Mercy General Hospital

“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:”

“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: 44780 Based on staff interview, hospital document review, and policy and procedure (P&P) review the facility failed to follow their P&Ps titled, “Expectations of Physicians Serving On-Call to the [Hospital B] Emergency Department”, “Inter-Facility Transfer,” and “EMTALA [Emergency Treatment and Active Labor Act] Emergency Procedure” and comply with CFR 489.24 (f) when they failed to accept the transfer of one of 21 sampled patients (Patient 1), from a referring hospital (who lacked capability), of a patient with an emergency medical condition. (see A 2411). This failure had the potential to delay treatment to stop bleeding and could have resulted in Patient 1’s death. The cumulative effect of this failure resulted in the hospital’s inability to meet EMTALA requirements.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 44780 Based on interview and document review, a hospital with capability and capacity (Hospital B) failed to accept the transfer for one of 21 sampled patients (Patient 1) with emergency medical condition (EMC) from Hospital A. Patient 1 required embolization (procedure to stop blood flow to a specific blood vessel) to treat diverticular disease (condition in which tiny pouches form in the colon). Hospital A did not have capability to perform embolization, but Hospital B did. This failure had the potential to delay treatment to stop bleeding and could have resulted in Patient 1’s death. Findings: During a review of Patient 1’s medical record from Hospital A, titled, “ED Documentation”, dated 10/16/25 at 2:54 p.m., the “ED Documentation” indicated, Patient 1 arrived to Hospital A’s Emergency Department (ED) via ambulance for gastrointestinal (GI) bleed requiring urgent medical treatment. The note indicated Patient 1’s medical initial evaluation was completed, initial treatment provided, and further evaluation performed. During a review of Patient 1’s medical record from Hospital A, titled, “Computerized Tomography (CT) [special radiologic test that helps doctors see inside your body]”, dated 10/16/25 at 4:28 p.m., the CT indicated an artery in the lower part of the large intestine (gut) had started to bleed. During a review of a Transport Center Report, titled, “Escalation Communication [EC]” dated 10/16/25 at 5:22 p.m., EC indicated ED medical doctor (MD) 1 at Hospital A had a conversation with Transfer Center Registered Nurse (RN)1 asking to transfer Patient 1 to higher level of care for Interventional Radiology (IR, medical specialty using minimally invasive, image-guided procedures to diagnose and treat disease) capabilities as Patient 1 required embolization (medical procedure to stop bleeding). During a continued review of the EC document, dated 10/16/25 at 5:22 p.m., EC indicated RN 1 at the Transport Call Center contacted various providers at Hospital B to obtain acceptance of Patient 1. The transcript of the communication indicated the following: 10/16/25 at 5:58 p.m., bed request was sent to Hospital B. 10/16/25 at 6:07 p.m., emergent transfer request was made for IR and GI. 10/16/25 at 6:17 p.m., IR MD has been consulted and agreed to provide specialty services. 10/16/25 at 6:20 p.m., GI MD stated, “Please have it see IR see [Patient 1] first... Hospitalist can call GI if needed”. 10/16/25 at 6:24 p.m., Hospitalist agreed to manage patient with IR and GI services. 10/16/25 at 7:14 p.m., General Surgeon (GS) declined Patient 1 transfer and suggested that Patient 1 be transferred to Hospital C as they had same capabilities as Hospital B. GS further indicated that Patient 1 “ ...was a 86-year-old, and cannot tolerate GI surgery if any potential complications occur from IR ...” 10/16/25 at 7:15 p.m., RN1 escalated GS refusal of patient to Chief Medical Officer(CMO). 10/16/25 at 7:26 p.m., CMO stated GS had refused to accept the patient transfer and Patient 1 will have to be transferred to Hospital C. During an interview on 12/2/25 at 3:10 p.m. with CMO, CMO stated Hospital B does not have colorectal surgery. During an interview on 12/3/25 at 8:35 a.m. with Senior Director Operation Room (SDOR), SDOR stated the hospital does colorectal surgery, and it is one of the common surgeries that they do. SRDO further stated that “ ...never heard that we had transferred a patient to another hospital for GI surgery ...” During an interview on 12/3/25 at 8:50 a.m. with Nurse Shift Manager (NSM), NSM stated that the hospital does an average of three to five colorectal surgeries a week. NSM further stated that the hospital had capabilities to take care of any emergency during GI procedures. During a concurrent interview and document review on 12/3/25 at 10 a.m. with Quality Director (QD), physician call schedules were reviewed, QD stated GS, IR, GI services had on call coverage for Hospital B on 10/16/25. During an interview on 12/3/25 at 10:20 a.m., with Director of Imaging (DI), DI indicated an on call IR team was available on 10/16/25. A review of an undated facility document titled, “[Hospital B] Request for Privileges,” indicated that GS had privileges to do surgeries involving the gastrointestinal tract, including the colon and rectum. During a review of a Hospital B policy titled, “Expectations of Physicians Serving On-Call to the [Hospital B] Emergency Department”, dated 1/2/25, the policy indicated, “All provision of on-call services are expected to comply with EMTALA requirements.” During a review of Hospital B policy titled, “Inter-Facility Transfer”, effective date 12/1/24, the policy indicated, “Inter-facility transfers are necessary to provide patient’s access to specialized providers or higher level of care/services at an appropriate unit/facility ....When a patient requires a higher level of care other than that available/provided at the sending facility, a receiving facility with capability and capacity to provide a higher level of a care may not refuse the request for transfer.” During a review of Hospital B document titled, “EMTALA Procedure,” dated 4/24/25, the document indicated, “Treatment or Transfer of Individuals with an Emergency Medical Condition (EMC): Requirements for an Appropriate Transfer. If the individual’s EMC cannot be Stabilized within the Capability and Capacity of the hospital, the individual shall be transferred in compliance with state and federal law if the hospital with the standards defined as an Appropriate Transfer.” The policy defined, “Capability means the physical space, ancillary services, equipment, supplies, and specialty provider services listed on the On-Call List available at the hospital ...Capacity means the ability of the hospital to accommodate an individual requesting examination or treatment of the transferred individual.