San Gorgonio Memorial Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure the patients’ rights were promoted in accordance with the facility’s policies and procedures (P&P), for four of 20 sampled patients (Patients 1, 2, 11, and 13), when; 1. For Patient 1, a birthing plan (a patient’s preference for labor [the process of childbirth, during which uterine contractions cause the cervix (the neck of the uterus) to dilate and thin out, ultimately pushing the baby through the birth canal] and delivery [the act of giving birth] of the unborn child) was not followed (Refer to A-0131); 2. For Patient 2, an obstetrics-gynecologist (a physician specializing in women’s reproductive health and childbirth) consultation (the evaluation of a patient being seen at a facility) was ordered by a physician and was not conducted within a timely manner. In addition, a laboratory test was not completed as ordered by the physician and was not documented accurately on Patient 2’s record (Refer to A-0144); 3. For Patient 11, who was brought to the Emergency Department (ED, a specialized department operating 24 hours a day to provide immediate care for sudden, life-threatening, or severe medical conditions) on a 5150 hold (a temporary involuntary detention of an individual typically for up to 72 hours) for being gravely disabled (a condition where a person, due to a mental health disorder, severe substance use disorder, or both, is unable to provide for his own basic needs for food, clothing, shelter, personal safety, or necessary medical care), was left unsupervised and eloped (a patient leaving the facility without authorization) from the ED (Refer to A-0144); and 4. For Patient 13, the assessment for the need for continued restraint (a physical method which limits a patient’s ability to move, often to prevent harm to themselves or others) was not conducted every two hours (Refer to A-0167). The cumulative effects of these systemic failures resulted in Patient 1 having to deliver by cesarean section (c-section, a surgical procedure used to deliver a baby) and Patient 11 being able to elope from the ED. These failures had the potential for delay of care and treatment for Patient 2, an increased risk for harm and injury for Patient 11, and continued unnecessary use of restraints for Patient 13.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the needs of one of 20 sampled patients (Patient 11) was met in accordance with the facility’s policy and procedure titled, “Fifty One Fifty Patients in the Emergency Department,” dated September 2023, when Patient 11 was brought to the Emergency Department ( a specialized hospital facility operating 24 hours a day to provide immediate care for sudden, life-threatening, or severe medical conditions) on a 5150 hold (a temporary involuntary detention of an individual typically for up to 72 hours) for being gravely disabled (a condition where a person, due to a mental health disorder, severe substance use disorder, or both, is unable to provide for his own basic needs for food, clothing, shelter, personal safety, or necessary medical care], was left unsupervised and eloped (a patient leaving the facility without authorization) from the ED (Refer to A-1104). The cumulative effects of this failure resulted in Patient 11 being able to elope from the ED and may place Patient 11 at increased risk for harm and injury.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure a patient’s right was promoted in accordance with the facility’s policy and procedures (P&P), for one of 20 sampled patients (Patient 1), when Patient 1’s birthing plan (a patient’s preferences for labor [process of childbirth, during which uterine contractions cause the cervix (neck of the uterus, the organ where the unborn child develops) to dilate and thin out, ultimately pushing the baby through the birth canal] and delivery [the act of giving birth] of the unborn child) was not followed. This failure resulted in Patient 1 having to deliver by cesarean section (c-section, a surgical procedure used to deliver a baby) and not being allowed time to deliver by normal vaginal delivery. Findings: On May 11, 2026, at 10:15 a.m., a review of Patient 1’s record was conducted with the Director of Infection Control (DIC). A review of the facility document titled, “OB [obstetrics, the branch of medicine focused on pregnancy, childbirth, and the period after the delivery of the baby] Triage [the process of quickly sorting and prioritizing patients based on the urgency of their needs],” dated April 16, 2026, at 4:01 a.m., was conducted. The document indicated Patient 1 arrived at the Labor and Delivery (L&D, a specialized unit dedicated to the care of pregnant women and their babies during labor, childbirth, and the immediate recovery period after delivery) department for intermittent (off and on, not constant) cramping and pressure to her lower abdominal (the region of the body between the chest and pelvis) area. The document indicated, “...Vaginal Exam [ a physical assessment where a physician or midwife gently inserts lubricated, gloved fingers into the vagina to check the progress of labor]...Dilation [the measurement of the opening of the cervix so the baby can pass through the birth canal. It is measured during vaginal exams using centimeters (cm, unit of measurement), from tightly closed at zero cm to a fully open at ten cm]...4.0 [four] cm...Effacement [the natural thinning, softening, and shortening of the cervix which happens during labor; the goal is to reach 100 percent effacement] (%) [percent]...90...Station [measures how far the baby’s head has descended into the pelvis used to determine the baby’s position, scoring uses a scale from -5 [minus five] to +5 [plus five]]...