Copper Springs East- Gilbert

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49638 Based on review of Hospital policy, observation during on-site tour, medical record review and staff interviews, it was determined that the Hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: Cross reference A-0144: Failure to ensure a patient receives care in a safe setting. Specifically, the presence within patient care areas of ligature points, water damage/rust, unrepaired holes in drywall, and loose wood paneling. Cross reference A-0168: Failure to ensure a provider order was documented for a patient restraint. The cumulative effect of these systemic deficient practices resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for Patient Rights.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 49638 Based on review of Hospital policy, Hospital documents, medical record review and staff interviews, it was determined that the Hospital failed to comply with requirements involved with developing, implementing and maintaining an effective and data-driven quality assessment and performance improvement program. Cross reference A-0286: Failure to implement Hospital policies and procedures related to quarterly data analysis for episodes of Medication adverse events. Cross reference A-0297: Failure to ensure quality performance improvement project documentation included measurable progress achieved. The cumulative effect of these systemic deficient practices resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for QAPI.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 49638 Based on review of Hospital policy, Hospital documents, video review, medical record review and staff interviews, it was determined that the Hospital failed to comply with requirements involved with the provision of nursing services. Cross-reference A-0395: Failure to assure that patients were properly identified prior to medication administration. Specifically, an immediate jeopardy situation was identified including a patient receiving medication prescribed for another patient and suffering respiratory and cardiac arrest, ultimately leading to patient death. Cross-reference A-0405: Failure to provide medication to patients as ordered by a provider. Specifically, an immediate jeopardy situation was identified including a patient receiving medication prescribed for another patient and suffering respiratory and cardiac arrest, ultimately leading to patient death. The cumulative and egregious nature of these deficient practices resulted in death to a patient and therefore the Hospital’s failure to meet the requirement for the Condition of Participation for Nursing Services.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 49638 Based on review of Hospital policy, medical record review and staff interviews, it was determined that the Hospital failed to ensure patient medical records contained complete documentation of patient condition. Cross-reference A-0431: Failure to ensure medical record documentation reflected implementation of patient precautions and close observations to protect the health and safety of patient. Specifically, an immediate jeopardy was identified including a patient self-asphyxiated using leggings, following a gap in close observation. The patient was determined a suicide risk and was on Q 15-minute observations. The last documented observation was at 0615. The patient was transferred to a higher level of care and was declared dead 3 days later. The egregious nature of this deficient practice resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for Medical Record Services.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 49638 Based on review of Hospital policy, Hospital documents, video review, medical record review and staff interviews, it was determined that the Hospital failed to ensure the presence of pharmaceutical services that meet the needs of its patients. Cross-reference A-0500: Failure to medication to patients as ordered by a provider. Specifically, an immediate jeopardy situation was identified including a patient receiving medication prescribed for another patient and suffering respiratory and cardiac arrest, ultimately leading to patient death. The egregious nature of this deficient practice resulted in death to a patient and therefore the Hospital’s failure to meet the requirement for the Condition of Participation for Pharmaceutical Services.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49638 Based on hospital policy and procedure review, hospital tour observations, and employee interview, it was determined that the hospital failed to ensure that the premises is to be free from any unsafe conditions or situations. This deficient practice poses a risk to the health and safety of the patients, including death. Findings include: A review of hospital policy titled “Patient Safety Plan,” policy #16957213, effective 10/2024, revealed “ ...The organizational Patient Safety Plan of the Hospital is to improve patient safety and reduce risk to patients through an environment that encourages ...Recognition and acknowledgment of risks to patient safety ...The program addresses maintenance and improvement in patient safety issues in ...Management of the Environment of Care ...The patient Safety Program includes ...quarterly written environmental rounds ....” A review of hospital policy titled “Facility Risk Assessment,” policy #17332657, effective 03/2025, revealed “ ...Definitions ...Ligature Risk ...may include anything which could be used to create a sustainable attachment point such as a cord, rope, or other material for the purpose of hanging or strangulation ...Policy ...The Facility will conduct a full risk assessment annually or whenever there is a change in the environment and will review the progress of the assessment and action plans related to the assessment at least quarterly at the facility safety committee ....” Observation while on tour of the hospital premises, conducted on October 7, 2025, revealed the following: Maple Unit: Bedroom 701: Bathroom door frame near floor had water damage/rust. Bedroom 702: Two unrepaired holes in bedroom walls. Wood paneling loose and able to pull from bedroom wall. Outlet cover was not flush to bedroom wall. Bathroom light fixture above sink was not flush to bathroom wall. Bathroom sink faucet was not flush to sink. Bedroom 707: Outlet cover was not flush to bedroom wall. Door paneling was splintering from top of bedroom door. Bedroom 718: Bathroom light fixture above sink was not flush to bathroom wall. Laurel Unit: Hallway Two unrepaired holes in hallway wall. Bedroom 801: Shower knob was not flush to shower wall. Bedroom 802: Bathroom door frame near floor and wall had water damage. Two grab bars were not flush to the bathroom walls. Bedroom 807: Yellowish substance on bedroom wall. Bathroom light fixture above sink was not flush to bathroom wall. Screw was missing from bathroom toilet metal panel. Bedroom 815: Outlet cover was not flush to bedroom wall. One unrepaired hole in hallway wall. Bedroom 816: Bathroom light fixture above sink was not flush to bathroom wall. Bedroom 817: One unrepaired hole in bedroom wall. Seclusion Room: Ante-room had a hole in the wall, and paint peeling off the wall. Seclusion room had a gap at the base of the padlocked restraint bed. Bathroom grab bar was not flush to the bathroom walls. An interview with employee #3, conducted on October 7, 2025, confirmed that ligature risks are present throughout the bedrooms, and bathrooms in the Maple, and Laurel units.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 49638 Based on Hospital policy and procedure, medical records and employee interview, it was determined the Hospital failed to ensure a staff physician order was documented, pursuant to Hospital policy. This deficient practice poses a potential risk of harm to a patient when a restraint is not ordered and overseen by a physician to ensure appropriate application and patient safety. Findings include: Hospital policy titled “Seclusion and Restraint,” Policy #18392662, Last Reviewed 06/2025, revealed “ ...RN/Designee ...Contacts the patient ’ s Treating Physician prior to, or immediately after, not to exceed 30 minutes to obtain verbal/telephone order for use of seclusion/restraint. Any emergency use of seclusion/restraints shall not exceed 30 minutes in duration without obtaining the verbal order of a staff Practitioners/Providers/Physicians ...Practioners/Providers/Physicians ...A. Provides verbal and written order for the employment of seclusion/restraint. The order is documented on the Seclusion/Restraint ...1. Order/Progress Note form ...C. Authenticates T/O order in the medical record within 48 hours ....” Medical record for Patient #2 revealed the following: Document titled “7:00PM-7:00AM Shift Nursing Assessment,” dated 9/28/25, revealed “ ...patient was put on a physical restraint for 5-10 seconds, then released ....” Document titled “Seclusion & Restraint Initiation of Intervention/Order,” dated “9/28,” revealed “ ...For initiation of physical restraint: ...Restraint start time: 2029hrs ...Restraint end time: 2029 hrs ....” Area of form for telephone order appeared blank, without information including physician name, RN name who verified/read back order, date and time, physician authentication, physician printed name, date and time. Employee #16 confirmed, during interview conducted on October 10, 2025, that the document titled “Seclusion & Restraint Initiation of Intervention/Order,” dated “9/28,” did not contain physician name, RN name who verified/read back order, date and time, physician authentication, physician printed name, date and time.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 52829 Based on review of policies and procedures, documents, medical records, and interview, it was determined the facility failed to implement their quality management program by ensuring that the hospital followed their policies and procedures related to quarterly data analysis for episodes of Medication adverse event. This deficient practice poses a potential risk to the health and safety of patients when potential system or individual performance problems may not be addressed. Findings include: Policy titled “ Performance Improvement Plan Policy #18866983 Last reviewed 9/2024” revealed: “...Prevention Performance Improvement Plan (PIP) is to promote safe and effective medication use through the reduction of preventable medication-related errors and adverse events ... Medication Error: A preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional ... Sentinel Event A patient safety event ... that reaches the patient and results in death ... Collect and analyze data to identify areas needing improvement and implement appropriate strategies for medication error reduction ... Utilize the data to identify additional opportunities to improve the medication use processes ... Reduce the risk of errors with high-alert medications ... Establish a consistent process for a cognitive, independent double check for defined high alert/high-risk medications and high-risk patient populations ... Ensure continuous compliance with medication management safety strategies recognized by professional and accreditation standards ....” “ ... The Medication Safety Team/Committee ... This committee is responsible for the Performance Improvement Plan’s implementation, monitoring, revisions, and improvements; and is responsible for reporting progress at least quarterly to the Pharmacy and Therapeutics Committee ... Evaluate improvement strategies ... Review the effectiveness of the existing plan and make adjustments ....” “ ... Annual Review ... The Medication Error Reduction and Prevention Performance Improvement Plan (PIP) is reviewed annually and modified as needed to focus efforts to reduce medication-related events ....” Hospital document titled “Annual Review and Approval of Quality Program” Dated January 9, 2025 revealed “ ... High Level Analysis of Hospitals QAPI Program: The top three priorities for 2024 ... A PI project was initiated in July to increase the number of pharmacological reassessments ... accurate documentation post incident events ... Decrease in the number of medication va1iance and an increase in medication scanning rate ....” Hospital document titled “Copper Springs East Quality Sub-Committee Minutes of August 28, 2025 [JULY DATA]” revealed, “ ... B. Continuous nursing audit on close observations, CIWA/COWS, Med administration and change in condition ... High Risk Processes ... A. No data ... Continue to monitor and report....” Hospital document titled “Copper Springs East Quality Sub-Committee Minutes of September 29, 2025 [AUGUST DATA” revealed, “ ... C. Continuous audit and monitoring of ongoing TJC and IJ findings ... Weekly Pl projects on ... Change in Condition Medication administration ... Monitor and report ....” Documentation demonstrating review and analysis of data collected for medication adverse events was requested on survey conducted 10/2/2025 through 10/14/2025, none provided for review. Employee #3 and Employee #5 confirmed on 10/10/2025 that they did not have data to present on medication adverse events that met their policy requirements.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 49638 Based on Hospital policy and procedure, Hospital documentation, and employee interview, it was determined the Hospital failed to ensure quality performance improvement project documentation included measurable progress achieved. This deficient practice poses the risk that project status will not be known and improvement goals will not be reached, adversely impacting patient care. Findings include: Hospital policy titled “Root Cause Analysis (RCA) and Sentinel Event,” Policy #17427474, Last Reviewed 01/2025, revealed “ ...Plan Implementation and Monitoring (Applies to RCA and Event Analysis) ...The identification and implementation of actions to eliminate or control vulnerabilities that have been identified in the causal factor statements is very important. In order to improve patient safety, corrective actions must be implemented and their effectiveness measured ....” Hospital document titled “Annual Review and Approval of Quality Program,” dated January 9, 2025, revealed performance improvement projects with the following progress documented: “ ...III. A PI Project was initiated to address BASIS032 return rates and outcome scores ...Massive improvements in our return rates were noted throughout Q3 and 4 ....” “ ...IV. A PI project was initiated in July to improve on new patient assessment and documentation ...An improvement was noted in the month of December ....” “ ...VI. A PI project was initiated in July to increase the number of pharmacological reassessments, completion of inpatient discharge form and accurate documentation post incident events ...A process was developed to ensure daily and monthly audit of patient’s record for 100% compliance ....” “ ...VII. We initiated a PI project in August to improve coordination of care and discharge planning ...Improvements were noted in Q4, and this continues to remain a focus....” Hospital document titled “Quality Sub-Committee ...Minutes of September 29, 2025 [August Data], revealed “ ...PI Project Updates ...Weekly PI projects on Provider Documentation ...Closed Observation ...CIWA/COWS ...Discharge Planning ...Treatment Plan ...MSE ...EMTALA ...Change in Condition ...Medication administration ....” No documentation of project updates was identified. Documentation demonstrating measurable progress toward completion of performance improvement projects was requested, none was provided. Employee #1 confirmed, during an interview conducted on October 3, 2025 through October 10, 2025, that measurable progress achieved toward Hospital performance improvement projects, including those projects noted within the “Annual Review and Approval of Quality Program,” dated January 9, 2025, and the Hospital document titled “Quality Sub-Committee ...Minutes of September 29, 2025 [August Data], was not present and available for review at the time of the survey.”