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50619 Based on interview, medical record review, and facility policy review, the hospital failed to ensure the protection of patient’s rights for 1 of 30 sampled patients (Patient 1) when: 1. The facility failed to ensure hospital clinician discussions and documentation regarding resuscitation preferences with Patient 1 and Patient 1’s Power of Attorney (POA) was documented in a timely manner (upon admission and prior to surgery) (Refer to A0132); 2. Facility failed to honor Patient 1 and POA’s right to make medical decisions when CPR (cardiopulmonary resuscitation- emergency life-saving procedure done when someone’s breathing or heartbeat has stopped) was performed and epinephrine (medication given to restart heart) was given when Patient 1’s had Do Not Resuscitate (DNR- perform no life-saving interventions such as CPR) orders (Refer to A0132); 3. Facility failed to escalate unresolved complaints to a grievance process for Patient 1’s POA (Refer to A0118); and 4. Facility failed to ensure restraints (medical device used to restrict a patient’s movement or alter behavior for therapeutic purposes) were evaluated by a medical doctor daily and indicated need for restraints was documented for Patient 1 (Refer to A0174). These failures resulted in lack of communication amongst hospital staff between other hospital staff and with Patient 1 and Patient 1’s POA, Patient 1 getting life-sustaining treatment with DNR orders, Patient 1’s POA being told inaccurate information regarding facility being able to override patient’s right to self-determination, prevention of POA’s right to file a Grievance, lack of timely response and documentation regarding service recovery efforts, and Patient 1 being restrained without MD oversight. The cumulative effect of these failures resulted in the hospital’s inability to honor Patient Rights in accordance with the statutorily-mandated Conditions of Participation Patient Rights.”

“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: 50619 Based on interview, medical record review, and facility policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to 1 of 30 sampled patients (Patient 1) when: 1. Patient 1’s nursing daily documented shift note was not initiated every shift (Refer to A-0398), 2. Patient 1’s Do Not Resuscitate (DNR, to withhold life saving interventions such as chest compressions) wristband was not placed and a DNR sign was not placed on Patient 1’s door after DNR orders were placed (Refer to A-0398), and 3. The facilities policies were not clear regarding DNR armband and door signs (Refer to A-0398). These failures contributed to lack of clarity surrounding Patient 1’s code status which resulted in Patient 1 receiving Cardiopulmonary Resuscitation (CPR- life saving interventions when breathing or the heart stops) against his wishes and lack of patient-centered communication amongst hospital staff. The cumulative effect of these failures resulted in the hospital’s inability to provide effective, safe, and quality nursing services in accordance with the statutorily mandated Conditions of Participation for Nursing Services.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 50619 Based on interviews and record reviews, the facility failed to escalate an unresolved complaint concerning staff not following orders when performing Cardiopulmonary Resuscitation (CPR- emergency procedures when someone’s heart or breathing stops) on Patient 1 who was Do Not Resuscitate (DNR, do not perform CPR) to the grievance (formal complaint) process, address concerns, document communication regarding grievance communications, and respond to a grievance in a timely manner for one of 30 sampled patients (Patient 1). . These failures caused emotional distress for Patient 1’s Power of Attorney (POA, a person legally authorized to make medical decisions for a patient) when an incomplete grievance process with unresolved concerns were not escalated, causing lack of communication, lack of documentation, concerns not being addressed regarding patient’s right to self-determination, a loss of trust in the healthcare team, and a delay in response to concerns. Findings: During a telephone interview on 4/30/25 at 5:04 p.m. with Patient 1’s POA and the Department, the POA stated that her father fell at home on 2/19/25 and that the caretaker who helps him 4 hours a day came and found him down. Patient 1 was taken to hospital by ambulance and had a Provider Orders for Life-Sustaining Treatment (POLST- a signed document for patient wishes specifically for end of life choices) signed that the patient filled out requesting to be DNR/DNI (Do not Resuscitate/Do Not Intubate, perform no heart or breathing life saving treatments). POA stated Patient 1’s POLST was not discussed prior to surgery on original phone call with doctor. POA stated she was out of town and assumed that Patient 1’s POLST that had been on file for many years still stood. POA stated Patient 1 changed to DNR/DNI after Patient 1’s spouse passed away many years ago with no changes since. POA stated Patient 1 had surgery on 2/20/25 and clarified with a Registered Nurse (RN) after surgery that the patient wishes to be DNR/DNI. According to the POA, the RN stated Patient 1 was a full code (provide CPR) and possibly the patient was changed to full code for surgery and would have the doctor call POA back to clarify. The POA stated she spoke to Medical Doctor (MD) 3 and clarified DNR/DNI orders. The POA stated she had concerns that Patient 1’s POLST was not acknowledged prior to surgery and concern how Patient 1 was a full code without POA’s permission to change code status. The POA stated on 2/21/25, Patient 1 choked, lost a pulse, and CPR was performed despite clarifying code status the day before with RN and MD to be DNR. The POA stated she was concerned if nurses were communicating code status during shift hand off and how CPR could have happened despite orders being placed. The POA stated Medical Doctor (MD) 4 called and apologized to POA regarding the event. The POA stated her complaint was escalated verbally to the nursing staff, management and upper leadership on 2/21/25 with concerns regarding staff not following DNR orders and the harm caused to Patient 1 from not following orders. The POA stated she spoke with the Chief Nursing Officer (CNO), who POA described as “dismissive” of POA’s concerns and made excuses with responses such as it being an accident and that they will do anything they can to save someone in an “accident” scenario. The POA stated she was concerned that staff could change code status for “accidents” without consulting a POA and was concerned that if nursing staff and management were not taking accountability, changes would not be enforced to prevent the same thing from happening to future patients. The POA stated that Patient 1 has declined significantly after the CPR and had concerns about the financial implications of paying for long-term care. The POA stated her written grievance was sent to “claims” and POA has not heard any formal response back addressing her concerns and it has been over two months since the incident occurred. During a review of Patient 1’s “History and Physical (H&P),” dated 2/19/2025, the