Yavapai Regional Medical Center

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 47669 Based on a review of the Yavapai Regional Medical Center East Campus facility Emergency plan, record review, and staff interview, it was determined that the facility failed to develop and implement emergency preparedness policies and procedures that address the subsistence needs of staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies, and alternate sources of energy are not planned for and available. Finding include During observations on tour from June 15 to June 18, 2026, it was revealed that the facilities lacked sufficient water (50 gallons of water on hand, 480 gallons needed) to sustain the staff, patients, and visitors for the three days, as described in their plan. The management team confirmed during the facility tour and exit conference from June 15, 2026, to June 18, 2026, that the facility lacked sufficient water to meet the needs of staff, patients, and visitors in the event of an emergency.”

“A Life Safety Code Survey was conducted on June 15-18, 2026. At this Survey, Yavapai Regional Medical Center Main Campus was found NOT to be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety Code from Fire and the related National Fire Protection Association (NFPA) standard 101 - 2012 edition. Yavapai Regional Medical Center is a 4-story building of Type I construction. The building is fully sprinklered, and there is supervised smoke detection located in the corridors, spaces open to the corridor, and resident rooms. The building is supplied with emergency power from a diesel generator. The requirement at 42 CFR, Subpart 482.41(b) was NOT MET as evidenced by: A Life Safety Code Survey was conducted on June 15-18, 2026. At this Survey, Yavapai Regional Medical Center East Campus was found NOT to be in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety Code from Fire and the related National Fire Protection Association (NFPA) standard 101 - 2012 edition. Yavapai Regional Medical Center is a 3-story building of Type II construction. The building is fully sprinklered, and there is supervised smoke detection located in the corridors, spaces open to the corridor, and resident rooms. The building is supplied with emergency power from a diesel generator. The requirement at 42 CFR, Subpart 482.41(b) was NOT MET as evidenced by:”

“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: 47669 Based on observation and interviews, it was found that the facility failed to maintain its fire suppression system in the generator warehouse of the main campus. Failing to inspect, test, and maintain the fire suppression system could cause the system to be inoperable due to a lack of maintenance during a fire, and could cause harm to property, staff, and patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. “Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.” 9.7.3.1. In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1. 19.3.2.1 Hazardous Areas.Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. NFPA 2001 Clean Agent Fire Extinguishing Systems, 2012, Chapter 7.5.1, these systems shall be maintained in full operating condition at all times. Actuations, impairment, and restoration of this protection shall be reported promptly to the authority having jurisdiction. Findings include: During the facility tour June 15-18, 2026, it was discovered that the fire suppression system in the generator warehouse of the main campus had been inoperable for over a year and that they had been on fire watch the entire time. No time frame was provided as to when the fire suppression system would be operational. The management team confirmed during the exit conference on June 18, 2026, that the fire suppression system in the generator warehouse on the main campus was not operational.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 47669 Based on observations and interviews, it has been determined that the facility failed to install fire extinguishers near fuel storage stations. Failure to provide and maintain access to fire extinguishers in key areas can result in the spread of a fire in the event of a fire due to a lack of fire prevention options, leading to an increased possibility of harm to patients and staff. NFPA 101 Life Safety Code 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 “Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1” Section 9.7.4.1 “Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers.” 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard Basic Minimum Extinguisher Rating Maximum Travel Distance to Extinguishers (moderate) 20-B 50ft. Findings include: Observations made during the facility tour on June 15-18, 2026, revealed that the facility had failed to ensure that a fire extinguisher was at the following locations: 1. No fire extinguisher at the day tanks. 2. No fire extinguisher at the N/W fueling station The management team confirmed that there had not been fire extinguishers at the fuel storage areas during the facility tour and exit conference on June 15-18, 2026.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47669 Based on observation, it was determined that Yavapai Regional Medical Center West Campus failed to seal multiple penetrations in the smoke barriers. Failing to seal penetrations, holes, and openings in smoke barriers will allow smoke and heat to spread to other wings or possibly the entire facility, which could harm patients, staff, and visitors in the event of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 “Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour.” Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations made during a facility tour conducted on June 15-18, 2026, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas: 1. Door LL116: stairwell doors: above ceiling tile, unsealed wall penetration on both sides of the door measuring approximately 6’X4’. 2. Door LL121: above ceiling tile, elevator side, drywall overlay patch measuring approximately 18” x 18”. 3. SPD Soiled Linen Room: 5 open unsealed ceiling penetrations. 4. Lower Level Mechanical Room: Unsealed full-thickness cracks in the firewall drywall. 5. Door 1FL125: above ceiling tile, 3 unsealed wall penetrations. 6. Door 1FL126: above ceiling tile 2 drywall overlay patches. 7. Door IM142: above ceiling tile, multiple wall penetrations. 