“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: 52829 Based on review of hospital policies/procedures, Hospital documents, video review, medical records review, and interviews, it was determined that the hospital failed to assure that patients were properly identified prior to medication administration evidenced by. 1. Failure to identify patients prior to administering a medication. 2. Failure to identify the right dose prior to administering a medication. 3. Failure to identify the right drug prior to administering a medication. This deficient practice led to a patient suffering respiratory and cardiac arrest, being transported to an emergency room, and ultimately the patient #1’s death. Findings include: Review of the hospital policy titled “Medication Administration Policy” #18426147 Last reviewed 9/2024 revealed: “ ... Medications are administered pursuant to a prescriber’s order; to the patient for whom they were ordered ... All medication administration is documented in the patient’s permanent medical record ... Policy ... Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient ... Medication Administration Procedure ... Prepared medications for one patient at a time ... Administer medications immediately after the medication is prepared without a break in the process OR appropriately label the medication ... Verifies the medication is administered in the correct dose and the dose does not reflect an unsafe dosage level ... Positively identify the patient before administering the medication. Check the patient’s identification with two hospital-approved identifiers (i.e., name band, date of birth, patient specific number, photograph) and ask the patient (when possible) to state his/her name. If barcode medication administration is utilized, the patient’s wristband is scanned for confirmation prior to proceeding ... Document the exact time the medication is administered ... Monitor the effects of the medication to ensure effective patient response ....” Review of the hospital policy titled “High-Alert Medications Policy #17741340 Last reviewed 09/2024 revealed “ ... Definitions, High-Alert Medications: Medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes ... Policy ... The hospital identifies and maintains a hospital-specific list of high-alert medications ... Risk-reduction strategies are developed and are layered throughout the medication-use process ... High-alert medication safety strategies are consistently implemented throughout the organization and apply to prescribers, pharmacists, nurses, and other practitioners ... Hospital-defined high-alert medications and safeguards for each medication are accessible to healthcare providers ... High-alert medication safeguards are established at various points throughout the medication use process (e.g., Selection and procurement, storage, ordering and transcribing, preparation and dispensing, administration, and monitoring) ....” Review of hospital document titled “High Alert Medication List” revealed, “ ... Methadone blind count required ....” Review of Hospital document titled “All device event reports” revealed, “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0505, quantity 10, patient name #8 ....” “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0509, quantity 7, patient name #7 ....” “ ... User Name Employee #24, Med Description Pantoprazole, transaction date and time 9/28/2025 0511, quantity 1, patient name #1 ....” “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0512, quantity 9, patient name #6 ....” Employee #3and #5 confirmed in interview conducted 10/10/2025 that removing medications for multiple patients during the same session is not per policy. Review of video surveillance on 10/7/2025 revealed, camera labeled “ ... Laurel Med Room” and time and date stamped: · 05:02:51 09/20/2025 Shows employee #24 enter the medication room and proceed to remove medication from the PIXIS machine. · 05:04:32 employee #24 places medications in blue cup and places on counter to the left of the machine · 05:05:16 employee #24 begins to remove medication for another patient · 05:06:05 employee places medications into a second unmarked, unlabeled, blue cup and places it on the counter to the left of the machine next to the previous cup · 05:06:17 employee #24 returns to the machine and begins pulling medication for another patient · 05:07:31 employee #24 places medications into a third unmarked, unlabeled blue cup and places on counter to the left and behind the working position, returns to the machine and begins pulling medication for another patient · 05:09:53 employee #24 places medications into a fourth unmarked, unlabeled blue cup and sits in next to the previous to the left and behind the working position · 05:10:15 employee #24 returns to the machine and begins pulling medication for another patient · 05:11:20 employee #24 picks up a stack of what appears to be hand written labeled blue cups and places medications in cup to the right of the machine and returns to the machine and begins pulling medications for another patient · 05:06:09 employee #24 picks up first cup with medication inside and exits the medication room Employee #3 verified the last medication removed by employee #24 is Methadone 10mg tablets, 9 tablets and placed in blue cup next to the previous cup. Employee #3 further verified that employee #24 removed medications for five separate patients during the time spent in the med room leaving four additional cups, two of which contain controlled medications and one verified with Methadone 10mg tablets 9 tablets, which is against policy and not an acceptable standard of practice. Continued review of video surveillance 10/7/2025 revealed a second nurse, employee #15, enter “Laurel Med Room” and time and date stamped: · 06:16:00 09/28/2025 shows employee #15 enter medication room and pick up two blue plastic cups containing medication and returns to the nurse ’ s station · 06:17:50 employee #15 scans medication at computer work station · 06:18:30 removes 9 tablets from blister packs and places tablets into clear medication cup Camera labeled “Laurel Hallway W” time stamp 06:20:08 employee #15 enters patient #1 ’ s room with medication cup · 06:20:50 employee #15 exits patients ’ room Employee #3 verified in interview conducted 10/10/2025 that the medication that employee #15 had scanned, removed from blister packs, and administered to patient #1 was 10mg Methadone tablets, quantity of 9. Employee #3 further verified that there was no order for 90mg of Methadone in Patient #1 chart. Continued review of video surveillance 10/7/2025 revealed, Camera labeled “Laurel Hallway W” 07:06:52 Staff seen entering patient #1 ’ s room 07:08:00 Staff exits patient #1 ’ s room 07:12:35 Patient #1 exits room 07:25:57 to 08:41:47 Patient #1 seen socializing in common area 08:41:17 Patient #1 enters own room 09:11:43 staff member enters Patients #1 ’ s room 09:12:36 staff exits Patient #1 ’ s room 09:29:27 staff enter Patients #1 ’ s room 09:34:41 additional staff member enters Patients #1 ’ s room 09:37:14 staff urgently exits Patient #1 ’ s room 09:37:53 staff enters Patient #1 ’ s room with vitals machine 09:39:30 numerous staff seen entering and exiting Patient #1 ’ s room 09:47:47 EMS (Emergency Medical Services) arrives to Patient #1 ’ s room 09:59:52 video ends prior to EMS exiting Patient #1 ’ s room Employee #3 verified in interview conducted 10/10/2025 that after the video ended the patient was transported to emergency room with EMS performing CPR. Patient #1 ’ s medical record revealed the following: Hospital document titled “Nursing Shift Progress Note” revealed hand written note by employee #15 “ ... date ... 9-28-25 ... time 0640 ... This RN gave medication to the wrong patient 90mg Methadone was given ... House supervisor and DR notified ....” Hospital document titled “Nursing Shift Progress Note” revealed Typed entry bu employee #17 “ ... Date 9/28/25 ... Time 0930 ... Writer received report at 0800 from night shift nurse ... Stated that patient received wrong medication, Methadone. Night shift nurse notified writer that ... notified provider ... interventions post med error not outlined during report ... Patient received awake, alert, and ambulatory ... 0930- Difficulty waking patient ... 0932 vitals 203/168/163, SpO2-23 ... Repeat vitals 116/71/129, SpO2 16 ... 0939- Code blue called ....” Hospital document titled “Inpatient Progress Note” by employee #46, dated 09/28/2025 12:04:45 revealed “ ... called by RN this morning ... 7:17am ... reported ... incorrectly gave 9mg of Methadone to patient ... states patient responded to his first name therefore date of birth was not verified by RN ... confirmed with RN 3 times as to specific dose given ... Advised close observation given incorrect administration ... relatively low dose was reportedly administered ... Observation was recommended as opposed to ED transfer ... Was called later in the morning by house supervisor at 10:02AM ... Patient found unresponsive and was in fact given 90mg not 9mg ... EMS was alerted and patient to be transported to emergency department ....” Hospital document titled “Medication Administration Record (MAR)” revealed” ... pantoprazole (Protonix) 40mg ... scheduled 6:30 ... Administered 6:40 ....” Employee #3 verified in interview conducted 10/10/2025 that patient #1 death, on 9/28/25 was attributed to numerous system failures, circumventing established policy and procedure, and safeguards that are in place to protect patient safety. Employee #3 also confirmed that the medication administered to patient #1 was not done in accordance with applicable standards of practice.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 52829 Based on hospital policies and procedures, medical record review, and staff interview, it was determined that the Hospital failed to administer drugs to patients as ordered by a provider as evidenced by: 1. Administering medications outside scheduled times. 