- [minus] 1 [one]...Exam By...[name of registered nurse (RN)] Membrane status [the condition of the amniotic sac (the “bag of water”) surrounding the infant]...Intact...Vaginal Bleeding...None...Plan of Care...Plan of care Discussed; Vaginal Delivery...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 6 a.m., was conducted. The document indicated, “Vaginal Exam...Dilation...6 [six].0...Effacement...90...Station...- 1...Exam By...[Name of RN]...Category 1 [a normal fetal tracing (a continuous recording of a baby’s heartbeat alongside the mother’s uterine contractions during pregnancy or labor) which strongly indicates the baby is well-oxygenated (he developing baby is successfully receiving a consistent, healthy supply of oxygen-rich blood from the mother) and thriving in the womb]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 7:30 a.m., was conducted. The document indicated, “...Category 1...07:40 [7: 40 a.m.]...[Name of OBGYN 1] at bedside to assess pt [Patient 1]...07:49 [7:49 a.m.]...Vaginal Exam...Dilation (cm)...8.0 [eight]...Effacement (%)...90...Station...0...Exam by...[name of an OBGYN (a physician trained to manage both pregnancy and general women’s reproductive health) Physician (OBGYN) 1]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 7:50 a.m., was conducted. The document indicated, “...Membrane [amniotic sac, the fluid-filled membranes surrounding the baby in the womb status...Ruptured [water breaking, the tearing of the amniotic sac]...Membranes Ruptured Date/Time...04/16/26 [April 16, 2026]...07:50 [7:50 a.m.]...Membranes Rupture Method...Artificial [AROM, an obstetrical procedure where a healthcare provider intentionally punctures the amniotic sac surrounding the unborn child]...Amniotic Fluid Color...Light Meconium [the baby’s first bowel movement]...Amniotic Fluid Amount...Small...Amniotic Fluid Odor...None...” A review of facility document titled, “OB Admission Note,” dated April 16, 2026, at 8:23 a.m., authored by (OBGYN) 1, was conducted. The document indicated, “...OBSTETRICS STATUS: Gravida [the total number of times a woman has been pregnant] 2 [two]...Para [the number of times a woman has given birth to a baby past 20 weeks of gestation (how far along a pregnancy is, measured in weeks and days, with normal pregnancy lasting an average of 40 weeks)]...0...Reason for Admission...normal labor...Presenting symptoms...Uterine Contractions [the rhythmic tightening and relaxing of the uterine muscles to prepare the body for childbirth]...Uterine Contractions...Regular...Uterine Contraction Frequency...3 [three]- [to] 4 minutes...AROM with slight meconium...PROBLEM/ASSESSMENT PLAN...Problem...38 weeks in active labor [the most intense phase of the first stage of labor, during which the cervix opens from about 6 cm to a full 10 cm]...Assessment/Plan...Patient [Patient 1] is Progressing well...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 8:30 a.m., was conducted. The document indicated, “...Category 1...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:15 a.m., was conducted. The document indicated, “...Vaginal Exam...Dilation...8.0...Effacement...90...Station...0...Exam By...[Name of OBGYN 1]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:55 a.m., was conducted. The document indicated, “...Vaginal Exam...8.0...Exam By...[Name of OBGYN 1] Annotation: provider did not give full check stated that cervix is starting to swell and recommending a csection [c-section]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:57 a.m., was conducted. The document indicated, “...Pitocin [a synthetic version of oxytocin, a hormone which can help induce labor] (milliunits) [mU, unit of measurement]...Started @ [at] 09:57 [9:57 a.m.]...Annotation: pit [Pitocin] started at 2 [two] mL [millimeters, unit of measurement] = [equal] 2 m unit [mU] cosigned with [Name of Labor and delivery RN [L&DRN]]...09:59 [9:59 a.m.]...Pitocin (milliunits)...Discontinued Annotation: pit [Pitocin] stopped per [Name of OBGYN 1] wants to do a c-section...10:00 a.m...Category 1...” (Pitocin medication was administered for two minutes before being discontinued and a decision to deliver the unborn child by C-section was made.) A review of facility document titled, “OB Triage,” dated April 16, 2026, at 10 a.m., was conducted. The document indicated, “...Fetus [unborn baby in the later stages of development] A Comments...