8. Room 3073 Telecom: unsealed wall penetrations on the left side wall. 9. Door IMG111: above ceiling tile, unsealed wall penetrations. 10. Door IMG112: above ceiling tile, unsealed wall penetrations. 11. Lab: unsealed holes in the east wall, unsealed holes in the south wall. 12. IFL252- unsealed hole on interior wall above door. 13. Door 3A114: drywall overlay patch measuring approximately 8”X8” on room 316 wall. 14. CVICU 100: above the ceiling tile, unsealed drywall joints. 15. 2ND114: above ceiling tile, unsealed wall penetrations. 16. 2ND115: above ceiling tile wall penetrations and an approximately 6” X6” drywall overlay patch. 17. PACU105: above ceiling tile, unsealed wall penetrations. 18. 2ND127: above ceiling tile, drywall not sealed, unsealed cabling, wall penetration. 19. 2ND131 RQI Stations side: above ceiling tile, unsealed wall penetrations. 20. Room 228: above ceiling tile, unsealed drywall, cabling penetration, drywall overlay patch. 21. PCU002: 211 side above ceiling tile, unsealed wall penetrations. 22. OR wall across from the nurses’ station, above ceiling tile, unsealed wall penetrations. Yavapai Regional Medical Center East Campus 1. 4J062: 4 drywall overlay patches measuring approximately 3”X6”, 3”X18”, 3”X16” and 3”X10” 2. 5J979: Second-floor electrical room had a drywall overlay patch measuring approximately 10”X12”. 3. 2C 5JVGP: above ceiling tile, multiple unsealed penetrations, and drywall seams not sealed. 4. 2B Interior side above door ceiling tiles, multiple unsealed penetrations, and a drywall overlay patch measuring approximately 12”X12”. 5. Telecom TRIE multiple drywall overlay patches on the door wall. 6. CCN entrance: above the door/ceiling tile, multiple unsealed wall penetrations. 7. EVS 5J240: missing a ceiling tile. The management team acknowledged the wall/ceiling penetrations during the facility tour and during the exit conference on June 15-18, 2026.”

“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: 47669 Based on observations during the facility tour and interviews, it has been determined that the facility failed to ensure that positive-pressure gases were properly and securely stored. The facility failed to segregate empty and full oxygen cylinders in a separate storage rack or stand. The facility failed to ensure there was proper signage for empty and full oxygen cylinders. The facility failed to ensure that oxygen storage areas were free from combustible materials. Failure to securely and properly store positive-pressure gases can result in a fire, leading to potential harm to patients or staff. Failing to segregate compressed gas medical cylinders could cause harm to the patients if a full bottle is needed in a hurry for the patients. 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 2012 Edition Chapter 11, Section 11.2, Subsection 11.2.1 indicated, “...Cylinders and containers shall comply with 5.1.3.1....” Section 5.1.3.1, Subsection 5.1.3.3.2 Design and Construction indicated: “...Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:...(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits...New to the 2012 edition is this requirement for outdoor storage enclosures to have two entries/exits. This requirement is intended to address the situation where, if a person was in the enclosure and an event occurred that prevented egress via the one opening, the person could exit via the other opening. The most common form in which this requirement will be implemented will be placing two gates in a chain-link fence surrounding a bulk system....” NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) indicated: “...They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty...Paragraph 5.1.3.3.2 (7) is a change to the 2002 requirement for individual securing of the cylinders. In the 2005 edition, the standard returned to the more relaxed “secure all cylinders” which permits, for instance, the single chain around multiple cylinders, which was common practice prior to the 2002 edition...Exhibit 5.3 illustrates two arrangements: one in which the cylinders are secured properly, and one in which the cylinders are not secured properly....” NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: 1. Minimum distance of 6.1 m (20 ft) 2. Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13 3. Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour. 11.3.4 Signs. 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: 1. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. 2. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. 3. Cylinders shall be protected from tampering by unauthorized individuals. 4. Cylinders or cylinder valves shall not be repaired, painted, or altered. 5. Safety relief devices in valves or cylinders shall not be tampered with. 6. Valve outlets clogged with ice shall be thawed with warm - not boiling - water. 7. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. 8. Sparks and flame shall be kept away from cylinders. 9. Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. 10. Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1 11. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. 12. Cylinders shall not be supported by radiators, steam pipes, or heat ducts. Findings include: Main campus oxygen room on the dock 1. No signage for empty and full cylinders. 2. Unsecured Argon gas cylinder. 3. Combustible materials- garbage can with trash, wooden table. Main campus helicopter pad 1. Unsecured oxygen cylinders/tanks. 2. No covering for oxygen cylinders/tanks. Main campus basement 1. Unsecured oxygen cylinders in the bed storage room. Yavapai Regional Medical Center East Campus 1. The loading dock oxygen storage room did not have signage for empty/full cylinders. 2. The loading dock metal oxygen storage had no venting. The management team confirmed the oxygen storage deficiencies during the facility tour and exit conference on June 15-18, 2026.