H&P indicated Patient 1 was admitted to the hospital on 2/19/25 with diagnoses which included a right broken hip related to a fall, dementia (a brain disease that affects memory, thinking, and reasoning), B-Cell lymphoma (a type of blood cancer that affects white blood cells) in remission (not actively progressing), chronic pain, and Coronary Artery Disease (CAD, damage or disease in heart’s major blood vessels). The H&P indicated that the patient lived alone at home with a caretaker that visits in the morning and was ambulatory with walker at baseline. A Heart Healthy (low sodium) diet was ordered and the patient was documented as Full Code (Indicates consent to do all life saving measures in the event of cardiac or respiratory arrest). Medical Doctor (MD) 1 documented that all questions and concerns were addressed with family, however, discussion regarding code status clarification was not specifically documented. During a review of Patient 1’s “Consultation” note, dated 2/19/25, the note indicated, “Patient’s Power of Attorney is his daughter ...My findings and recommendations were reviewed with both patient and his daughter ...who has medical decision-making over her father ...” During an interview on 5/6/25 at 3:28 p.m. with Registered Nurse (RN) 5, RN 5 stated the “...daughter called in on her own after [Patient 1’s] surgery. She was concerned about it [DNR status] ...that he’s normally a DNR, supposed to be DNR and concerned that she wasn’t there, but wanted to make sure he was DNR”. RN 5 stated she relayed to POA that Patient 1 was documented as a full code and probably because of surgery, but would talk to the doctor. RN 5 stated the order was changed to DNR and it was passed along in report to the next shift in person because the unit was right next door. RN 5 stated, “I always give code status in report. It is one of the first things I say ...” During a review of Patient 1’s “Orders”, dated 2/20/25, the order indicated the code status was changed by Medical Doctor (MD) 3 to DNR/DNI: If no pulse and not breathing (Cardiopulmonary arrest) DO NOT RESUSCITATE/ALLOW NATURAL DEATH. NO chest compression. Any other treatment as medically necessary.” During a review of Patient 1’s “Orders” dated 2/21/25, the orders indicated that Registered Nurse (RN) 4 acknowledged the DNR/DNI orders entered by MD 3. In a telephone interview on 5/6/25 at 11:40 a.m. with RN 4, RN 4 stated, “When I received [Patient 1], he was already DNR ...I remember telling the next nurse he was DNR.” During a review of Patient 1’s “Physician Note,” dated 2/21/25, the Note entered by MD 3 indicated that Patient 1 had hip surgery on 2/21/25 and was briefly admitted to Intensive Care Unit (ICU) for low blood pressure, but later downgraded to medical surgical telemetry floor and that “CODE STATUS was changed to DNR/DNI per patient’s daughter’s request and original CODE STATUS per POLST ... The patient was eating peanut butter and quickly went unresponsive, choked on peanut butter and lost pulse. CPR was started and [Patient 1] received 1 round of epinephrine [a drug used during CPR to stimulate the heart and improve blood flow during cardiac arrest] before he was identified as DNR/DNI ...His airways was suctioned out clean after which patient started breathing again and had organized rhythm [a return of normal heart rhythm] ...”. During a review of Patient 1’s “RRT (Rapid Response Team) Note,” dated 2/21/25, the RRT Note, written by Registered Nurse (RN) 3, stated that Patient 1 was sitting in bed working with Physical Therapy (PT) and Patient 1 was eating a peanut butter and jelly sandwich. The note indicated at 12:14 p.m. the heart rate monitor alarmed in the 40’s (normal heart rate 70-100 beats per minute) and upon entering the room to check, Patient 1 was found unresponsive, purple, and with a carotid pulse. The note stated a RRT was called to bedside. The note included that some of the sandwich was suctioned out of the mouth/ airway with a Yankauer (a tool that suctions the mouth). The note indicated, at 12:15 p.m., RRT arrived to bedside and Patient 1 had no palpable pulse with pulseless electrical activity (PEA-electrical activity shown on a monitor of the heart but no contractions or blood flow are occurring). The note continues, “CPR was started. See code blue sheet. CPR stopped and return of spontaneous circulation (ROSC) obtained.” The note revealed, “Deep suction provided by [MD 5]. DNR armband was not on patient and DNR sign not on door. Family called by [MD 3], no answer and left message. [MD 4] called and spoke to [POA] and explained situation... Addendum: [MD 3] stated patient was DNR/DNI and code was stopped. Prior to CPR, code status was not discussed with code team.” During a telephone interview on 5/6/25 at 2:12 p.m. with RN 3, RN 3 stated DNR patients should have a purple wristband and sign. RN 3 stated she was told in handoff report from prior nurse that Patient 1 was a DNR/DNI. RN 3 described Patient 1 as confused and stated she was with him most of the morning and he ate breakfast “fine”. PT was working with him and gave him a sandwich. RN 3 noticed Patient 1’s heart rate was in the 40’s on the heart monitor and immediately went in room and saw Patient 1 unresponsive with sandwich hanging out of his mouth. RN 3 stated Patient 1 had a pulse and she “did not realize he was DNR off the bat”. RN 3 recalled Patient 1 lost his pulse, and a Code Blue (medical emergency) started. RN 3 stated one round of CPR (chest compressions) and one dose of epinephrine was given to Patient 1. RN 3 stated “...I was floated to a unit I’ve never been to before, felt out of sorts from the start ...”. RN 3 stated there was no CNA (certified nurse assistant) on the unit, it was very busy and, it was a sudden event”. RN 3 explained, “In the heat of the moment, they [RRT] came in ...Usually am able to collect thoughts, they [RRT] just came so fast, we hit the ground running. I was not asked if patient full code, but I did not stop CPR when it started. It was stressful, it didn’t come to mind to say something [about stopping CPR]. I’m not sure if POLST was on file.” The RN 3 stated MD 3 came into Patient 1’s room and clarified Patient 1 was DNR and “at that point it clicked in my head...the patient is DNR” and the code blue was stopped. During an interview on 5/5/25 at 1:10 p.m. with Patient Safety Manager (PSM), PSM indicated, “Grievances are escalated complaints ...If unable to resolve in real-time, it [complaint] gets escalated to a grievance ...The process usually takes about a week. A “bridge” letter gets sent if takes longer than usual to process. The PSM stated if the complaint was considered a “claim”, “it goes to [Name of Corporation] and it is usually about a week for claims as well. We don’t deal with claims.” During an interview on 5/5/25 at 2:56 p.m. with PSM, PSM stated the POA came to the hospital and wanted to speak to the manager, director and CNO, and that was how it came to the Quality Department’s awareness. The PSM stated service recovery was attempted, but