2. Failure to identify the correct patient, right dose and right drug prior to administering a medication. These deficient practices led to a patient suffering respiratory and cardiac arrest, being transported to an emergency room, and ultimately the patient ’ s death. These deficient practices have the potential to cause greater patient harm if not corrected. Findings include: 1. Administering medications outside scheduled times. Review of the hospital policy #18426147 titled “Medication Administration” last reviewed 9/2024 revealed: “ ...Non-time Critical Scheduled Medication Dose Administration Times ...Medications prescribed for daily, weekly, or monthly administration are administered within 2 hours before or after the scheduled dosing time, for a total window that does not exceed 4 hours ...When medications eligible for a scheduled dosing time are not administered within the defined time period ...Document the reason the dose was missed or delayed ...Reschedule missed or delayed doses, as appropriate ....” Patient #14 ’ s medical record revealed the following: Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED ...diazepam Oral 5 mg TAB 1 ea ...5 mg ...PO ...TID ...Start: 06/12/25 09:02 ...gabapentin Oral 300 mg CAP ...300 mg ...PO ...TID ...Start: 06/12/25 09:02...” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...diazePAM (*Valium)...5 mg ...Oral THREE TIMES DAILY for detox ...Scheduled ...06/13/25 ...21:00 ...Administered ...06/13/25 ...23:34 ...gabapentin (Neurontin)...300 mg ...Oral THREE TIMES DAILY for detox ...Scheduled ...06/13/25 ...21:00 ...Administered ...06/13/25 ...23:34 ...” Employee #3 confirmed in an interview conducted on October 9, 2025 that the aforementioned medications for Patient #14 were administered outside the total two (2) hour medication administration window and there was no reason documented for the delay. 2. Failure to identify the correct patient, right dose and right drug prior to administering a medication. Review of the hospital policy #18426147 titled “Medication Administration” last reviewed 9/2024 revealed: “ ...Medications are administered pursuant to a prescriber’s order; to the patient for whom they were ordered ... All medication administration is documented in the patient’s permanent medical record ...Policy ...Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient ...Medication Administration Procedure ...Prepared medications for one patient at a time ...Administer medications immediately after the medication is prepared without a break in the process OR appropriately label the medication ...Verifies the medication is administered in the correct dose and the dose does not reflect an unsafe dosage level ...Positively identify the patient before administering the medication ...Check the patient’s identification with two hospital-approved identifiers (i.e., name band, date of birth, patient specific number, photograph) and ask the patient (when possible) to state his/her name ...If barcode medication administration is utilized, the patient’s wristband is scanned for confirmation prior to proceeding ... Document the exact time the medication is administered ...Monitor the effects of the medication to ensure effective patient response ....” Review of the hospital policy #17741340 titled “High-Alert Medications” last reviewed 09/2024 revealed “ ...Definitions, High-Alert Medications: Medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes ...Policy ...The hospital identifies and maintains a hospital-specific list of high-alert medications ...Risk-reduction strategies are developed and are layered throughout the medication-use process ...High-alert medication safety strategies are consistently implemented throughout the organization and apply to prescribers, pharmacists, nurses, and other practitioners ...Hospital-defined high-alert medications and safeguards for each medication are accessible to healthcare providers ...High-alert medication safeguards are established at various points throughout the medication use process (e.g., Selection and procurement, storage, ordering and transcribing, preparation and dispensing, administration, and monitoring) ....” Review of hospital document titled “High Alert Medication List” revealed, “ ...Methadone blind count required ....” Review of hospital document titled “All device event reports” revealed, “ ...User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0505, quantity 10, patient name #8 ....” “ ...User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0509, quantity 7, patient name #7 ....” “ ...User Name Employee #24, Med Description Pantoprazole, transaction date and time 9/28/2025 0511, quantity 1, patient name #1 ....” “ ...User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0512, quantity 9, patient name #6 ....” Employee #3 and #5 confirmed in an interview conducted October 10, 2025 that removing medications for multiple patients at the same time is not per policy. Review of video surveillance on 10/7/2025 revealed, camera labeled “Laurel Med Room” and time and date stamped: 05:02:51 09/20/2025 Shows Employee #24 enter the medication room and proceed to remove medication from the PIXIS machine. 05:04:32 Employee #24 places medications in blue cup and places on counter to the left of the machine 05:05:16 Employee #24 begins to remove medication for another patient 05:06:05 Employee #24 places medications into a second unmarked, unlabeled, blue cup and places it on the counter to the left of the machine next to the previous cup 05:06:17 Employee #24 returns to the machine and begins pulling medication for another patient 05:07:31 Employee #24 places medications into a third unmarked, unlabeled blue cup and places on counter to the left and behind the working position, returns to the machine and begins pulling medication for another patient 05:09:53 Employee #24 places medications into a fourth unmarked, unlabeled blue cup and sits in next to the previous to the left and behind the working position 05:10:15 Employee #24 returns to the machine and begins pulling medication for another patient 05:11:20 Employee #24 picks up a stack of what appears to be hand written labeled blue cups and places medications in cup to the right of the machine and returns to the machine and begins pulling medications for another patient 05:06:09 Employee #24 picks up first cup with medication inside and exits the medication room Employee #3 verified the last medication removed by Employee #24 is Methadone 10mg tablets, nine (9) tablets and placed in blue cup next to the previous cup. Employee #3 further verified that Employee #24 removed medications for five separate patients during the time spent in the med room leaving four additional cups, two of which contain controlled medications and one verified with nine (9) Methadone 10mg tablets, which is against policy and not an acceptable standard of practice. Continued review of video surveillance 10/7/2025 revealed a second nurse, employee #15, enter “Laurel Med Room” and time and date stamped: 06:16:00 09/28/2025 shows Employee #15 enter medication room and pick up two blue plastic cups containing medication and returns to the nurse ’ s station 06:17:50 Employee #15 scans medication at computer work station at the nurses desk 06:18:30 removes 9 tablets from blister packs and places tablets into clear medication cup Camera labeled “Laurel Hallway W” time stamp: 06:20:08 Employee #15 enters patient #1 ’ s room with medication cup 06:20:50 Employee #15 exits patient ’ s #1 ’ s room Employee #3 verified in an interview conducted October 10, 2025 that the medication that Employee #15 had scanned, removed from blister packs, and administered to Patient #1 was 10mg Methadone tablets, a quantity of nine (9). Employee #3 further verified that there was no order for 90mg of Methadone in Patient #1 ’ s chart. Continued review of video surveillance 10/7/2025 revealed, Camera labeled “Laurel Hallway W” 07:06:52 Staff seen entering patient #1 ’ s room 07:08:00 Staff exits patient #1 ’ s room 07:12:35 Patient #1 exits room 07:25:57 to 08:41:47 Patient #1 seen socializing in common area 08:41:17 Patient #1 enters own room 09:11:43 staff member enters Patients #1 ’ s room 09:12:36 staff exits Patient #1 ’ s room 09:29:27 staff enter Patients #1 ’ s room 09:34:41 additional staff member enters Patients #1 ’ s room 09:37:14 staff urgently exits Patient #1 ’ s room 09:37:53 staff enters Patient #1 ’ s room with vitals machine 09:39:30 numerous staff seen entering and exiting Patient #1 ’ s room 09:47:47 EMS (Emergency Medical Services) arrives to Patient #1 ’ s room 09:59:52 video ends prior to EMS exiting Patient #1 ’ s room Employee #3 verified in an interview conducted on October 10, 2025 that after the video ended Patient #1 was transported to the emergency room with EMS performing CPR. Patient #1 ’ s medical record revealed the following: Hospital document titled “Nursing Shift Progress Note” revealed hand written note by employee #15 “ ...date ...9-28-25 ...time 0640 ...This RN gave medication to the wrong patient 90mg Methadone was given ...House supervisor and DR notified ....” Hospital document titled “Nursing Shift Progress Note” revealed Typed entry by employee #17 “ ...Date 9/28/25 ...Time 0930 ...Writer received report at 0800 from night shift nurse ...Stated that patient received wrong medication, Methadone. Night shift nurse notified writer that ...notified provider ...interventions post med error not outlined during report ...Patient received awake, alert, and ambulatory ...0930- Difficulty waking patient ...0932 vitals 203/168/163, SpO2 23 ...Repeat vitals 116/71/129, SpO2 16 ...0939- Code blue called ....” Hospital document titled “Inpatient Progress Note” by employee #46, dated 09/28/2025 12:04:45 revealed “ ...called by RN this morning ...7:17am ...reported ...incorrectly gave 9mg of Methadone to patient ...states patient responded to his first name therefore date of birth was not verified by RN ...confirmed with RN 3 times as to specific dose given ...Advised close observation given incorrect administration ...relatively low dose was reportedly administered ...Observation was recommended as opposed to ED transfer ...Was called later in the morning by house supervisor at 10:02AM ...Patient found unresponsive and was in fact given 90mg not 9mg ...EMS was alerted and patient to be transported to emergency department ....” Hospital document titled “Medication Administration Record (MAR)” revealed” ...pantoprazole (Protonix) 40mg ...scheduled 6:30 ...Administered 6:40 ....” Office of the Medical Examiner Case Status revealed Patient #1 ’ s Manner of Death: “...Accident...” with the Primary Cause of Death: “...Methadone intoxication...” Employee #3 verified in interview conducted on October 10, 2025 that Patient #1 ’ s death from the incident that occurred on 9/28/25 was attributed to numerous system failures, circumventing established policy and procedure, and safeguards that are in place to protect patient safety. Employee #3 also confirmed that the medication administered to Patient #1 was not done in accordance with applicable standards of practice.”