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure five out of seven inpatients (Patients #8, #10, #11, #17, #18) with Medicare received written notice of their rights as inpatient, and their right to appeal hospital discharge within two days of admission. This deficient practice poses a risk of patients not being informed of the discharge appeal process, and the Quality Improvement Organization contact information to report any concerns on quality of care they receive. Findings include: Hospital policy titled, “Regulatory Patient Notifications,” revealed: “ ...Procedure ...I. Responsibility ...A. The local Chief Nursing Officer and Chief Financial Officer are responsible for the oversight of all regulatory patient notifications ....II. Important Message from Medicare (IM) ...A. Care Coordination and Patient Access must use the CMS approved IM form CMS-10065 to Medicare FFS and Medicare Advantage beneficiaries who are hospital inpatients. This notice informs the hospitalized inpatient beneficiaries of their hospital discharge appeal rights ....B. Care Coordination and Patient Access must follow the CMS IM form instructions for completing the form ....C. Hospitals may not develop procedures for routine delivery of the follow-up copy of the notice; in the rare instance that the notice is given to the patient on the day of discharge, the patient must be given at least four hours prior to discharge to consider their right to request an appeal of the discharge to the Quality Improvement Organization (QIO). D. The notice is delivered to the patient in person whenever possible. If the patient is unable to comprehend the notice; it is delivered to the patient ’ s representative. If unable to deliver the notice to the representative in person, discharge appeals right(s) may be delivered via telephone and acknowledgement of understanding is to be obtained. That conversation is to be documented on the form. E. Patient Access will deliver the first IM to the patient or representative at time of admission or within two (2) days of admission. F. Care Coordination will deliver the IM follow-up copy of the first signed IM form or will deliver a new IM form to the patient or representative within two (2) days of discharge ....K. Patient Access shall: 1. Provide a copy of the signed IM to the patient or representative. 2. Place a copy of the IM in the EMR. L. Care Coordination shall: 1. Provide a copy of the signed IM to the patient or representative. 2. Document in the EMR that the IM was issued. 3. Place a copy of the IM in the EMR ....” Medical record review revealed seven patients with Medicare were admitted as inpatient. Further review of the seven medical records revealed five out of seven inpatients (Patients #8, #10, #11, #17, #18) with Medicare, or their representative, did not sign the “Important Message from Medicare” form within two days of admission. Employee #74 confirmed during an interview conducted on 06/10/2026 that patients are given the “Important Message from Medicare” form at the time of admission and within four hours by registration. Employee #74 confirmed if patients cannot sign the form at the time of admission, then the facility seeks for a surrogate decision maker to sign the form. Employee #74 confirmed if registration cannot obtain the patient or patient ’ s representative signature at the time of admission, then they are to notify case management. Employee #74 confirmed there was a gap in communication between registration and case management. Employee #74 confirmed Patients #8, #10, #11, #17, and #18, or their representative, did not receive or sign the “Important Message from Medicare” form within two days of admission. Employee #74 confirmed the facility ’ s policy was not followed.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 50367 Based on record reviews and staff interviews, the Department determined the administrator failed to ensure hospital grievance policy regarding a patient care complaint was followed. This deficient practice poses a risk to the health and safety of patients if patient care complaints are not investigated and identifying potential breakdown in care could lead to continued poor quality of care and potential injury or harm to patients. Findings Include: Policy titled, “Grievances and Complaint Management,” revealed: “...1. Grievance Process and Decision a. The Point of Contact shall provide a response to a Grievance in writing within seven (7) calendar days of the complaint. If the investigation will not be completed, or if the Grievance will not be resolved, within seven (7) calendar days, the organization shall inform the patient or visitor that the organization needs additional time to resolve the Grievance and indicate the timeframe in which the response will be provided. b. Reasonable efforts shall be made to resolve all Grievances within thirty (30) calendar days and in accordance with regulatory requirements. If the matter cannot be resolved within thirty (30) calendar days, then a written status report shall be provided to the patient or visitor within that time frame. This status report shall include the estimated timeframe for completing the investigation and issuing a written report....” A review of hospital documents revealed that Patient #53 submitted the complaint to the healthcare institution on 01/05/2026. Further review of hospital documents revealed that the final decision letter was sent on 01/20/2026. Final review of the hospital document failed to reveal documentation that the seven (7) day extension letter was sent to Patient #53 on 01/11/2026 A review of hospital documents revealed that the Patient #55 submitted the complaint to the healthcare institution on 10/31/2025. Further review of hospital documents revealed that the final decision letter was sent on 11/19/2025. Final review of the hospital document failed to reveal documentation that the seven (7) day extension letter was sent to Patient #55 on 11/08/2025. A review of hospital documents revealed that Patient #54 submitted the complaint to the healthcare institution on 01/13/2026. Further review of hospital documents revealed that the seven (7) day extension letter was sent on 01/14/2026. Final review of hospital documents failed to reveal documentation that a written response to Patient #54 was provided to the complainant within thirty (30) calendar days. Employee #1 confirmed during an interview conducted on 06/10/2026, that the seven (7) day extension response letter is sent to the complainant within seven (7) days of receipt of the complaint. Employee #1 also confirmed during the interview that if the grievance is still not resolved a thirty (30) calendar day response letter will be sent out to the complainant. Employee #1 confirmed during an interview conducted on 06/10/2026, that the facility did not send the seven (7) day extension response letter for Patient #53 and Patient #55. Employee #1 confirmed during an interview conducted on 06/10/2026, that the facility did not send the thirty (30) calendar day response letter for Patient #54.