the service recovery did not meet the POA’s expectations, and the POA continued to call. The PSM stated, “We did not address her concerns to her liking ...I’m unsure if [POA] was given a timeline.” During an interview on 5/5/25 at 3:16 p.m. with Quality and Patient Safety Program Manager (QSM), QSM stated, “ ...Every service recovery was unsuccessful ...Service recovery is documented in IRIS (facility’s grievance documentation software) ... It [complaint] was sent to claims platform shortly after. We have no policy and procedure regarding claims. We received the claim and are reviewing. Our claims process is only verbal.” In an interview on 5/6/25 at 10:47 a.m. with Chief Medical Officer (CMO), CMO stated, “If CPR started after heart stopped, it falls outside of an accident ...Doing CPR on a stopped heart is considered resuscitative.” During an interview on 5/6/25 at 11:06 a.m. with the CNO, the CNO stated that she spoke to POA after the manager and director called. The CNO stated the POA was “very upset” and “could not understand why we resuscitated [Patient 1].” The CNO stated the POA “could not understand change to code status for surgery and the first comments right out the gate was that she contacted attorneys.” The CNO stated she told the POA, “I will get you in touch with claims”. The CNO stated, “...the nurses were acting in his [Patient 1’s] best interest. It was an accident and the team was trying to help him” and, “Staff reacted to the choking situation with good intent to try and help him.” The CNO stated, “In her [POA] mind, we failed her. I feel like she was crossing the line in what we would treat and do a code blue on.” The CNO described the conversation with the POA as, “a lot of anger was directed at us. She was overly angry...It was misdirected anger towards us. She was just angry it took place while she was on vacation” During a continued interview on 5/6/25 at 11:14 a.m. with CNO, CNO stated, “[POA] was upset about us suctioning and CPR. Most people would say thank you for helping...[POA] had no empathy about what the caregiver team went through.” The CNO stated, “Ultimately, the nurse needs to follow code status.” During an interview on 5/7/25 at 11:23 a.m. with PSM, PSM stated, the POA’s “Claim is still open” and, “have not sent [POA] any formal letters yet.” During an interview on 5/7/25 at 1:22 p.m. with PSM, the PSM stated that the initial complaint came from POA to hospital on 2/21/25. CNE, RN 5, a charge nurse, and a manager had initial contact with POA regarding the complaint. CNE was notified via an internal communication system regarding the complaint on 2/21/25 and it only holds messages for 30 days. The PSM stated the CNE told PSM on 2/21/25 at 4:40 p.m. that CNE spoke to POA and it would be a claims case. PSM stated the complaint was not considered a grievance, “because there was resolution while here. Service recovery done in real-time ...We apologized for CPR and Epi[nephrine] . The PSM stated, “we do not have documentation of the conversations had with [POA]. We recognize that we should have documented the conversations and opened a grievance.”. The PSM stated the claims department staff are not medical professionals and would not be able to address medical concerns, only the financial aspects. The PSM stated there was, “no bridge letter was sent [letter to notify investigation process will take longer than usual]” The PSM stated there was no documentation on file of attempts to resolve [POA’s] grievance.” During a review of “Patient Rights and Responsibilities,” undated, indicated, “...If you need help filing a grievance, the Patient Safety Officer is available to help you. The grievance committee will review each grievance and provide you with a written response within seven days. The written response will contain the name of a person to contact at the hospital, the steps taken to investigate the grievance, the results of the grievance process and date of completion of the grievance process...” During a review of the facility’s policy and procedure (P&P) titled, “[Corporate Name] HEALTH ADMINISTRATIVE POLICY,” dated 5/2024, the P&P stipulated, “ ...POLICY: It is the policy of [Corporate Name] that patients or their representative’s grievances or complaints are communicated in a timely, reasonable, and consistent manner to the appropriate departments for investigation, problem resolution and follow up.” During a review of the facility’s P&P titled, “[Corporate Name] HEALTH ADMINISTRATIVE PROCEDURE,” dated 10/2023, the P&P directed, “B. IDENTIFYING A GRIEVANCE: 1. Grievances ...can be ...expressions of dissatisfaction submitted by ... oral complaints ...that are not immediately resolved to the patient’s satisfaction by the staff present. 2. Grievances may be made by patients, visitors or their representatives ...3. Grievances include, but are not limited to: a. Complaints regarding dissatisfaction with the patient’s treatment or visit b. Complaints regarding patient’s rights, privacy and safety ...d. Accusations of abuse- ...or neglect ...e. Complaints regarding noncompliance with CMS [Centers for Medicare and Medicaid] requirements ...C. RESPONSIBILITIES RELATED TO THE GRIEVANCE PROCESS: 1. The organization’s governing body shall approve and be responsible for the effective operation of the Grievance Process with respect to Patient Care Grievances consistent with the standards set forth in this Policy. The governing body may delegate this responsibility in writing to a Grievance Committee. a. The governing body or Grievance Committee shall review and resolve such Grievances in compliance with CMS regulations, including following timeframes set forth in CMS Interpretive Guidelines to investigate and resolve grievances. D. PROCEDURES APPLICABLE TO ALL GRIEVANCES: 1. Based on the nature of the complaint, it shall be handled as a patient care grievance or a Civil Rights Grievance as set forth in this Procedure. Coordination and resolution of all Grievances will be handled in accordance with this Procedure ...5. The organization will document its efforts related to the handling of Grievances, including all communications with the patient or visitor, the investigation process and the resolution, if any ...E. COMPLAINTS RELATED TO PATIENT CARE AND SERVICES (“Patient Care Grievance(s)”): 1. Grievance Process and Decision a. The Point of Contact shall provide a response to a Grievance in writing within seven (7) calendar days of the complaint. i. If the investigation will not be completed, or if the Grievance will not be resolved, within seven (7) calendar days, the organization shall inform the patient or visitor that the organization needs additional time to resolve the Grievance and indicate the timeframe in which the response will be provided. b. Reasonable efforts shall be made to resolve all Grievances within thirty (30) calendar days and in accordance with regulatory requirements. If the matter cannot be resolved in thirty (30) calendar days, then a written status report shall include the estimated