“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: 49638 Based on Hospital policy and procedure review, medical record review, video footage review, and employee interview, it was determined the Hospital failed to ensure policy and procedures were implemented for patient precautions and close observation to protect the health and safety of a patient as evidenced by: 1. Precautions not being documented on Shift Nursing Assessments and Patient Observation Sheets. 2. Rounding not occurring per policy resulting in gaps on Patient Observation Sheets. These deficient practices have the potential to result in patient harm or even death if staff are not aware if a patient is on precautions and if staff are not adequately rounding and completing close observations on every patient per policy. Findings include: 1. Precautions not documented on Shift Nursing Assessments and Patient Observation Sheets. A review of hospital policy “Levels of Observation and Precautions,” policy #18040290, reviewed 04/2025, revealed “...7. A Provider ’ s order is required to decrease or discontinue a level of observation or precautions ...A progress note by the Provider accompanies the order with the rationale for decreasing or discontinuing the level of observation or precaution ....” A review of hospital policy “Assessment - Fall,” policy #17332628, reviewed 03/2024, revealed: “...A. An Initial Screen for Fall Precautions will be completed on all Inpatient patients upon admission on the Nursing Admission Assessment ...K. The patient will be identified as a fall risk after falling, if not done upon admission ....” A review of hospital policy “Suicide Prevention Program Guidelines,” policy #15562536, reviewed 04/2024, revealed: “...C. Following the initial patient evaluation, including the above information, the assessment clinician will contact the on-call provider to review the case, determine a level of care, and if inpatient, obtain admission orders, and determine an overall level of risk ...1. For patients identified as moderate to high risk, the patient will be placed on individualized suicide precautions ...D. At the start of each shift, during report, the staff will be made aware of any patient who is on suicide precautions to increase awareness of safety risks and to be alert for any changes in behavior that might suggest the patient may act on suicidal thoughts ....” Medical record for Patient #2 revealed the following: Document titled “Ancillary (non-medication) Orders” revealed “ ...Precautions ...Suicide Precautions ...Start Time: 7/3/25 20:00 ...Stop Time (blank) ....” Document titled “Patient Observation Sheet” revealed “ ...Date: 7/4/25 ...Time Initiated: 2400 ...Precautions (blank) ....” Suicide precautions were not documented, despite the presence of a provider order. Medical record for Patient #9 revealed the following: Document titled “Ancillary (non-medication) Orders” revealed “ ...Precautions ...Suicide Precautions ...Start Time: 7/3/25 0:00 ...Stop Time (blank) ....” Document titled “Ancillary (non-medication) Orders” revealed “ ...Precautions ...Fall Precautions ...Start Time: 7/4/25 17:00 ...Stop Time (blank) ....” Document titled “Patient Observation Sheet” for dates 7/5/25, 7/6/25, 7/7/25, and 7/8/25 revealed suicide precautions were not documented, despite the presence of a provider order. Document titled “Patient Observation Sheet” for dates 7/4/25, 7/5/25, 7/6/25, 7/7/25, and 7/8/25 revealed fall precautions were not documented, despite the presence of a provider order. Patient #14 ’ s medical record revealed the following: Documentation titled “Ancillary (non-medication) Orders” revealed “...Falls Precautions ...Start Time: 06/11/25 11:00 ....” Documentation titled “7:00AM-7:00PM Shift Nursing Assessment,” dated 6/15/25, revealed that fall precautions were not documented, despite having a provider order. Documentation titled “7:00AM-7:00PM Shift Nursing Assessment,” dated 6/16/25, revealed that fall precautions were not documented, despite having a provider order. Medical record for Patient #18 revealed the following: Document titled “Ancillary (non-medication) Orders” revealed “ ...Precautions ...Suicide Precautions ...Start Time: 8/4/25 19:00 ...Stop Time (blank) ....” Document titled “Patient Observation Sheet” for dates 8/4/25, 8/5/25, and 8/8/25 revealed suicide precautions were not documented, despite the presence of a provider order. Employees #3 and #16 confirmed in interviews, conducted on October 2, 2025 through October 14, 2025, that fall precautions were not documented on either the Shift Nursing Assessments or the Patient Observation Sheets for Patients #9 and #14, and that suicide precautions were not documented on either the Shift Nursing Assessments or the Patient Observation Sheets for Patients #2, #9, and #18, despite having a provider order. 2. Rounding not occurring per policy, resulting in gaps in observation. A review of hospital policy “Rounds for Patient Observations,” policy #17787642, reviewed 04/2025, revealed: “......E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient, noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation...F. Close observation Sheets must be with a staff member who is with the particular patient....G. During the nighttime, (or during times the patient is resting or asleep) the observation of the patient is required ...The staff assigned must observe and document their findings ...The staff assigned should ensure that the patient is breathing and not in any distress ...This includes watching the chest rise and fall at least three times, and includes walking around the bed to determine that the correct patient is asleep in the bed ....” A review of hospital policy “Levels of Observation and Precautions,” policy #18040290, reviewed 04/2025, revealed: “...1. Every 15 minute observation:...This is moderately restrictive for the patient and involves monitoring every 15 minutes on the Close Observation Sheet ...Staff members must complete the Close Observation Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation ...Staff must make visual contact with the patient at least every 15 minutes. This includes when the patient is toileting and/or showering, in groups, or attending off unit activities ...When using the “Special Bathing” area of the Hospital, staff will be required to monitor the patient inside the “Special Bathing” area at all times ...3. 1-to-1 Observation at all times:...This is the most restrictive level of observation for the patient. Staff must be within arms-length to the patient at all times, including toileting and/or showering to continuously monitor patient behavior ...Staff members must complete the Close Observation Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation ....” Patient #1 ’ s medical record revealed the following: Documentation titled “Patient Observation Sheet,” dated 9/28/25, revealed “... 0900-1000 15 min mark ...0945 through 1145 all fields filled in ....” Review of video footage 10/07/2025 revealed, “... time and date stamp 09:11:43 9/28/25 ... staff entering and exiting patients room through time stamp 09:59:52 ....” Medical record for Patient #2 revealed the following: Document titled “Ancillary (non-medication) orders” revealed “ ...Observations ...Level Of Observation One on One ...Start Time: 7/9/25 0:00 ...Stop Time: 7/9/25 11:21 ....” Document titled “Patient Observation Sheet” revealed ...”Date: 7/9/25 ...Time Initiated: 0000 ...Observation Level: 1:1 ....” Document review revealed employee initials at 15 minute intervals from 24:00 through 07:15. Patient #5 ’ s medical record revealed the following: Documentation titled “Patient Observation Sheet,” dated 9/11/25, revealed that observation rounding was completed for Patient #5 at 17:45, 18:00, and 18:15. Employee #34 ’ s initials were missing from the “Patient Observation Sheet” at 18:15. Documentation of observation rounding was blank at 18:30. Review of video footage, 09/11/2025 from 5:01 PM to 6:34 PM, revealed that Employee #25 took over observation rounding for Employee #34 from 5:38 PM to 5:48 PM. At 5:44 PM, Employee #25 passed by Patient #5 ’ s room without completing observation rounding. Employee #34 returned to observation rounding at 5:48 PM. Observation rounding was not completed by Employee #34 at 6:00 PM, 6:15 PM, and 6:30 PM. At 6:31 PM, Employee #34 completed observation rounding and called out to the unit for assistance with Patient #5 at 6:32 PM. Observation rounding for Patient #5 was not completed on 9/11/25 at 5:44 PM, 6:00 PM, 6:15 PM, and 6:30 PM. Patient #11 ’ s medical record revealed the following: Documentation titled “Patient Observation Sheet,” dated 6/28/25, revealed “...06:00-07:00 ...15 (Minute mark)...Location ...Blank ...Behavior ...Blank ...Initials ...Blank ...30 (Minute mark)...Location ...Blank ...Behavior ...Blank ...Initials ...Blank ...45 (Minute mark)...Location ...Blank ...Behavior ...Blank ...Initials ...Blank ....” There was a 45 minute rounding gap. Patient #14 ’ s medical record revealed the following: Documentation titled, “Patient Observation Sheet” dated 6/16/25 revealed, “...07:00-08:00 ...15 (Minute mark)...Location ...Blank ...Behavior ...Blank ...Initials ...Blank ....” There was a 15 minute rounding gap. Medical record for Patient #18 revealed the following: Document titled “Ancillary (non-medication) orders” revealed “ ...Observations ...Level Of Observation Every 15 minutes ...Start Time: 8/4/25 19:00 ...Stop Time: (blank) ....” Document titled “Ancillary (non-medication) orders” revealed “ ...Observations ...Level Of Observation One on One ...Start Time: 8/8/25 20:15 ...Stop Time: 8/9/25 7:12 ....” Document titled “Patient Observation Sheet” revealed ...”Date: 8/5/25 ...Time Initiated: 0000 ...Observation Level: Q15 ....” Document review revealed employee initials not present at 03:15 time interval. Document titled “Patient Observation Sheet” revealed ...”Date: 8/8/25 ...Time Initiated: 0000 ....” Document review revealed employee initials reflecting every 15 minutes observations between 20:00 through 23:00, despite the presence of a provider order for one on one observations during this time period. Document titled “Patient Observation Sheet” revealed ...”Date: 8/9/25 ...Time Initiated: 2400 ....” Document review revealed employee initials reflecting every 15 minutes observations between 24:00 through 01:30 and 03:45 through 07:00, despite the presence of a provider order for one on one observations during this time period. Document review also revealed employee initials not present between 01:35 through 03:40. Employee #3 confirmed in interviews conducted October 2, 2025, through October 10, 2025, that observation rounding form for patient #1 appeared to be pre-filled for the time frame mentioned. Employee #3 confirmed in interviews conducted October 2, 2025, through October 10, 2025, that observation rounding was not completed for patient #5 on 09/11/2025, at 5:45 PM, 6:00 PM, 6:15 PM, and 6:30 PM. Employee #3 confirmed in interviews conducted October 2, 2025, through October 10, 2025, that employees were not completing the Close Observation Sheets per policy for patient #1, #5, #11, and #14. Employee #16 confirmed, in an interview conducted on October 10, 2025, that the Patient Observation Sheets for Patients #2 and #18 presented with employee initials, or missing employee initials, corresponding with observation time intervals that did not reflect provider orders.