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure a patient (Patient #18) in restraints were assessed and monitored every two hours per facility ’ s policy. This deficient practice poses the risk of patients in restraints not being monitored, and restraints causing poor circulation, muscle atrophy, and pressure injuries, and delay in determination if restraints are still needed. Findings include: Hospital policy titled, “Restraints and Seclusion,” revealed: “ ...II. Purpose ...To ensure that patients are free from unnecessary restraint and/or seclusion and to establish guidelines for the safe and appropriate use of restraints and seclusion in accordance with state and federal regulations ....V. Procedure ...1. The use of restraint/seclusion is based on the assessed individualized needs of the patient. The determination of the necessary frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient ’ s condition, cognitive status, risks associated with the use of the chosen intervention, and other relevant factors ....7. Assessment and Reassessment of the patient in Restraint/Seclusion: a. The condition of the patient must be continually assessed, monitored and evaluated ....c. Intermittent Reassessment: Staff will monitor/evaluate and (as appropriate) document the following: Patient specific behavior(s) requiring the restraint i.e., justification for restraint use ...Safety checks: ...NA/Tech Safety checks include: ...Checking appropriate restraint application ...Their physical wellbeing: including elimination needs, repositioning, oral intake, and oral care ...Checking that the restraint is not too tight and that 1-2 fingers can be inserted between the restraint and the patient ’ s skin ...Observe restrained limbs for: skin color- note abrasions or discoloration; coolness to touch; swelling ...Any patient reports of numbness or tingling ...RN Safety checks include: 1. patient response to restraint ...2. checking appropriate restraint application ...3. their physical wellbeing – including elimination needs, repositioning, oral intake, skin integrity, and oral care ...4. Circulation, sensation and movement ...should be assessed for limb/body restraints ....RN assessment/re-assessment includes: 1. Restraint justification ...2. Alternatives tried ...3. Restraint type and location ...4. Safety checks including circulation, sensation and movement ...for limb/body restraints ....5. Patient/family education ...d. Frequency of assessment: Non-Violent Restraint monitoring: patients will be re-assessed at least every two hours by the RN, or more frequently if necessary. Safety checks may be conducted more frequently, at intervals determined by the RN ’ s assessment; safety checks can be conducted and documented by the RN, Tech, or NA ....12. Documentation: a. Each episode of restraint/seclusion, must contain the following documentation in the patient ’ s medical record: ...5. The evaluation, monitoring, care provided, and reevaluation, of the patient along with any significant changes in the patient ’ s condition ....b. Documentation requirements for Non-violent Restraint ...When restraint ...is used for non-violent, non-self-destructive behavior, there must be documentation in the patient ’ s medical record at least every two hours of the following: A description of the patient ’ s behavior and the intervention used; Alternatives or other less restrictive interventions attempted (as applicable); The patient ’ s condition or symptom(s) that warranted the use of restraint; and The patient ’ s response to the intervention(s) used, including the rationale for continued use of the intervention ....” Patient #18 ’ s medical record revealed they had a medical history of dementia. Patient #18 ’ s medical record dated 03/31/2026 revealed they were in bilateral wrist non-violent restraints initiated at 0820 for agitation and pulling on medical equipment. Patient #18 ’ s medical record revealed they were discharged home on 04/02/2026 at 1200 with last documentation to continue the restraints on 04/02/2026 between 0600-0659, and no documentation of when the restraints were discontinued. Further review of Patient #18 ’ s medical record revealed no documentation of restraint safety checks and reassessment, patient ’ s behavior, restraint justification, restraint alternatives tried, and the patient ’ s response to the restraints on 04/01/2026 from 0900 to 1559, 04/01/2026 from 1700 to 1959, and 04/02/2026 from 0700 to discharge at 1200. Employee #39 confirmed during an interview conducted on 06/10/2026 that patients in non-violent restraints are reassessed for justification of continuing restraints, and safety checks are performed every two hours. Employee #39 confirmed restraint safety checks include checking for the patient ’ s circulation and range of motion. Employee #39 confirmed Patient #18 was in non-violent restraints, and was not reassessed every two hours. Employee #39 confirmed the facility ’ s restraint policy was not followed.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure two patients (Patients #13, #14) psychosocial history was obtained at admission. This deficient practice poses a risk of the facility not knowing the patient ’ s living situation, financial stability, and safety barriers to facilitate safe discharge planning. Findings include: Hospital policy titled, “Core Nursing Standards of Practice,” revealed: “ ...II. Standards of Care ...Standard 1: Nursing Process ...1. Assessment – The registered nurse performs and/or oversees the collection of pertinent data and information relative to the patient ’ s health or the situation. Data will be obtained by interview, observation, physical exam, and review of the patient record ....d. Admission history should be completed within 24 hours; updates should be documented PRN when new/additional data is obtained. The admission history includes the following information: ...7. Psycho-social history ...Standard 2: Documentation Expectations ...1. Documentation is considered a communication tool. As such, nursing documentation should reflect the nursing assessment process, admission data, patient and family education, discharge planning, plan of care ...As a communication tool, documentation should inform the care team succinctly of the patient ’ s status. a, Document in chronological order: Pertinent, factual, objective data ...Selected subjective data that validates or clarifies ...Additional plans needing to be implemented ...2. Documentation should be entered into the electronic health record (EHR) or paper chart using the fields provided. a The following activities are documented: ...History ...Assessment ....” Review of the facility ’ s electronic health record (EHR) system revealed psychosocial history for new admissions include 10 questions, as listed below: 1. What is your living situation today? 