timeframe for completing the investigation and issuing a written report. c. A written report regarding the outcome of the investigation as to each Grievance must be provided to the patient or visitor. The report shall include the following: i. The name of the organization contact person. Ii. The steps taken on behalf of the individual to investigate the Grievance. Iii. The results of the Grievance Process. Iv. The date of completion of the Grievance Process. d. Patients shall also be made aware of: i. A notice of the right to appeal the decision is provided and includes how to submit a written statement setting forth reasons the action taken is inadequate and including any additional facts to be considered on review. ii. Validation of the individual’s right to raise any concern (even if investigation shows such a concern to be unfounded or to be the result of an unrealistic expectation). iii. Acknowledgement that it is apparent from the concerns raised that the organization did not meet or exceed the individual’s expectation of the quality of the care/service received. iv. A list of agencies that the individual has a right to contact to file an external grievance such as CMS, the applicable state licensing agency, the accrediting organization and the Quality Improvement Organization (QIO). 2. Appeal of Grievance Decision a. There may be situations where the organization has taken appropriate steps in response to a Grievance, yet the patient/Representative or visitor remains dissatisfied with the organization’s actions. In such cases, the individual’s written written request for further action shall be taken to the organization’s Grievance Committee for resolution. b. The Grievance Committee shall review the written request for further action in conjunction with the actions taken by the organization in response to the original complaint and determine what further actions, if any, shall be taken. c. The Grievance Committee shall send a letter to the individual explaining its decision. d. Although the individual may not agree with the Grievance Committee’s decision, the organization may consider the decision final and the Grievance closed. 3. Patient care grievances that involve a Physician or Advanced Practice Provider will be handled through the organization’s Peer Review process as outlined in the Medical Staff Bylaws. An explanation of the Peer Review process shall be communicated to the patient or visitor; however, because the outcome of the Peer Review is confidential, the results are not released as part of the Grievance Process.””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 35598 Based on interview and record review, the facility failed to follow policy and procedures and to ensure one of 30 sampled patients (Patient 1) had the right to implement their plan of care and the right to self-determination when; 1. The facility failed to ensure physician discussions and documentation of Cardiopulmonary Resuscitation (CPR, or code status, emergency procedures when someone’s heart or breathing stops) preferences with Patient 1 or Patient 1’s Power of Attorney (POA) in a timely manner (upon admission and prior to surgery); and 2. The facility failed to ensure POA’s right to make medical decisions for Patient 1 when Do Not Resuscitate (DNR, do not perform Cardiopulmonary Resuscitation) orders were not followed during a code blue (medical emergency when breathing or the heart stops) . These failures resulted in a lack of communication between staff and POA, confusion surrounding Patient 1’s code status leading to not honoring Patient’ 1’s right to self-determination. This had potential to result in physical pain and suffering for Patient 1, decrease in quality of life for Patient 1, and emotional distress for Patient 1 and Patient 1’s family. Findings: During a review of Patient 1’s “History and Physical (H&P),” dated 2/19/2025, the “H&P” indicated that Patient 1 was admitted to the hospital on 2/19/25 with diagnoses which included a right broken hip related to a fall, dementia (a brain disease that affects memory, thinking, and reasoning), B-Cell lymphoma (a type of blood cancer that affects white blood cells) in remission (not actively progressing), chronic pain, and Coronary Artery Disease (CAD, damage or disease in heart’s major blood vessels). 1. During a review of Patient 1’s “H&P,” dated 2/19/2019, written by Medical Doctor (MD) 1 indicated that Patient 1 was Full Code (indication of consent to receive all life-saving measures and resuscitation efforts in the event of a loss of pulse or breathing) and there was no documentation regarding code status clarification with POA or reference to Patient 1’s Provider Orders for Life Sustaining Treatment (POLST- a signed document for patient wishes specifically for end of life choices). During a review of Patient 1’s “POLST” dated 12/2016, there was no documentation of when POLST was given to the hospital. POLST was scanned into electronic medical record after Patient 1’s hospital discharge on 2/27/25. During an interview on 5/6/25 at 10:47 a.m. with Chief Medical Officer (CMO), CMO stated the facility was not sure if POLST came with Patient 1 or came later during the stay. CMO stated the POLST was “scanned in” to Patient 1’s medical record after discharge. The CMO stated a patient’s code status was supposed to be documented in the admission note and admitting doctor orders the code status. The CMO stated MD 1 did not document a code status discussion. During a review of Patient 1’s note titled, “Consultation,” dated 2/19/25 documented by MD 2, the “Consultation” note indicated that MD 2 spoke with the POA regarding consenting to surgery. Code status was not documented nor was there documentation regarding discussion of resuscitation wishes with Patient 1 or POA. During a review of “Anesthesia (medication used to prevent pain and awareness during surgery) Physician Note,” dated 2/19/25, Medical Doctor 6 did not document Patient 1’s code status or reflect discussion with Patient 1, POA, or other Providers regarding resuscitation preferences. During a review of “ANESTHESIA H&P,” dated 2/20/25, MD 6 did not document the code status or if any communication that occurred with Patient 1, POA, or other Providers to discuss resuscitation preferences. During a review of “ANESTHESIA RECORD (an intra-operative record),” dated 2/20/25, Medical Doctor (MD) 7 did not document code status or if any communication that occurred with Patient 1, POA, or other Providers to discuss resuscitation preferences. During a review of “Physician Note,” dated 2/21/25, the “Physician Note” indicated it was a surgical progress note done after Patient 1’s hip surgery completion. MD 2 did not include a documented a code status or mention conversation with POA for Patient 1 to discuss code status plans postoperatively. During an interview on 5/6/25 at 3:28 p.m. with Registered Nurse (RN) 5, RN 5 stated the “...daughter called in on her own after [Patient 1’s] surgery. She was concerned about it [DNR status] ...that he’s normally