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 52829 Based on review of hospital policies/procedures, Hospital documents, video review, medical records review, and interviews, it was determined that the hospital failed to assure that patients were properly identified prior to medication administration evidenced by. 1. Failure to identify patients prior to administering a medication. 2. Failure to identify the right dose prior to administering a medication. 3. Failure to identify the right drug prior to administering a medication. This deficient practice led to a patient suffering respiratory and cardiac arrest, being transported to an emergency room, and ultimately the patient ’ s death. Findings include: Review of the hospital policy titled “Medication Administration Policy” #18426147 Last reviewed 9/2024 revealed: “ ... Medications are administered pursuant to a prescriber’s order; to the patient for whom they were ordered ... All medication administration is documented in the patient’s permanent medical record ... Policy ... Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient ... Medication Administration Procedure ... Prepared medications for one patient at a time ... Administer medications immediately after the medication is prepared without a break in the process OR appropriately label the medication ... Verifies the medication is administered in the correct dose and the dose does not reflect an unsafe dosage level ... Positively identify the patient before administering the medication. Check the patient’s identification with two hospital-approved identifiers (i.e., name band, date of birth, patient specific number, photograph) and ask the patient (when possible) to state his/her name. If barcode medication administration is utilized, the patient’s wristband is scanned for confirmation prior to proceeding ... Document the exact time the medication is administered ... Monitor the effects of the medication to ensure effective patient response ....” Review of the hospital policy titled “High-Alert Medications Policy #17741340 Last reviewed 09/2024 revealed “ ... Definitions, High-Alert Medications: Medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes ... Policy ... The hospital identifies and maintains a hospital-specific list of high-alert medications ... Risk-reduction strategies are developed and are layered throughout the medication-use process ... High-alert medication safety strategies are consistently implemented throughout the organization and apply to prescribers, pharmacists, nurses, and other practitioners ... Hospital-defined high-alert medications and safeguards for each medication are accessible to healthcare providers ... High-alert medication safeguards are established at various points throughout the medication use process (e.g., Selection and procurement, storage, ordering and transcribing, preparation and dispensing, administration, and monitoring) ....” Review of hospital document titled “High Alert Medication List” revealed, “ ... Methadone blind count required ....” Review of Hospital document titled “All device event reports”(sic), revealed, “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0505, quantity 10, patient name #8 ....” “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0509, quantity 7, patient name #7 ....” “ ... User Name Employee #24, Med Description Pantoprazole, transaction date and time 9/28/2025 0511, quantity 1, patient name #1 ....” “ ... User Name Employee #24, Med Description Methadone oral 10mg tab, transaction date and time 9/28/2025 0512, quantity 9, patient name #6 ....” Employee #3and #5 confirmed in interview conducted 10/10/2025 that removing medications for multiple patients at the same time is not per policy. Review of video surveillance on 10/7/2025 revealed, camera labeled “ ... Laurel Med Room” and time and date stamped: · 05:02:51 09/20/2025 Shows employee #24 enter the medication room and proceed to remove medication from the PIXIS machine. · 05:04:32 employee #24 places medications in blue cup and places on counter to the left of the machine · 05:05:16 employee #24 begins to remove medication for another patient · 05:06:05 employee places medications into a second unmarked, unlabeled, blue cup and places it on the counter to the left of the machine next to the previous cup · 05:06:17 employee #24 returns to the machine and begins pulling medication for another patient · 05:07:31 employee #24 places medications into a third unmarked, unlabeled blue cup and places on counter to the left and behind the working position, returns to the machine and begins pulling medication for another patient · 05:09:53 employee #24 places medications into a fourth unmarked, unlabeled blue cup and sits in next to the previous to the left and behind the working position · 05:10:15 employee #24 returns to the machine and begins pulling medication for another patient · 05:11:20 employee #24 picks up a stack of what appears to be hand written labeled blue cups and places medications in cup to the right of the machine and returns to the machine and begins pulling medications for another patient · 05:06:09 employee #24 picks up first cup with medication inside and exits the medication room Employee #3 verified the last medication removed by employee #24 is Methadone 10mg tablets, 9 tablets and placed in blue cup next to the previous cup. Employee #3 further verified that employee #24 removed medications for five separate patients during the time spent in the med room leaving four additional cups, two of which contain controlled medications and one verified with Methadone 10mg tablets 9 tablets, which is against policy and not an acceptable standard of practice. Continued review of video surveillance 10/7/2025 revealed a second nurse, employee #15, enter “Laurel Med Room” and time and date stamped: · 06:16:00 09/28/2025 shows employee #15 enter medication room and pick up two blue plastic cups containing medication and returns to the nurse ’ s station · 06:17:50 employee #15 scans medication at computer work station · 06:18:30 removes 9 tablets from blister packs and places tablets into clear medication cup Camera labeled “Laurel Hallway W” time stamp 06:20:08 employee #15 enters patient #1 ’ s room with medication cup · 06:20:50 employee #15 exits patients ’ room Employee #3 verified in interview conducted 10/10/2025 that the medication that employee #15 had scanned, removed from blister packs, and administered to patient #1 was 10mg Methadone tablets, quantity of 9. Employee #3 further verified that there was no order for 90mg of Methadone in Patient #1 chart. Continued review of video surveillance 10/7/2025 revealed, Camera labeled “Laurel Hallway W” · 07:06:52 Staff seen entering patient #1 ’ s room 07:08:00 Staff exits patient #1 ’ s room 07:12:35 Patient #1 exits room 07:25:57 to 08:41:47 Patient #1 seen socializing in common area 08:41:17 Patient #1 enters own room 09:11:43 staff member enters Patients #1 ’ s room 09:12:36 staff exits Patient #1 ’ s room 09:29:27 staff enter Patients #1 ’ s room 09:34:41 additional staff member enters Patients #1 ’ s room 09:37:14 staff urgently exits Patient #1 ’ s room 09:37:53 staff enters Patient #1 ’ s room with vitals machine 09:39:30 numerous staff seen entering and exiting Patient #1 ’ s room 09:47:47 EMS (Emergency Medical Services) arrives to Patient #1 ’ s room 09:59:52 video ends prior to EMS exiting Patient #1 ’ s room Employee #3 verified in interview conducted 10/10/2025 that after the video ended the patient was transported to emergency room with EMS performing CPR. Patient #1 ’ s medical record revealed the following: Hospital document titled “Nursing Shift Progress Note” revealed hand written note by employee #15 “ ... date ... 9-28-25 ... time 0640 ... This RN gave medication to the wrong patient 90mg Methadone was given ... House supervisor and DR notified ....” Hospital document titled “Nursing Shift Progress Note” revealed Typed entry bu employee #17 “ ... Date 9/28/25 ... Time 0930 ... Writer received report at 0800 from night shift nurse ... Stated that patient received wrong medication, Methadone. Night shift nurse notified writer that ... notified provider ... interventions post med error not outlined during report ... Patient received awake, alert, and ambulatory ... 0930- Difficulty waking patient ... 0932 vitals 203/168/163, SpO2-23 ... Repeat vitals 116/71/129, SpO2 16 ... 0939- Code blue called ....” Hospital document titled “Inpatient Progress Note” by employee #46, dated 09/28/2025 12:04:45 revealed “ ... called by RN this morning ... 7:17am ... reported ... incorrectly gave 9mg of Methadone to patient ... states patient responded to his first name therefore date of birth was not verified by RN ... confirmed with RN 3 times as to specific dose given ... Advised close observation given incorrect administration ... relatively low dose was reportedly administered ... Observation was recommended as opposed to ED transfer ... Was called later in the morning by house supervisor at 10:02AM ... Patient found unresponsive and was in fact given 90mg not 9mg ... EMS was alerted and patient to be transported to emergency department ....” Hospital document titled “Medication Administration Record (MAR)” revealed” ... pantoprazole (Protonix) 40mg ... scheduled 6:30 ... Administered 6:40 ....” Review of patient #1 medical record revealed the following: Employee #3 verified in interview conducted 10/10/2025 that patient #1 death, on 9/28/25 was attributed to numerous system failures, circumventing established policy and procedure, and safeguards that are in place to protect patient safety. Employee #3 also confirmed that the medication administered to patient #1 was not done in accordance with applicable standards of practice.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient’s rights as evidenced by: Cross reference A-0144: The hospital failed to ensure staff followed policy and physician orders concerning: administering medication within set time frame, notifying the physician of late medication administration, rounding, and notifying the physician of a patient change in condition that led to a patient’s death. The egregious nature of this deficient practice resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45202 Based on the review of documents and interviews, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following references to standard-level deficiencies: Cross reference A-0395: The Nurse Executive failed to ensure appropriate supervision of non licensed staff providing services related to patient care. Cross reference A-0405: The Nurse Executive failed to ensure: 1. Medications were administered in compliance with an order and per policy; 2. A patient’s medication administration record contained accurate documentation. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45202 Based on policies and procedures, hospital documentation review, medical record review, medical examiner case review and interview, it was determined the hospital failed to ensure Patient #1 received care in a safe setting. An immediate jeopardy was called in regards to Patient #1 receiving contradictory medications too closely together, staff falsifying medical record documentation, and staff not notifying a physician of a patient’s change in condition that ultimately lead to patient death. Findings include: Policy titled “Patient Bill of Rights, Policy #15835613, last reviewed 05/2024,” revealed, “...Procedures...B. An Administrator shall ensure that:...2. A patient is not subjected to...b. Neglect....” Policy titled “Nursing Care Standards, Policy #16957141, effective 10/2024,” revealed, “...Procedures...Assessment:...Standard of Care: The patient is assessed by the RN in a timely, comprehensive, accurate, and systemic manner...Standards of Nursing Practice: The RN continuously and systematically collects, records, and analyzes data that is comprehensive and accurate....” Policy titled “Shift Nursing Assessment/Reassessment, Policy #16019044, last reviewed 07/2024,” revealed, “...I. Anytime that there is a change in the patient ’ s behavior or variance from the normal, it must be documented....” Policy titled “Change in Patient Condition Chain of Command Notification, Policy #15769455, last reviewed 06/2024,” revealed, “...as necessary, notify the charge nurse, assistant nurse manager, nurse manager, nursing supervisor and/or administrator on call for administrative and/or clinical consultation and/or assistance...The nurse notifies the on-call or attending (depending on the time of day) Physician utilizing appropriate channels and chain of command...Decrease in Baseline Level of Functioning...Notify Provider if the patient exhibits any acute changes in status including but not limited to:...Change in level of independence, increased need for assistance...Change in ability to perform self-care...Change in gait/coordination....” Policy titled “Rounds for Patient Observations, Policy #162352784, last reviewed 07/2024,” revealed, “...Procedures...E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient, noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation...F. Close observation Sheets must be with a staff member who is with the particular patient....” Policy titled “MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024,” revealed, “...Medications prescribed for daily, weekly, or monthly administration are administered within 2 hours before or after the scheduled dosing time...Missed or Delayed Administration of Scheduled Medications...When medications eligible for a scheduled dosing time are not administered within the defined time period...Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for medication errors that are the result of missed or late dose administration must be reported to the attending physician and in accordance with hospital policy...Medication Administration Procedure...Verifies there is no contraindication with respect to allergy, sensitivity, or diagnosis...Verifies the medication is administered by the correct route and the route is appropriate for the medication and patient...Verifies the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration...Document the exact time the medication is administered...Report medication administration errors, adverse drug events, and incompatibilities immediately to the attending physician....” Policy titled “MM 06-004 Adverse Drug Reactions (ADRs) Reporting, Policy #15968803, last reviewed 09/2024,” revealed, “...DEFINITIONS...Medication Administration Error...is an error in medication administration that actually reaches the patient...(i.e., a medication administered to a patient when it should not be, or medication is administered as the wrong dose, wrong route, or wrong time)...Sentinel Event is a patient safety event (not primarily related to the natural course of the patient ’ s illness or underlying condition), that reaches a patient and results in death, permanent harm, or severe temporary harm...Responding to an Adverse Drug Event...Immediately upon identification or suspicion of an adverse drug reaction, medication administration error or incompatibility...Assess the patient ’ s current condition...Immediately notify the attending physician and implement treatment as ordered...Document the factual description of the event; medication given; notification of the physician; subsequent monitoring and patient response, in the patient’s medical record...All medication administered are documented including those given in error...The pharmacist ’ s input is included in the documentation...Report events using the organization-wide event reporting process/system....” Hospital document titled “Position Title: Registered Nurse,” revealed, “...Will oversee and supervise the shift...delegating taste such as groups, close observation, meal supervision, etc...Will also oversee staff to ensure nursing policies and procedures are followed and exemplary patient care is consistently delivered by self and all members of the team...Will monitor patient for change of condition and respond accordingly up to and including notification of the physician....” Hospital document titled “Position Title: LVN/LPN,” revealed, “...Ensures that individual patient observation/checks are conducted...Medications are administered safely and accurately with demonstrated knowledge of indications and side effect...Will monitor patient for change of condition and respond accordingly up to and including notification of the physician...Will follow hospital policy for medication administration....” Review of Patient #1 ’ s medical record revealed the following: Hospital document titled, “Ancillary (non-medication) Orders,” revealed, “...Observations...Level of Observation: Every 15 minutes...Start Time: 1/9/25 17:00....” Hospital document titled, “Ancillary (non-medication) Orders,” revealed, “...Nursing Orders - General...CIWA ArScale (CIWA) Q 4H...Start Time: 1/10/25 0:00...Comments...Contact physician for...unarousable patient....” Hospital document titled, “Medication Orders,” revealed, “...PRN...hydrOXYzine pamoate Oral 50 mg CAP...50 mg...PO...Q4HPRN...Start: 01/09/25 17:00....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...gabapentin Oral 300 mg CAP...300 mg...PO...TID...Start: 01/10/25 15:00....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...QUEtiapine Oral 100 mg TAB...100 mg...PO...HS...Start: 01/10/25 21:00....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...methadone Oral 10 mg TAB 1 ea...40 mg...PO...QDAY...Start: 01/11/25 06:00....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...hydrOXYzine pamoate (Vistaril) 50 mg...Administered 09:59 1/10/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...QUEtiapine (SEROquel) 100 mg...Administered 21:16 1/10/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...gabapentin (Neurontin) 300 mg...Administered 09:12 1/11/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...methadone (Methadose) 40 mg...Administered 09:14 1/11/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...CIWA ArScale...Not Administered 13:07 1/11/25...Pt too sedated, unable to obtain....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 1.5 mg...Not Administered 15:06 1/11/25...Pt sedated, unable to wake up....” Hospital document titled, “Nursing Shift Progress Note” dated 1/11/2025 15:00, revealed, “...RN went to check on pt(sic) c(sic) med(sic) nurse...Pt ’ s(sic) left shoulder was off the bed...RN attempted to wake up pt(sic), pt(sic) snoring...Chest rising & falling...Pt(sic) took a deep breath....appeared to be sleeping....” Hospital document titled, “7:00AM-7:00PM Shift Nursing Assessment” dated 1/11/2025 15:03, revealed incomplete assessment with “unable to assess” written with a line across the page. Section titled “Progress Note,” revealed, “...Pt(sic) sedated, unable to assess...Respirations even & unlabored...Difficulty waking up, snoring...Pt(sic) on back...Pt(sic) awake this morning, went to breakfast & went to bed...Obs(sic) done Q 15”...Pt(sic) repositioned in bed after laying with L(sic) shoulder off bed....” Section “Progress Note” further revealed, “...Has patient experienced any medical problems or change in overall condition during the shift?...No...Was physician notified?...No....” Hospital document titled, “Code Blue Record” dated 1/11/2025 16:55, revealed, “...Code Called at: 16:55...911 called at: 16:56...AED applied at: 16:57...CPR begun at: 16:56...911 arrived at: 16:59...Reason for calling code: Pt(sic) unresponsive, not breathing, no pulse...PATIENT CONDITION ST ONSET OF CODE: unable to obtain, no pulse/not breathing...17:02...Narcan given, EMS arrived, CPR continued...17:04...intubated by EMS...17:06...Epinephrine given by EMS...17:12...Pt(sic) transferred by EMS...Attending Physician...Time Notified: 17:03....” Office of the Medical Examiner Case Status revealed Patient #1 ’ s Manner of Death: “...Accident...” with the Primary Cause of Death: “...Combined toxic effects of gabapentin, hydroxyzine, lorazepam, methadone and olanzapine...” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that Patient #1 was not administered Ativan 1.5 mg at 10:44 as documented, but was administered Ativan 1.5 mg at 09:33. Nineteen (19) minutes after Methadone 40 mg was administered at 09:14. Employee #1 confirmed this medication administration was falsified by Employee #30. Employee # 1 confirmed that Employee #23 ’ s nursing assessment was incomplete and failed to notify the provider of a change in patient condition. Employee #1 also confirmed that close observations were falsified at times: 08:45, 10:30, 12:15, 12:30, 12:45, 13:00, 14:00, 15:00, 15:15, 15:45, 16:15 and 16:45 by Employee #37 on the patient observation sheet. Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #1’s medical record contained inaccurate documentation after video review. Employee #1 confirmed that staff failed to follow policy and provider orders by not administering medication within set time frame, failing to notify the provider of late medication administration, failing to perform close observation, and failing to notify physician of a patient change in condition.”