2. Within the past 12 months, you worried that your food would run out before you got money to buy more 3. Within the past 12 months, the food you bought just didn ’ t last and you didn ’ t have money to get more 4. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? 5. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? 6. (A response of YES will trigger an automatic consult to social services) Would you like someone to speak to you regarding these needs? 7. How often does anyone, including family and friends, physically hurt you? 8. How often does anyone, including family and friends, insult or talk down to you? 9. How often does anyone, including family and friends threaten you with harm? 10. Observable signs/symptoms of abuse, neglect, or violence Review of Patients #13 and #14 medical records revealed they were admitted to inpatient. Further review of Patients #13 and #14 medical records revealed psychosocial history was not obtained as part of the admission history. Employee #39 confirmed during an interview conducted on 06/10/2026 that psychosocial history should be obtained at admission. Employee #39 confirmed if a patient is unable to respond or answer the questions, then that should be documented. Employee #39 confirmed the psychosocial history is important because it is essential for discharge planning and ensures patient is discharged to a safe environment, and patient ’ s answers can prompt case management involvement. Employee #39 confirmed the psychosocial history was not completed for Patients #13 and #14. Employee #39 confirmed the facility ’ s policy was not followed.”

“PROTECTING PATIENT RECORDS CFR(s): 482.24(b)(3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This Standard is not met as evidenced by: 50367 Based on a review of hospital record and staff interview the Department determined that the administrator failed to ensure medical records were kept secured and confidential. This deficient practice may result in various detrimental outcomes, including data prevention and fraud prevention. Findings Include: Policy titled, “Rights and Responsibilities of Patients,” revealed: “...Policy ...Rights of Patients - Each patient is entitled to the following rights: ...11. Right to privacy and confidentiality of all records pertaining to treatment, except as otherwise provided by law or third party payment contract. ....” Observation conducted on 06/09/2026 revealed patient medical record files in an unlocked filing cabinet inside of the massage therapy room of the rehabilitation center. Employee #2 confirmed during an interview conducted on 06/09/2026, that patient medical records must be kept secured from unauthorized personnel. Employee #35 confirmed during an interview conducted on 06/09/2026, that patients are left alone in the massage room for privacy to change into a gown. Employee #35 confirmed during an interview conducted on 06/09/2026, that the file cabinet that is in the massage room is not kept locked. Employee #35 also confirmed during the interview that there were patient medical records in the file cabinet.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure discontinuation of restraint was documented in a patient (Patient #18 ’ s) medical record. This deficient practice poses the risk of unclear documentation of restraint episode timeframe and time limited orders for restraint use was not followed, and patient ’ s rights not respected to release restraints at the earliest time possible to minimize circulatory and respiratory complications. Findings include: Hospital policy titled, “Restraints and Seclusion,” revealed: “ ...I. Policy ...All patients have the right to be free from physical or mental abuse ...have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time ....10. Termination of Restraint/Seclusion: a. Restraint/seclusion will be terminated at the earliest possible time regardless of the length of time in the order. The restraint or seclusion must be discontinued by an RN when alternative measures are effective and the behavior leading to restraint use ceases ....c. Non-Violent restraints will be terminated when the individual is able to: Safely engage in necessary medical treatment ...Follow directions ...Demonstrate compliance with safety instructions ...12. Documentation: a. Each episode of restraint/seclusion, must contain the following documentation in the patient ’ s medical record: ...9. Time restraint discontinued (Note: if patient is transferred in restraints document this in comments under restraint activity) ...The patient ’ s care plan must contain the following documentation: ...3. Discontinuation of the restraint ....” Patient #18 ’ s medical record revealed they had a medical history of dementia. Patient #18 ’ s medical record dated 03/31/2026 revealed they were in bilateral wrist non-violent restraints initiated at 0820 for agitation and pulling on medical equipment. Patient #18 ’ s medical record revealed they were discharged home on 04/02/2026 at 1200 with last documentation to continue the restraints on 04/02/2026 between 0600-0659. Further review of Patient #18 ’ s medical record revealed no documentation of when the restraints were discontinued. Employee #39 confirmed during an interview conducted on 06/10/2026 that Patient #18 was discharged home. Employee #39 confirmed the facility ’ s electronic health record system allows the nursing staff to document when restraint is initiated, continued, and discontinued in the restraint flowsheet. Employee #39 confirmed there was no documentation of the time Patient #18 ’ s restraints were discontinued.