a DNR, supposed to be DNR and concerned that she wasn’t there, but wanted to make sure he was DNR”. RN 5 stated she relayed to POA that Patient 1 was documented as a full code and probably because of surgery, but would talk to the doctor. RN 5 stated the order was changed to DNR and it was passed along in report to the next shift in person because the unit was right next door. RN 5 stated, “I always give code status in report. It is one of the first things I say ...” During a review of facility’s “Policy and Procedure (P&P),” dated 4/2025, the “P&P” indicated, “POLICY: B. Upon admission, all patients need to have code status defined ...I. GENERAL PRINCIPLES: B. As early as appropriate in the doctor-patient relationship, physicians should discuss resuscitation preferences with patients and should make recommendations regarding resuscitation to the patient. If the patient lacks decision-making capacity, it is the physician’s responsibility to discuss the issue with the patient’s agent or surrogate decision-maker ...D. The physician and other members of the health care team shall communicate among themselves information relevant to the patient’s decision about resuscitation and shall document that information in the patient’s medical record. I. DOCUMENTATION A. Physicians will document in the Patient Progress Notes the decision to write a DNR/ AND order including the wish of any selective treatments of ...no intubation ...c. Existence of advanced directive or POLST form ...” During an interview on 5/6/25 at 11:28 a.m. with Registered Nurse (RN) 7, RN 7 stated that around noon on 2/21/25, regarding a patient choking. RN 7 got to Patient 1’s room a minute later and asked if Patient 1 was full code and primary RN stated Patient 1 was full code. RN 7 stated another nurse performed CPR and MD 5 was there. RN 7 stated MD 3 showed up, recognized patient, and stated the patient was DNR. RN 7 stated she asked RN 3 if Patient 1 was DNR and RN 3 confirmed Patient 1 was DNR. During a telephone interview on 5/6/25 at 2:12 p.m. with RN 3, RN 3 stated DNR patients should have a purple wristband and sign. RN 3 stated she was told in handoff report from prior nurse that Patient 1 was a DNR/DNI. RN 3 described Patient 1 as confused and stated she was with him most of the morning and he ate breakfast “fine”. PT was working with him and gave him a sandwich. RN 3 noticed Patient 1’s heart rate was in the 40’s on the heart monitor and immediately went in room and saw Patient 1 unresponsive with sandwich hanging out of his mouth. RN 3 stated Patient 1 had a pulse and she “did not realize he was DNR off the bat”. RN 3 recalled Patient 1 lost his pulse, and a code blue started. RN 3 stated 1 round of CPR (chest compressions) and 1 dose of epinephrine was given to Patient 1. RN 3 stated “...I was floated to a unit I’ve never been to before, felt out of sorts from the start ...”. RN 3 stated there was no CNA (certified nurse assistant) on the unit, it was very busy and, it was a sudden event”. RN 3 explained, “In the heat of the moment, they [RRT] came in ...Usually am able to collect thoughts, they [RRT] just came so fast, we hit the ground running. I was not asked if patient full code, but I did not stop CPR when it started. It was stressful, it didn’t come to mind to say something [about stopping CPR]. I’m not sure if POLST was on file.” The RN 3 stated MD 3 came into Patient 1’s room and clarified Patient 1 was DNR and “at that point it clicked in my head...the patient is DNR” and the code blue was stopped. During a review of facility document titled, “Patient Rights and Responsibilities,” undated, the facility document indicated that patients have the right “3. To communicate effectively with your care team...5...You have the right to effective communication and to participate in the development and implementation of your plan of care. You have to right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services...6. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse course of treatment...7...refuse treatment..9. Reasonable response to any reasonable requests made...11. Formulate Advanced Directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care shall comply with these directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf. “ During a review of facility P&P titled, “Do Not Resuscitate,” dated 10/2022, the P&P indicated, “I. GENERAL PRINCIPLES: D. The physician and other members of the health care team shall communicate among themselves information relevant to the patient’s decisions about resuscitation and shall document the information in the patient’s medical record. REVIEW OF DNR/AND ORDERS B. The DNR/AND order shall be reviewed by the physician with the patient and his/her agent or surrogate decision-maker whenever a change in circumstances occurs that, in the physician’s opinion, may affect consent to the order. Such as change of circumstances might include, for example, a change in patient’s condition, change in physician, or a change in the unit ...V. DO NOT RESUSCITATE ORDERS IN THE OPERATING AND RECOVERY ROOMS A. This policy recognizes that DNR orders may[ ]be continued during surgery, thereby providing greater freedom of choice for both patients and healthcare professionals. 1. Previously designated code status will be maintained throughout the operative and immediate postoperative phases unless the patient’s physician, and consultation with the patient or the patient’s agent or surrogate decision maker, and with the anesthesiologist and/ or surgeon agreement. 2. Physicians caring for the patient - the attending physician, surgeon and anesthesiologist -should confer about whether a DNR order should be continued. One of the physicians should then discuss the DNR order with the patient and/ or patient’s agent or surrogate decision- maker preoperatively and decide whether to continue the orders. 3. Discussions with the patient and/ or agent or surrogate decision-maker regarding code status during surgery, and a patient’s informed consent as to a change of code status, must be documented in the patient’s progress notes ...” During a review of facility P&P titled, “DO NOT RESUSCITATE,” dated 10/2022, the P&P indicated, “V. DO NOT RESUSCITATE ORDERS IN THE OPERATING AND RECOVERY ROOMS A. 6. A DNR order that has been suspended during an operative procedure should be reinstated by the surgeon’s orders after the patient leaves the Recovery Room/PACU, unless the patient and/or agent or surrogate decision-maker, in consultation with the anesthesiologist, have specified a different time frame. 