: Patient #3 - Patient registered on 01/10/2024 at 2004 with complaint of a toothache. No triage or MSE was performed for the patient and the patient left without being seen at 2030. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #5 - Patient registered on 01/01/2024 at 1558 with complaint of an allergic reaction. The RN triaged the patient at 1836 (2 hours 38 minutes after presentation to the ED). The ED provider did not conduct an MSE. The ED provider made a note on 01/02/2024 at 0711 that an MSE was not conducted because the patient left the ED. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #6 - Patient registered on 01/04/2024 at 1603 with complaint of flank pain. The RN triaged the patient at 1715 (1 hour 12 minutes after presentation to the ED). The ED provider did not conduct an MSE. The medical record revealed that the patient was missing from the ED lobby on 01/07/2024 at 0252. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #7 - Patient registered on 01/05/2024 at 1717 with complaint of abdominal pain. The RN triaged the patient at 1730. The ED provider did not conduct an MSE. There were no provider ED notes as to the reason an MSE was not conducted. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #8 - Patient registered on 01/05/20245 at 1744 with complaint of stepping on rusty nail. The RN triaged the patient at 1840 (56 minutes after presentation to the ED). The ED provider did not conduct an MSE. There were no provider ED notes as to the reason an MSE was not conducted. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #9 - Patient registered on 01/16/2024 at 1734 with complaint of abdominal pain. No triage or MSE was conducted for the patient as of 2029 when the patient was noted to be missing from the lobby by the RN attempting to triage the patient (2 hours 55 minutes after presentation to the ED). The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #10 - Patient registered on 01/19/2024 at 1243 with complaint of leg bleeding. The record only contained a face sheet and did not contain any progress notes. The RN did not triage the patient or enter a nursing note to document a disposition. The MD did not conduct an MSE or document why an MSE was not conducted. The patient was discharged at 1414 (1 hour 31 minutes after presenting for emergency medical care). The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #11 - Patient registered on 01/19/2024 at 1304 with complaint of dizziness. No triage or MSE was performed for the patient. The patient was missing form the facility when the RN went to lobby to triage at 1436 (1 hour 32 minutes after presentation to the ED). The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #12 - Patient registered on 01/25/2024 at 1232 with complaint of cough, wheezing. No triage or MSE was performed for the patient. The patient was found missing when the RN went to the lobby to triage the patient at 1419 (1 hour 47 minutes after presentation to the ED). The MD made a note that no MSE was done and documented a call to the patient in which the patient reported they sought treatment at another facility. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #13 - Patient registered on 02/08/2024 at 1458 with complaint of dislocated jaw. No triage or MSE was performed for the patient. The RN did not complete any notes or a reason why the patient was not triaged. The MD did not conduct an MSE and made a note that the patient left prior to triage. The patient was discharged at 1610 (1 hour 48 minutes after presentation to the ED). The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #15 - Patient registered on 02/20/2024 at 1403 with complaints of fever, rash, and abdominal pain. The RN triaged the patient at 1431. The RN made a note at 2048 that the patient left the ED because they were tired of waiting to see a provider for MSE. The patient was discharged at 2048 (6 hours 45 minutes after presentation to the ED). The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #16 - Patient registered on 02/20/2024 at 1520 with complaint of abdominal pain. No triage or MSE was performed for the patient. The RN documented a note that triage was attempted at 1655 (1 hour 35 minutes after presentation to the ED). The MD made a note that MSE was not conducted and an attempt to call the patient ’ s family on 02/21/2024 at 0844. The patient was discharged at 1728. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #17 - Patient registered on 02/20/2024 at 1527 with complaint of abdominal pain. No triage or MSE was performed for the patient. The RN documented that triage was not attempted until 1700 (1 hour 33 minutes after presentation to the ED). The MD did not conduct and MSE or make a note as to the patient ’ s disposition. The patient was discharged at 1729. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #18 - Patient registered on 02/20/2024 at 1736 with complaint of shortness of breath, cough. The RN triaged the patient at 1805. The patient was not present in the lobby when called back for MSE at 2000. The MD contacted the patient by phone who stated that they will seek treatment elsewhere. The patient was discharged at 2005. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #19 - Patient registered on 02/25/2024 at 1407 with complaint of cough. No triage or MSE done. The RN made a note when triage was attempted at 1553 (1 hour 44 minutes after patient presented to the ED) that the patient had left. The MD made a note that triage and MSE were not done and a call to the patient ’ s family revealed that they took the patient to another facility for treatment. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #20 - Patient registered on 12/26/2023 at 1322 with complaint of shortness of breath. The RN did not triage the patient or write a note why triage was not conducted. The MD made a not at 1733 that an MSE was not conducted because the patient had left the facility. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #22 - Patient registered on 01/08/2024 at 2022 with complaints of shortness of breath and brought in by ambulance. The RN triaged the patient at 2025. The RN made a note in the record that the patient was noted as missing when passing by the patient ’ s room at 2148. An MSE was not conducted and the patient was discharged at 2148. The ED log discharge disposition revealed “ Left Without Being Seen. “ Patient #23 - Patient registered on 01/09/2024 at 1820 with complaint of motor vehicle accident and right knee pain. The RN triaged the patient at 1938 (1 hour 18 minutes after presentation to the ED). An MSE was conducted at 2014 (1 hour 54 minutes after presentation to the ED). Both the RN triage assessment to determine the severity of the patient’s condition as well as the MSE to determine if an emergency medical condition existed and treatment were delayed. Patient #25 - Patient registered on 01/12/2024 at 1116 with complaint of shortness of breath. The RN triaged the patient at 1135. The provider conducted an MSE at 1437 (3 hours 21 minutes after presentation to the ED). There was a delay in the MSE to determine if an emergency medical condition existed and initiation of treatment. Employee #2 confirmed on 08/08/2024 and 08/12/2024 that the aforementioned patients left the ED without treatment because there was a delay in RN triage assessment and/or MSE. Employees #2 and 6 confirmed on 08/12/2024 that the goal for the facility was to have an RN triage assessment within 15 minutes or less and an MSE by a qualified medical provider within 30 minutes or less and that this was not done for the aforementioned patients.”