“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: 45202 Based on review of policy and procedure, personnel records, and interview, it was determined The Nurse Executive failed to document that clinical oversight was provided to Behavioral Health Technicians (BHT) at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period. This deficient practice resulted in Behavioral Health Professionals (BHP) not accurately rounding on patients resulting in an adverse event. Findings include: Policy titled “Clinical Oversight, Policy #17383375, last reviewed 01/2025,” revealed, “...Procedures...3. Clinical oversight will be provided by the BHP every two (2) weeks, 14 calendar days...a. Unlicensed clinical care staff that provide patient care must participate in at least one scheduled oversight, during each two week period, if the staff member provides services related to patient care during the two weeks; employee or supervisor of an employee may request additional clinical oversight...b. Clinical oversight may include monitoring the behavioral health services provided by a behavioral health staff member to ensure services are provided according to the health care institution’s policies and procedures, review skills and knowledge related to the provision of behavioral health services, guidance to improve skills and knowledge related to the provision of behavioral health services, training recommendation, or oversight in response to an incident, or an emergency safety response...5. Documentation of clinical oversight will include:...a. The date of the clinical oversight...b. The name of the staff member receiving clinical oversight...c. The signature and professional credential or job title of the individual providing clinical oversight and the date signed...d. Identification of topic(s) covered...6. Documentation of clinical oversight shall be maintained by the staff member ’ s director....” Clinical oversight was requested for the following Employees for the month of December 2024 through January 13, 2025 and none were provided at the time of survey: Employee #33 Employee #34 Employee #35 Employee #36 Employee #37 Employee #38 Employee #39 Employee #40 Employee #41 Employee #6 confirmed in an interview on April 16, 2025 through April 21, 2025 that Employees #33, 34, 35, 36, 37, 38, 39, 40, and 41 had no clinical oversight documentation for review at the time of survey for the month of December 2024 through January 13, 2025, despite providing services related to patient care at the facility during that time frame.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45202 Based on policies and procedures, medical records and interview, it was determined that the The Nurse Executive failed to ensure that: 1. Medications were administered to Patients #1, 2, 3, and 4 in compliance with an order and per policy. 2. Patient #1’s Medication Administration Record (MAR) contained factual documentation. These deficient practices contributed to Patient #1’s adverse outcome as contradictory medications were administered too closely together despite physician order and policy and Patient’s #1 MAR did not accurately reflect when medications were administered. This could result in additional adverse patient outcomes if not corrected. Findings include: 1. Medications were administered to Patients #1, 2, 3, and 4 in compliance with an order and per policy as evidenced by: Policy titled “MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024,” revealed, “...Medications prescribed for daily, weekly, or monthly administration are administered within 2 hours before or after the scheduled dosing time...Missed or Delayed Administration of Scheduled Medications...When medications eligible for a scheduled dosing time are not administered within the defined time period...Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for medication errors that are the result of missed or late dose administration must be reported to the attending physician and in accordance with hospital policy...Medication Administration Procedure...Verifies there is no contraindication with respect to allergy, sensitivity, or diagnosis...Verifies the medication is administered by the correct route and the route is appropriate for the medication and patient...Verifies the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration...Document the exact time the medication is administered...Report medication administration errors, adverse drug events, and incompatibilities immediately to the attending physician....” Policy titled “MM 06-004 Adverse Drug Reactions (ADRs) Reporting, Policy #15968803, last reviewed 09/2024,” revealed, “...DEFINITIONS...Medication Administration Error...is an error in medication administration that actually reaches the patient...(i.e., a medication administered to a patient when it should not be, or medication is administered as the wrong dose, wrong route, or wrong time)...Sentinel Event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition), that reaches a patient and results in death, permanent harm, or severe temporary harm...Responding to an Adverse Drug Event...Immediately upon identification or suspicion of an adverse drug reaction, medication administration error or incompatibility...Assess the patient’s current condition...Immediately notify the attending physician and implement treatment as ordered...Document the factual description of the event; medication given; notification of the physician; subsequent monitoring and patient response, in the patient’s medical record...All medication administered are documented including those given in error...The pharmacist’s input is included in the documentation...Report events using the organization-wide event reporting process/system....” Office of the Medical Examiner Case Status revealed Patient #1 ’ s Manner of Death: “...Accident...” with the Primary Cause of Death: “...Combined toxic effects of gabapentin, hydroxyzine, lorazepam, methadone and olanzapine...” Review of Patient #1’s medical record revealed the following: Hospital document titled, “Ancillary (non-medication) Orders,” revealed, “...Nursing Orders - General...CIWA ArScale (CIWA) Q 4H...Start Time: 1/10/25 0:00...Comments...Contact physician for...unarousable patient....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...methadone Oral 10 mg TAB 1 ea...40 mg...PO...QDAY...Start: 01/11/25 06:00....” Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...methadone (Methadose) 40 mg...Administered 09:14 1/11/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...CIWA ArScale...Not Administered 13:07 1/11/25...Pt too sedated, unable to obtain....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 1.5 mg...Not Administered 15:06 1/11/25...Pt sedated, unable to wake up....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Employee #30 administered Methadone 40 mg over three (3) hours after the time it was ordered for, Ativan was administered at 09:33 and not at 10:44 as documented, did not notify the physician of the late medication administration per policy and did not notify the physician for a change in patient condition despite provider order. Review of Patient #2’s medical record revealed the following: Hospital document titled, “Medication Administration Record (MAR),” revealed, “...buprenorphine (*Subutex) 2 mg...for TAPER...May Crush and give Sublingual...DO NOT GIVE WITHIN 2 HOURS OF A BENZO...Administered...20:07 7/22/24....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...clonazePAM (*KlonoPIN) 1 mg...Oral AT BEDTIME...To give 1 mg use 2 of 0.5 mg...for Insomnia...Administered 20:07 7/22/24....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #2 was not administered medication in compliance with the provider’s order. Review of Patient #3’s medical record revealed the following: Hospital document titled, “Medication Administration Record (MAR),” revealed, “...buprenorphine (Subutex) 4 mg...Sublingual GIVE EVERY 6 HOURS AS NEEDED PRN...for FOR COWS SCORE MORE THAN 11...DO NOT GIVE WITHIN 2 HOURS OF A BENZO...Administered...15:04 8/30/24....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 2 mg...Oral THREE TIMES DAILY (3 Doses)...for INPATIENT DETOX...Administered 14:54 8/30/24....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #3 was not administered medication in compliance with the provider’s order. Review of Patient #4’s medical record revealed the following: Hospital document titled, “Medication Administration Record (MAR),” revealed, “...paliperidone (*Invega Sustenna) 234 mg...Intramuscular ONCE ONLY...for Psychosis...GIVE IN GLUTEAL INJ SITE...Administered...11:29 12/10/24....” Hospital document titled, “Incident Abstract Report,” revealed, “...Incident Description...Nurse gave medication in right deltoid despite provider order to be given in gluteal....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #4 was not administered medication in compliance with the provider’s order. 2. Patient #1’s Medication Administration Record (MAR) contained factual documentation as evidenced by: Policy titled “MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024,” revealed, “...Medication Administration Procedure...Document the exact time the medication is administered....” Hospital document titled “Position Title: LVN/LPN,” revealed, “...Medications are administered safely and accurately with demonstrated knowledge of indications and side effect...Will follow hospital policy for medication administration....” Review of Patient #1’s medical record revealed the following: Hospital document titled, “Medication Orders,” revealed, “...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00....” Hospital document titled, “Medication Administration Record (MAR),” revealed, “...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that Patient #1 was not administered Ativan 1.5 mg at 10:44 as documented, but was administered Ativan 1.5 mg at 09:33. Nineteen (19) minutes after Methadone 40 mg was administered at 09:14. Employee #1 confirmed this medication administration was falsified by Employee #30.”

“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: 45202 Based on policies and procedures, hospital documentation review, medical record review, and interview, it was determined The Nurse Executive failed to ensure Patient #1’s medical record contained factual rounding documentation. This deficient practice contributed to Patient #1’s adverse outcome as staff were not completing close observations on Patient #1 every fifteen (15) minutes as ordered and per policy. Findings include: Policy titled “Rounds for Patient Observations, Policy #162352784, last reviewed 07/2024,” revealed, “...Procedures...E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient, noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation...F. Close observation Sheets must be with a staff member who is with the particular patient....” Hospital document titled “Position Title: Patient Care Assistant (PCA),” revealed, “...Responsible for observation and maintenance of safe milieu through patient checks, safety monitoring, etc.: completes 15 minute checks, monitors for contraband, evaluates for change in condition, and provides line of sight or one on one care as directed....” Hospital document titled “Position Title: LVN/LPN,” revealed, “...Ensures that individual patient observation/checks are conducted....” Hospital document titled “Position Title: Registered Nurse,” revealed, “...Will oversee and supervise the shift...delegating taste such as groups, close observation, meal supervision, etc...Will also oversee staff to ensure nursing policies and procedures are followed and exemplary patient care is consistently delivered by self and all members of the team....” Review of Patient #1 ’ s medical record revealed the following: Hospital document titled, “Ancillary (non-medication) Orders,” revealed, “...Observations...Level of Observation: Every 15 minutes...Start Time: 1/9/25 17:00....” Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that rounding was falsified at times: 08:45, 10:30, 12:15, 12:30, 12:45, 13:00, 14:00, 15:00, 15:15, 15:45, 16:15 and 16:45 by Employee #37 on the Patient #1 ’ s observation sheet on January 11, 2025.”