2. During a review of “Orders,” dated 2/20/25, MD 3 indicated that the code status changed from full code to “DNR/DNI: If no pulse and is not breathing (Cardiopulmonary arrest). DO NOT RESUSCITATE/ALLOW NATURAL DEATH. NO chest compression ...” During a review of “Progress Note,” dated 2/21/25 at 1: 24 p.m., the “Progress Note” written by MD 3 indicated, “CODE STATUS was changed to DNR/DNI per patient’s [POA’s] request and original CODE STATUS per POLST. This morning, the patient was eating peanut butter and quickly went unresponsive, choked on peanut butter and lost pulse. CPR was started and [Patient 1] received 1 round of epinephrine before Patient 1 was identified as DNR/DNI ...” During a review of “Physician Note,” dated 2/21/25, the “Physician Note” entered by MD 5 indicated, “CODE BLUE called overhead, patient was eating peanut butter and quickly went unresponsive with [physical therapy] in room, patient choked and lost pulse, [when I] came in[,] CPR was in progress and patient had already received epinephrine. At pulse check patient had pulse (total 3 min[utes] downtime), patient identified as DNR/DNI ...” During a review of “RRT Note,” dated 2/21/25, the “RRT Note” written by RN 3 indicated that Patient 1 was sitting in bed and working with Physical Therapy and eating a peanut butter and jelly sandwich and at 12:14 p.m. Patient 1 was found “purple, nonresponsive with carotid pulse”. Rapid Response Team (RRT) called and suctioned some of sandwich with oral suction equipment. At 12:15 p.m. RRT arrived to bedside and Patient 1 now had no pulse, and per RRT patient had cardiac rhythm of pulseless electrical activity (PEA, a type of cardiac arrest where heart shows electrical activity, but no pulse). CPR started and ROSC (return of spontaneous circulation) was obtained ...In an addendum, RN 3 wrote that MD 3 said Patient 1 was DNR/DNI and code was stopped. Prior to CPR, code status was not discussed with code team. During a review of “Code Blue Audit”, dated 2/2025, the “Code Blue Audit” indicated that Patient 1 was eating a sandwich, started choking, RN requested RRT and stated Patient 1 was full code. The note continues, CPR started for 2 minutes and once discovered confusion with code status, then ROSC. During an interview on 5/6/25 at 10:47 a.m. with Chief Medical Officer (CMO), CMO stated that “If CPR started after heart stopped, it falls outside of [being] an accident ...Doing CPR on a stopped heart is considered resuscitative.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 35598 Based on interview, medical record, and facility policy review, the facility failed to ensure that restraints use (medical device used to restrict a patient’s movement or behavior for therapeutic purposes) was evaluated and indicated need was documented by a medical doctor (MD) daily for 1 of 30 sampled patients (Patient 1). This failure resulted in Patient 1 lacking MD oversight and possibly remaining in restraints unnecessarily which had potential to contribute to injury or other serious outcome. Findings: Patient 1 was admitted to the hospital on 2/19/25 with diagnoses which included recent fall resulting in a broken hip, dementia (a brain disease that affects memory, thinking, and reasoning), chronic pain, and Coronary Artery Disease (CAD, damage or disease in heart’s major blood vessels). During a concurrent interview and medical record review on 5/8/25 at 10:54 a.m. with Nurse Educator 2 (NE 2), Patient 1’s “Physician Notes”, dated 2/24/25, and “Orders”, dated 2/24/25, were reviewed. The “Physician Note” indicated, “[Patient 1] is less agitated, but more sleepy today.” The NE 2 confirmed that documentation from MD 4 re-evaluating support of continued use of restraints was missing in progress notes dated 2/24/25 at 8:22 a.m. and a restraint order was placed by MD 4 to renew restraints on 2/24/25 at 8:00 a.m. During an interview on 5/8/25 at 2:48 p.m. with Chief Medical Officer (CMO), CMO stated that physicians need to determine the need for restraints and document reasoning in progress notes and would not expect to continue restraints if less agitated and more sleepy. The CMO stated if restraint use was continued, progress notes should state they are still on and if restraints use was not documented in note, would be considered a “miss”. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Management,” dated 4/2025, the P&P indicated, “ ...V. Notification of the Patient’s Attending Physician C ...When the physician ... renews an order or writes a new order authorizing the continued use of restraint, there must be documentation in the patient’s medical record that describes the findings of the physician’s ...re-evaluation supporting the continued use of restraint.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50619 Based on interview, medical record, and facility policy review, the facility failed to follow policy and procedure for one of 30 sampled patients (Patient 1) when: 1. The facility failed to ensure nursing documented daily shift progress notes every shift for Patient 1; 2. The facility failed to ensure Do Not Resuscitate (DNR, to withhold life-saving interventions such as chest compressions) wristband was placed on Patient 1 and DNR sign placed on Patient 1’s door after DNR orders placed, 3. The facility failed to have clear policies regarding DNR armbands and door signs. These failures resulted in lack of patient-centered communication amongst hospital staff, chain of command not being followed, and lack of clarity surrounding Patient 1’s code status which resulted in Patient 1 receiving Cardiopulmonary Resuscitation (CPR, emergency procedures when someone’s heart or breathing stops) when Patient 1’s wishes were to be a DNR. Findings During a review of Patient 1’s “History and Physical (H&P),” dated 2/19/2025, the H&P indicated Patient 1 was admitted to the hospital on 2/19/25 with diagnoses which included a right broken hip related to a fall, dementia (a brain disease that affects memory, thinking, and reasoning), B Cell lymphoma (a type of blood cancer that affects white blood cells) in remission (not actively progressing), chronic pain, and Coronary Artery Disease (CAD, damage or disease in heart’s major blood vessels). 1. During a concurrent interview and record review of Patient 1’s medical record on 5/8/25 at 10:54 a.m. with Nurse Educator (NE) 2, NE 2 stated nursing shift progress notes are to be completed at end of shift every shift and two shift progress notes should be in chart per day. NE 2 confirmed Patient 1 was missing shift progress notes on: Day shift of 2/20/25; Night shift of 2/21/25; Day and Night shift of 2/22/25; Day shift of 2/24/25; and Night shift of 2/26/25. During an interview on 5/8/25 at 4:29 p.m. with Nurse Educator (NE) 3, NE 3 stated the daily shift progress notes were to be done at the end of shift every shift to highlight events that took place on shift, give an overall picture of how the patient did, if patient was moving towards goals or not. NE 3 stated notes should include anything new, concerns, how shift went, change in status, family meetings. NE 3 stated a code status (full code- perform CPR versus a DNR) change would be important to put in shift summary note. During a review of the facility’s policy and procedure (P&P) titled, “Core Nursing Standards of Practice,” dated 12/2024, the P&P indicated, “ ...II. Standard 2: DOCUMENTATION EXPECTATIONS ...A. As a communication tool, documentation should inform the care team succinctly of the patient’s status ...C ...1. Nurse’s notes are entered for the following instances: ...d. Shift Summary ...D. Documentation should be done ...to ...ensure availability of most recent information for all caregivers using the record ...Appendix A: Nursing intervention minimum frequency and documentation: Documentation: Nurse[’]s Notes: Shift Summary: When event occurs, note for each event ...” 