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 45706 Based on policy and procedure, observation, and staff interview it was determined the hospital (Yavapai Regional East) failed to ensure: 1. food items were marked with open/discard dates; 2. food items were discarded after expiration dates; and 3. employee personal food items were not stored in the kitchen area. The cumulative effect of these deficient practices poses a risk of harm to patients and other individuals who may consume food that was stored and prepared in the facility kitchen that does not follow guidelines set forth in dietary guidelines. Findings include: Policy titled, “ ...Food and Nutrition Services (FNS): Food Handling” revealed: “Food must be store according to food safety guidelines and regulatory standards. General food storage guidelines are followed for all stored foods including refrigerated, frozen, and dry storage goods ...follow expiration date and food storage guidelines ...foods removed from the original box must be covered, labeled and dated at all times ...food stored refrigerated will be kept no longer than the expiration date ...non perishable items such as cereal, honey, cake, pancake mixes, rice, pasta, flour, dehydrated potato, and sugar follow expiration dates ....” Observation of the kitchen on 06/08/2026 revealed the following food items with no discard date and expired food items: · (1) bag light brown sugar no open date · sausage patties re packaged in plastic bag, no discard date · 3+ packages of tofu · White gravy packaged individual plastic containers, use by date 04/30/2026 · Crumbled pizza sausage in gallon size bag with no open dates · Rolling bin marked “white rice” with open date 11/16/2025 expires 02/16/2026 · Rolling bin marked “granulated white sugar” open date 02/14/2026 expires 08/14/2026 · Rolling bin marked “brown rice” opened 11/07/2025 expires 05/07/2025 Further observation revealed a plastic 24 count plastic egg container labeled “Kennys” in the kitchen area stored on a shelf. Employee #75 confirmed on 06/08/2026 the above-mentioned items were either expired or did not contain an open/discard date on the package. Further interview confirmed the eggs belonged to an employee that owns chickens.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 45706 Based on policy and procedure, observation, and staff interview, it was determined the hospital failed to ensure (1) carbon dioxide cylinder with compressed gas was stored in a secure manner. This deficient practice poses a risk to patient, staff, and visitor safety as unanchored cylinders can rupture and become high-pressure projectiles. Findings include: Policy titled, “Chemical Hazard” revealed: “ ...Bulk flammable liquids will be received by the Material Management Department, and they are responsible for the handling and storage of the product until they leave their area. Once delivered to the requisitioning department, that department assumes responsibility for the product. E. Compressed Gas Cylinders will be received, stored and controlled by the Material Management Department until delivered to a specific department. The requisitioning department accepts responsibility for handling, securing and storage upon delivery ....” Observation on 06/08/206 revealed (1) unsecure carbon dioxide gas cylinder stored on the dry storage room. Employee #75 confirmed on 06/08/2026 the cylinder was not stored in a secure manner.”

“DISPOSAL OF TRASH CFR(s): 482.41(b)(6) (4) The hospital must have procedures for the proper routine storage and prompt disposal of trash. This Standard is not met as evidenced by: 48110 Based on record reviews, observation, and staff interviews, it was determined the hospital failed to ensure the biohazardous waste was stored in a secured area. This deficient practice poses the potential risk of patients, visitors, and unauthorized personnel being exposed to infectious or contaminated supplies and materials. Findings include: Arizona Administrative Code R18-13-1408.B. requires: “ ...Once biohazardous medical waste has been packaged for shipment off site, a generator shall provide a storage area for biohazardous medical waste until the waste is collected and shall comply with both of the following requirements: 1. Secure the storage area in a manner that restricts access to, or contact with the biohazardous medical waste to authorized persons....” The policy for biohazard waste storage and disposal was requested. The policy titled, “Chemical Hazard Communication,” was presented. Hospital policy titled, “Chemical Hazard Communication,” revealed: “ ...II. Policy ...Hazardous materials, or chemicals on Yavapai Regional Medical Center campuses will be handled in compliance with local, state and federal laws and in a manner that ensures a safe environment for all employees, visitors, and patients ....” Hospital policy titled, “Infection Control – Inpatient/Outpatient Areas,” revealed: “ ...I. Policy ...A. It is the policy of the Organization to establish a mechanism for the prevention of infections and transmission of infectious agents to patients and/or employees. The department manager and his/her designee ...will be responsible for administering the Infection Prevention activities of the department ....” Observation made on tour of facility on 06/08/2026 revealed packaged biohazardous waste stored in an area enclosed by fences outside the facility building. The area had a closed gate, with an unlocked padlock hanging on the gate. Employee #25 confirmed during an interview conducted on 06/08/2026 that biohazardous waste is picked up by a contracted service once a week, and they come to the facility a few times a week to replace sharp containers. Employee #25 confirmed the biohazardous waste storage area was not locked on tour. Employee #46 and Employee #48 confirmed on 06/10/2026 that biohazardous storage area should be locked and secured. Employee #46 and Employee #48 confirmed employees and vendors should be entering the facility through designated entrances, and not walk through the biohazardous waste storage area. Employee #48 confirmed the facility ’ s engineering department was removing items from the biohazardous waste storage area, and left the gate unlocked.”