“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: 49638 Based on review of Hospital policy and procedure, Hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure a medical screening examination (MSE) was completed by an individual who is determined by Hospital Bylaws or Rules and Regulations to be qualified to complete an MSE. 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: Hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA), Effective March 2025, “ revealed “...Qualified Medical Personnel (QMP) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example: Registered Nurse in Psychiatric Services...Physician Assistant...Advanced Registered Nurse Practitioner...A psychiatric MSE should include a screening assessment by a QMP...” Hospital document titled “Governing Board Bylaws,” Effective August 2023, revealed “...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel (“QMP”) who may perform the medical screening examinations (“MSE”) for EMTALA purposes....” Hospital document titled “Annual Review of Qualified Medical Personnel,” dated January 23, 2024, revealed “...The Governing Board designates masters level clinicians (MSW, etc.) and RNs, working within their scope of practice, as Qualified Medical Professionals (QMPs) when they are conducting Medical Screening Exams...” Hospital document titled “(Hospital) Governing Board Bylaws,” Effective December 2024, revealed “...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel (“QMP”) who may perform the medical screening examinations (“MSE”) for EMTALA purposes....1. Qualified Medical Person or Personnel (“QMP”) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example:...i. Psychiatric Social Worker...ii. Registered Nurse in Psychiatric Services...iii. Psychologist...iv. Physician Assistant...v. Advanced Registered Nurse Practitioner...” Hospital document titled “(Hospital) Governing Board Bylaws,” Effective March 2025, revealed “...”...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel (“QMP”) who may perform the medical screening examinations (“MSE”) for EMTALA purposes....1. Qualified Medical Person or Personnel (“QMP”) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example:...i. Registered Nurse in Psychiatric Services...ii. Physician Assistant...iii. Advanced Registered Nurse Practitioner...” Medical record review revealed the following: Patient #1: Medical Screening Examination, no documented date, contained no documented entries for “...QMP Printed Name...QMP Signature...Date...Time...” Patient #3: Screening Assessment dated February 18, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW). Patient #4: Screening Assessment dated February 26, 2025, completed by an unlicensed employee with the credential Master of Science in Professional Counseling. Patient #5: Screening Assessment dated April 4, 2025, completed by an unlicensed employee with the credential Master of Science (MS). Patient #10: Screening Assessment dated March 1, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW). Patient #13: Screening Assessment dated February 14, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW). Patient #14: Screening Assessment dated December 31, 2024, completed by an unlicensed employee with the credential Master of Social Work (MSW). Patient #16: Screening Assessment dated October 3, 2024, completed by an unlicensed employee with the credential Behavioral Health Technician (BHT). Patient #19: Medical Screening Examination dated March 13, 2025, contained only one (1) of two (2) pages, missing documented entries for “...QMP Printed Name...QMP Signature...Date...Time...” Patient #20: Screening Assessment dated February 6, 2025, completed by an unlicensed employee with the credential Master of Science (MS). Employee #9 confirmed, during an interview conducted on April 10, 2025, that the employees who completed the MSEs for Patients #1, #3, #4, #5, #10, #13, #14, #16, #19, and #20 were not QMPs for purposes of completion of Medical Screening Examinations or Screening Assessments.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on review of hospital policy and procedure, hospital documentation, medical record request and employee interview, it was determined that the hospital failed to ensure a medical record for a patient was established and maintained. This deficient practice poses the risk of patient treatment not being accurate, timely and of continuity of care being compromised. Findings include: Hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” revealed “...Treatment...A. A person who comes to (the hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists...The chart should document continued monitoring until the patient is stabilized or transferred...Signs & Records...C. Transfer records...(the hospital) will maintain medical and other records related to individuals transferred or discharged to or from the Hospital for six (6) years....” Hospital document titled “EMTALA Log” revealed Patient #2 arrived at the hospital on February 17, 2025, at 01:48, with a departure at 02:05, “...Recom...Medical Send Out...Dispo...911...” Hospital document titled “Incident Report Log” revealed “...Incident Date...2/17/2025...Involved Party Name...(Patient #2)...Incident Type...Unscheduled Transfer...” Hospital document titled “Incident Abstract Report” revealed “...Involved Party Name: (Patient #2)...Incident Date: 2/17/2025...Incident Note: Additional Comments from Intake...(Patient #2) was dropped off via car came in and sat down to have vitals taken, (he/she) stated (he/she) did not feel good then (he/she) started to have a seizure (he/she) came out of it after 2 minutes but then (he/she) had another code was called as well as 911. (he/she) had a couple more seizures after that before the ambulance came and (he/she) was transported to the hospital....” A request was made on April 9, 2025, for medical records for Patient #2. None were provided. Employee #9 confirmed in an interview on April 9, 2025, that no medical record or additional documentation for Patient #2 was available for review at the time of the survey.”

“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: 49638 Based on review of Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure a medical screening exam (MSE) was completed for patients coming to the facility to determine whether or not an emergency medical condition exists. This deficient practice poses a potential 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: Hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” revealed “...Treatment...A. A person who comes to (the Hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists... Hospital document titled “EMTALA Log” revealed the following: Patient #2 arrived at the Hospital on February 17, 2025, at 01:48. Patient #11 arrived at the Hospital on March 20, 2025 at 16:21. Patient #17 arrived at the Hospital on April 5, 2025, at 15:35. Patient #19 arrived at the Hospital on March 13, 2025 at 12:05. Hospital medical records revealed the following: Patient #2 - MSE was requested, none was provided. Patient #11 - Document titled “Screening Assessment,” dated March 20, 2025, did not contain the name or signature of the employee who completed the document. Patient #17 - Document titled “Screening Assessment,” dated April 5, 2025, did not contain patient name or identifying information. Patient #19 - Document titled “Medical Screening Examination,” dated March 13, 2025, did not contain page two (2) of two (2), including the name or signature of the employee who completed the document. Employee #9 confirmed during interviews conducted on April 9, 2025 through April 10, 2025, that the MSEs for Patients #2, #11, #17 and #19 were either missing or incomplete.”

“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: 49638 Based on Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital delayed examination and/or treatment for two (2) of 20 patients who presented to the Hospital seeking emergency 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 Active Labor Act (EMTALA)” revealed “...Treatment...A. A person who comes to (the Hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists...C. If the specific...Hospital does not have the capacity or capability to treat the patient’s EMC...the Hospital will stabilize the patient’s medical condition within its capacity and capability and appropriately transfer the patient to another facility for further appropriate care...No Delay in Treatment or Examination...Reasonable registration processes may be followed...if those processes do not delay or discourage the person from receiving the emergency care described above....” A total of 20 patient medical records were randomly selected for review from the Hospital’s EMTALA Log, Incident Report Log and Unscheduled Transfer Log. Two (2) out of 20 medical records and related Hospital documents revealed the following: Patient #19 Hospital document titled “EMTALA Log” revealed Patient #19 arrived at the Hospital on March 13, 2025, at 12:05 as a “walk-in,” and that the recommendation was “...Medical Send Out...Dispo...non-911 Transp....” Medical Screening Examination dated March 13, 2025, stated “ ...Diabetic: Yes ...Accucheck: 235 @ 12:45 ....” Screening Assessment dated March 13, 2025, stated “...Based on discussion with the consulting provider, recommendations for care/follow up: INPATIENT (MENTAL HEALTH) ....” Interdisciplinary Progress Note dated March 14, 2025, stated “...Patient (Pt) stated (he/she) is a diabetic and stated (he/she) needed insulin early, after arrival...Per Pt, Nurse stated insulin could not be given because (he/she) is not a patient. Pt expressed concerns that (he/she) knew (his/her) blood sugar would increase without being medicated....” Employee #9 confirmed during interview conducted on April 10, 2025, that Patient #19 arrived at the hospital on March 13, 2025, at 12:05, that he/she was screened to have a psychiatric emergency medical condition but that medical exclusionary criteria existed that the Hospital did not have the capability to provide care for. Employee #9 further confirmed Patient #19 was not able to self-administer insulin until March 13, 2025, at 21:36 and that he/she was transferred “...to the closest emergency room for medical clearance...” on March 13, 2025, at 23:45. Patient #20 Hospital document titled “EMTALA Log” revealed Patient #20 arrived at the Hospital on February 6, 2025, at 10:15 as a “walk-in,” and that the recommendation was “...IPMH (verified by Employee #9 to be defined at Inpatient Mental Health)...Dispo...Referred Out....” Screening Assessment dated February 6, 2025, was completed at 11:02 and discussed with consulting provider at 11:48, stated “...Based on discussion with the consulting provider, recommendations for care/follow up: Pt. is recommended for inpatient mental health treatment for psychois [sic] and stabilization for safety....” Employee #9 confirmed during interview conducted on April 10, 2025, that Patient #20 arrived at the hospital on February 6, 2025, at 10:15, that he/she was screened to have a psychiatric emergency medical condition but that medical exclusionary criteria existed that the Hospital did not have the capability to provide care for. Employee #9 further confirmed Patient #20 and his legal representative “...were provided referrals for other facilities...and allowed to leave the hospital...,” departure time was 16:20.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49638 Based on Hospital policy and procedure, Hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure patient transfers occurred pursuant to Hospital policy. This deficient practice poses the potential risk that patients will receive inappropriate transfers and health needs will not be met as a result. Findings Include: Hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” revealed “...Transfers...A. When a patient is being transferred from (the Hospital) to another medical facility because it does not have the capacity or capability to treat the patient’s EMC (defined in the policy as Emergency Medical Condition), the following procedure will be followed:...1. Contact the on-call physician to initiate the Consent to Transfer EMTALA Form;...2. Call the Emergency Department able to provide appropriate care to the patient and obtain a verbal acceptance of transfer, including the name of the accepting physician;...3. Discuss transfer and risks with the patient;...4. If the patient consents for transfer call EMS for transfer;...5. Complete and send a copy of the Consent to Transfer EMTALA Form and assessment to the receiving hospital...” Hospital document titled “Consent to Transfer EMTALA Form” revealed the following elements: “...1. Patient Condition, Risks and Benefits of Transfer and including Physician Certification...2. Reason for Transfer...3. Receiving Hospital of Procedural Area Acceptance...4. Mode of Transport...5. Medical Records Sent...6. Patient Consent to Transfer...” A total of 20 Hospital medical records were randomly selected for review including patients who were transferred to another facility due to Hospital lack of capacity or capability to treat patient EMC. Medical records for Patients #2, #5, #7, #10, #11, #19, and #20 contained missing or incomplete Consent to Transfer EMTALA Forms. Employee #9 confirmed, during interviews conducted from April 9, 2025 through April 10, 2025, that Patients #2, #5, #7, #10, #11, #19, and #20 were transferred from the Hospital due to Hospital lack of capacity or capability to treat patient EMCs and that Consent to Transfer EMTALA Forms for each were either incomplete or missing from the patients’ medical records.”