2. During a record review of Patient 1’s “Orders,” dated, 2/20/25, Medical Doctor (MD) 3 placed orders at 8:59 p.m. and Registered Nurse (RN) 4 acknowledged orders at 1:27 a.m. to change code status from full code to, “DNR/DNI: If no pulse and is not breathing (Cardiopulmonary arrest). DO NOT RESUSCITATE/ALLOW NATURAL DEATH. NO chest compression ...” During a telephone interview on 5/6/25 at 11:44 a.m. with RN 4, RN 4 stated that training was completed regarding placing the purple armband on patients and purple signs on doors for DNR patients. RN 4 stated Patient 1 was placed in an “overflow” unit and she was the first night shift on the unit after opening it up and there were “no resources there”. RN 4 stated she, “couldn’t find any [purple signs or wristbands]...I did not escalate to charge nurse or manager”. RN 4 stated the risk was ,”If no purple arm band, purple sign, people might think patient is full code, patient could code, they could do CPR when in cardiac arrest.” During an interview on 5/6/25 at 10:06 a.m. with Nurse Educator (NE) 1, NE 1 stated, “The nurse acknowledging [DNR] order should put armband on and purple sign up. Part of change of shift hand off report is to identify code status and making sure necessary things are implemented. If DNR, make ensure [arm]band [on] and [DNR] sign up.” During a review of Patient 1’s “RRT (Rapid Response Team- a team of staff to respond to potential emergency situations for early intervention) Note,” dated 2/21/25, the RRT Note, written by Registered Nurse (RN) 3, stated Patient 1 was sitting in bed working with Physical Therapy (PT) and Patient 1 was eating a peanut butter and jelly sandwich. The note indicated at 12:14 p.m. the heart rate monitor alarmed in the 40’s (normal heart rate is 70 to 100 beats per minute) and upon entering the room to check, Patient 1 was found unresponsive, purple, and with a carotid (neck) pulse. The note stated a RRT was called to bedside. The note included that some of the sandwich was suctioned out of the mouth/ airway with a Yankauer (a tool that suctions the mouth). The note indicated at 12:15 p.m., RRT arrived to bedside and Patient 1 had no palpable pulse (cannot feel pulse with fingers) with pulseless electrical activity (PEA electrical activity shown on a monitor of the heart but no contractions or blood flow are occurring). The note continues, “CPR was started. See code blue sheet. CPR stopped and return of spontaneous circulation (ROSC) obtained.” The note revealed, “Deep suction provided by [MD 5]. DNR armband was not on patient and DNR sign not on door. Family called by [MD 3], no answer and left message. [MD 4] called and spoke to [POA- Power of Attorney] and explained situation... Addendum: [MD 3] stated patient was DNR/DNI and code was stopped. Prior to CPR, code status was not discussed with code team.” During in interview on 5/6/25 at 11:28 a.m. with Registered Nurse (RN) 7, who responded to Patient 1’s code blue, RN 7 indicated that the DNR armband and sign were instilled a while ago to help the code team. Patient 1 did not have DNR armband on or DNR sign up. During a review of the note titled, “RRT Activation and Response,”, dated 2/21/25 at 4:28 p.m., RN 7 documented that RN in room was asked if the patient was full code and that RN 7 was told that Patient 1 was “full code”. The note indicated CPR was started, lasted 3 minutes, epinephrine given (medication to restart or strengthen the heart beat), and heart restarted. The note indicated, “Discovered [Patient 1] was DNR/DNI per intensivist [a physician] recognizing the patient from the prior night ...Patient 1 did not have DNR armband on and intensivist stated that DNR armbands needs to be placed. During a review of “Progress Notes-Nursing,” dated 2/21/25 at 8:16 p.m., RN 3 documented that Patient 1 coded due to choking, CPR was started and stopped after MD 3 stated that Patient 1 was DNR/DNI ...” DNR band not on patient and sign not on door. DNR band placed on patient and DNR sign on door ...” During a concurrent interview and review of internal quality documents on 5/8/25 at 12:21 p.m. with Patient Safety Manager (PSM), the PSM stated an internal review was conducted and a deviation from performance standards by staff led to event due to DNR indicators not being visible. The PSM stated the event could have been prevented. During a review of facility P&P titled, “Do Not Resuscitate.” Dated 10/2022, the P&P indicated, “II. IDENTIFYING DNR/AND [allow natural death] PATIENTS: A ...Patients that are DNR/AND status will have a purple door sign indicating specific DNR/AND direction on the back of the sign, so information is covered.” During a review of facility P&P titled, “Emergency Response: Code Blue and Medical Emergency,” dated 12/2024, the P&P indicated, “All patients are to be resuscitated except in the presence of a written physician “Do Not Resuscitate” (DNR) order in the medical record or completed POLST (Physician’s Orders for Life Sustaining Treatment) form. Check the patient for a purple armband, which indicates that the patient has a “Do Not Resuscitate” order or the electronic health record for code status ...” 3. During an interview on 5/6/25 at 1:45 p.m. with Chief Medical Officer (CMO), CMO stated upon review of the hospital’s policy, it was noted that the policy titled, “Do Not Resuscitate”, only had the purple sign mentioned in it and was missing the purple wristband. The policy titled, “Code Blue” was missing the verbiage regarding the sign, but had language regarding the wristband. The CMO acknowledged the inconsistency. During a concurrent interview and record review of internal quality documents on 5/8/25 at 12:21 p.m. with Patient Safety Manager (PSM), the PSM stated an internal review was conducted and a deviation from performance standards by staff led to event due to DNR indicators not being visible. The PSM stated the event could have been prevented. The PSM stated there was also inconsistency in policy about wristband and door sign requirements. During a review of facility P&P titled, “Do Not Resuscitate.” Dated 10/2022, the P&P indicated, “II. IDENTIFYING DNR/AND PATIENTS: A ...Patients that are DNR/AND status will have a purple door sign indicating specific DNR/AND direction on the back of the sign, so information is covered.” DNR armband missing from policy. During a review of facility P&P titled, “Emergency Response: Code Blue and Medical Emergency,” dated 12/2024, the P&P indicated, “ ...Check the patient for a purple armband, which indicates that the patient has a “Do Not Resuscitate” order or the electronic health record for code status ...” DNR door sign missing from policy.”