“REGULAR FIRE AND SAFETY INSPECTIONS CFR(s): 482.41(b)(8) (6) The hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. This Standard is not met as evidenced by: 45706 Based on policy and procedure, document review, and staff interview the hospital failed to ensure (7) single group licensed facilities and the hospital maintained documentation of a current fire inspection report. This deficient practice poses a risk to patient, staff, and visitor safety if mechanical issues are not identified and corrected according to current standards of practice. Findings include: Policy titled, “Dignity Health Quality Improvement Plan” revealed: “ ...ENVIRONMENT OF CARE (EOC) / SAFETY COMMITTEE: The EOC/Safety Committee develops, implements, and monitors plans/activities to create and manage the organization’s environment of care to ensure a safe, functional, supportive, and effective environment for patients, staff, and other individuals in the medical center related to the following: Safety Management ...Security Management ...Hazardous Materials and Waste Management ...Emergency Management / Disaster Planning ...Fire Safety ....” Request was made to review the current fire marshal reports for the following single group license facilities and hosptial main campus on 06/09/2026: Yavapai Regional Medical Center Dignity Health Yavapai Regional Medical Center Rehabilitation Services Harold James Center for Rehabilitation Services Dignity Health Yavapai Regional Medical Center Cardiac Diagnostics Dignity Health Yavapai Regional Medical Center Cardiac Rehabilitation Dignity Health Yavapai Regional Medical Center Pre-Operation Testing Dignity Health Yavapai Regional Medical Center Respiratory, Suite 1100c Prescott Medical Imaging None was provided. Employee #27 confirmed on 06/09/2026 the above-mentioned single group licensed outpatient treatment centers and the main hosptial campus did not have a current fire inspection report.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 50367 Based on a review of hospital record and staff interview the Department determined that the administrator failed to ensure a post-anesthesia evaluation was completed and documented following the administration of anesthesia. This deficient practice may result in various detrimental outcomes, including the inability to assess the patient ’ s recovery from anesthesia, identify complications and ensure that the patient has returned to an appropriate level of consciousness and physiologic stability prior to discharge or transfer. Findings Include: Policy titled, “Anesthesia Care Policy,” revealed: “...Postoperative Anesthesia Evaluation 1. The post-anesthesia evaluation is completed and documented by any practitioner qualified to administer anesthesia; it need not be performed by the same practitioner who delivered the anesthesia. 2. The evaluation should begin in the PAC/IC and be completed within 48 hours. Anesthesia may utilize a telephone evaluation on patients that leave the facility prior to an examination. 3. The evaluation should be performed when the patient is sufficiently recovered from the acute administration of anesthesia and is able to participate in the evaluation. 4. For patients unable to participate in the post-anesthesia evaluation (e.g., ventilated, unconscious, mentally impaired patients) the evaluation is completed and the documentation notes that the patient was unable to participate. 5. Elements of the post-anesthesia evaluation include: a. Respiratory function, including rate, airway patency, 02 saturation b. Cardiovascular function, including pulse rate and BP c. Mental status d. Temperature e. Pain f. Nausea and vomiting g. Postoperative hydration....” Patient #3’s medical record failed to contain post anesthesia evaluation documentation in the electronic medical record. Employee #39 confirmed during an interview conducted on 06/09/2026, every patient should have a post anesthesia evaluation documented in the medical record, Employee #39 and Employee #21 confirmed during an interview conducted on 06/09/2026, that Patient #3 ’ s medical record did not contain a post anesthesia evaluation.”

“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: 45618 Based on document review and staff interviews, it was determined that the hospital failed to provide an appropriate Medical Screening Examination (MSE) to four (4) out of twenty-one (20) patients (Patients #1, 2, 9, and 10) who presented to the ED for examination and treatment. Findings include: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” revealed: “ ...Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will provided to all individuals presenting at Dignity Health Dedicated Emergency Departments (DED) requesting examination or treatment of a medical condition, and to individuals presenting on hospital property (including parking lots, sidewalks and driveways on all Dignity Health campuses) within 250 yards of the hospital requesting examination or treatment of an Emergency Medical Condition, and if one exists, either to stabilize the emergency condition or to Transfer the individual appropriately and in conformity with the legal and regulatory requirement, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation or ability to pay...All individuals who come to a DED of the hospital (whether on campus or off-campus) for examination or treatment of an Emergency Medical Condition shall receive an appropriate Medical Screening Examination. The hospital shall not delay in providing a Medical Screening Examination or necessary stabilizing treatment in order to inquire about an individual’s ability to pay or to inquire about eligibility for financial assistance under the hospital’s Financial Assistance Policy ....” A review of Patient #1’s medical record contained a note titled “Triage Note,” which revealed: “ ....Performed on: 06/28/2024 14:32...Pt arrived via pov with boyfriend. Cc abdominal pain 8/10. Took Advil and Zofran at 0600am. Denies fevers and diarrhea. Furthermore, fatigue x2days. Hx: IBS...Tracking Acuity: 3 ....” Patient #1’s medical record revealed a note titled “Clinical Discharge Summary,” which revealed: “...Arrival 06/28/2024 14:27...Check Out Time 06/28/2024 15:30....” Patient #1’s medical record revealed a note titled “ED Abnormal Results Call to Pt,” dated 07/01/2024, which revealed: “...Called to speak to pt about positive urine culture. Pt had left AMA so adviced {sic} pt to f/u with [her] PCP for treatment of [her] UTI. Pt was angry and states that [she] waited hours in the waiting room....” Nineteen additional ED medical records were randomly selected for review, which included patients who were transferred, admitted, as well as six who left before Medical Screening Examinations. The review revealed the following patients who left before an MSE was completed: - Patient #1- arrived 06/28/2024 at 14:27, triaged 14:32, ESI 3, chief complaint 8 out of 10 abdominal pain, left before MSE at 15:30; called 07/01/2024 for a positive urine culture from ED visit (63 minutes elapsed time between registration and leaving) - Patient #2 (5 years old)- arrived 07/07/2024 at 15:28, triaged 15:35, ESI 4, chief complaint foot pain, left before MSE at 19:30. X-ray image of foot taken at 16:23 and read at 18:47 revealed: “...there is a comminuted fracture through the right metatarsal extending from the proximal growth plate through to the distal head. Fracture fragments are mildly displaced....” The ED provider spoke with mom via telephone at 19:34 regarding results of the xray and urged follow up care the following day. (4 hours, 2 minutes elapsed time between registration and leaving) - Patient #9- arrived 06/17/24 at 11:22, triaged 11:27, ESI 2, chief complaint shortness of breath and light headed, left before MSE at 14:55; Chest X-ray at 12:25 revealed a right-sided transvenous defibrillator device, and no acute cardiopulmonary findings. Refusal of MSE for signed at 14:55 with no further documentation by ED staff after 11:29. (3 hours 28 minutes elapsed time between registration and leaving) - Patient #10- arrived 08/01/2024, at 15:58, triaged at 16:04, ESI 3, chief complaint relapsed on meth and feeling very anxious. Provider note at 18:46 revealed: “...The patient eloped after triage but prior to evaluation....” (2 hours, 48 minutes time elapsed between registration and leaving) Employee #1 and #3 confirmed in an intervew on 09/09/2024, that Patients #1, 2, 9, and 10 left before receiving a medical screening exam.”

“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: 45618 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for four (4) out of twenty (20) patients (Patients #1, 2, 9, and 10) 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: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” revealed: “...Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at Dignity Health Dedicated Emergency Departments (DED) requesting examination or treatment of a medical condition, and to individuals presenting on hospital property (including parking lots, sidewalks and driveways on all Dignity Health campuses) within 250 yards of the hospital requesting examination or treatment of an Emergency Medical Condition, and if one exists, either to stabilize the emergency condition or to Transfer the individual appropriately and in conformity with the legal and regulatory requirement, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation or ability to pay...All individuals who come to a DED of the hospital (whether on campus or off-campus) for examination or treatment of an Emergency Medical Condition shall receive an appropriate Medical Screening Examination. The hospital shall not delay in providing a Medical Screening Examination or necessary stabilizing treatment in order to inquire about an individual’s ability to pay or to inquire about eligibility for financial assistance under the hospital ’ s Financial Assistance Policy...Once the Medical Screening Examination is completed and there is a determination that the individual does not have an Emergency Medical Condition or the Emergency Medical Condition has been stabilized, the individual may be (i) treated; (ii) discharged as clinically appropriate and the individual is given a reasonable plan for appropriate follow-up care and/or discharge instructions; or (iii) transferred for continued care in accordance with appropriate Transfer procedures....” A review of 20 ED records randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Four patients were found to have a delay in treatment due to failure to receive an MSE: · Patient #1- arrived 06/28/2024 at 14:27, triaged 14:32, ESI 3, chief complaint 8 out of 10 abdominal pain, left before MSE at 15:30; called 07/01/2024 for a positive urine culture from ED visit (63 minutes elapsed time between registration and leaving) · Patient #2 (5 years old)- arrived 07/07/2024 at 15:28, triaged 15:35, ESI 4, chief complaint foot pain, left before MSE at 19:30. X-ray image of foot taken at 16:23 and read at 18:47 revealed: “...there is a comminuted fracture through the right metatarsal extending from the proximal growth plate through to the distal head. Fracture fragments are mildly displaced....” The ED provider spoke with mom via telephone at 19:34 regarding results of the xray and urged follow up care the following day. (4 hours, 2 minutes elapsed time between registration and leaving) · Patient #9- arrived 06/17/24 at 11:22, triaged 11:27, ESI 2, chief complaint shortness of breath and light headed, left before MSE at 14:55; Chest X-ray at 12:25 revealed a right-sided transvenous defibrillator device, and no acute cardiopulmonary findings. Refusal of MSE for signed at 14:55 with no further documentation by ED staff after 11:29. (3 hours 28 minutes elapsed time between registration and leaving) · Patient #10- arrived 08/01/2024, at 15:58, triaged at 16:04, ESI 3, chief complaint relapsed on meth and feeling very anxious. Provider note at 18:46 revealed: “...The patient eloped after triage but prior to evaluation....” (2 hours, 48 minutes time elapsed between registration and leaving) Employees #1 and #3 confirmed in an interview on 09/09/2024, the Patients #1, 2, 9, and 10, did not get treatment for the symptoms that brought them to the ED because they did not receive an MSE.”