[Name of OBGYN 1] at bedside wanting to do a c-section for fail to progress [also known as prolonged labor, when labor lasts for approximately 20 hours or more] and swelling of the cervix. Per pt [Patient 1] refusing c-section at this time...Communication...RN at bedside Annotation: pt [Patient 1] is refusing a c-section at this time and wanting more time to labor and requesting an epidural [the type of pain medication administration used during childbirth which is administered in the lower back]. MD [OBGYN 1] notified that pt [Patient 1] is not wanting a c-section...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 10:15 a.m., was conducted. The document indicated, “...Communication Comments...This RN entered the patient room and observed the patient crying while speaking with [Name of OBGYN 1]. The patient [Patient 1] verbalized she did not want a cesarean section and requested additional time to continue labor...This RN asked [Name of OBGYN 1] to clarify the indication [a valid reason to use a specific test, medication, procedure, or surgery] for caesarean delivery. From a nursing assessment, the fetal [baby] heart rate tracing was Category 1. [Name of OBGYN 1] stated that a cesarean section was indicated due to fail to progress...This RN asked the patient for consent to perform a vaginal exam to assess current cervical status. The patient [Patient 1] verbally consented...[Name of OBGYN 1] then stated that he did not want this RN to perform a vaginal exam and requested that this RN step outside the room to speak with him...Recorded by: a registered nurse [Name of RN] and Director of L&D [Name of DLD]...” A review of facility document titled, “Incident Statement,” dated April 16, 2026, at approximately 10:15 a.m., authored by the Director of Labor and delivery (DLD) was conducted. The document indicated, “...Upon arrival to the patient room, I observed that patient [Patient 1] visibly distressed and crying. The patient was verbally expressing that she did not want to proceed with a cesarean section at that time. The patient stated, “No, I am scared. I don’t want a c-section. I want more time to deliver normal.”...I reviewed the fetal monitoring strip and did not identify any immediate concerns form a nursing perspective...I asked [Name of OBGYN 1] when the last vaginal exam [examination] had been performed and by whom. He stated that he performed the exam approximately two hours prior. I then asked the patient if she would consent to a vaginal exam for an updated assessment. The patient agreed...At that time, [Name of OBGYN 1] instructed me not to proceed with the exam and asked me to step outside the room...Once outside...I responded that my intent was to advocate for the patient, as she expressed that she did not want a cesarean section and was requesting additional time to labor. [Name of OBGYN 1] then stated, “I will not do this. I have two surgeries at 11 and I’m falling behind. She [Patient 1] can take hours. If this continues, I will have to go to [Name of Chief Nursing Officer]”...After leaving the room, I spoke with [Name of Chief Nursing Officer] regarding the situation. Upon returning, I was informed that the patient had agreed to and signed consent for the caesarean section...” A review of the facility document titled, “CONSENT TO SURGERY, SPECIAL PROCEDURE AND/OR BLOOD TRANSFUSION,” dated April 16, 2026, at 10:26 a.m., was conducted. The document indicated, “...Your doctors have recommended the following operation or procedure: PRIMARY [first time a woman is having a C-section] CESAREAN SECTION and the following type of anesthesia: Spinal or general [anesthesia, a type of pain medication usually used for surgical procedures]...Name of the practitioner who is performing the procedure or administering the medical treatment: [Name OBGYN 1]...Date: 04/16/26 [April 16, 2026]...Time: 10:26 a.m...Signature: [Name of Patient 1]...Witness Signature: [Name of operating room RN]...Date: 4/16/26...Time: 10:26 a.m...PHYSICIAN CERTIFICATION...Date: 4/16/26...Time 10:26 a.m...Physician’s Signature: [Name of OGBYN 1]...” A review of the facility document titled, “OB Triage,” dated April 16, 2026, at 10:30 a.m., authored by L&D RN, was conducted. The document indicated, “...pt [Patient 1] now amendable to c-section, pt has been consented and prepped [procedures done before a surgery] for c-section...” A review of facility document titled, “LD [Labor and Delivery] Delivery Summary [Name of Patient 1],” dated April 16, 2026, at 11:58 a.m., was conducted. The document indicated, “...Delivery Information...Delivery Time: 4/16/26 at 11:58 a.m....Delivery Type: C-Section...Birthweight (lb [pounds, unit of measurement]) 6 lb 0.3 oz [ounces, unit of measurement]...Infant Information...Condition: Stable...” A review of the facility document titled, “Operative Note,” dated April 16, 2026, at 1 p.m., was conducted. The document indicated, “...PROCEDURE: Primary cesarean via low-transverse [horizontal or across] uterine incision [a type of surgical cut]...Surgeon: [Name of OBGYN 1]...PREOPERATIVE DIAGNOSIS...38 gestation...Failure to dilate [diagnosed when there has been no progress in cervical dilation for four hours despite adequate uterine contractions or no progress for six hours despite inadequate uterine contractions and oxytocin augmentation (the use of oxytocin to aid a slowly progressing childbirth)]...Thin meconium...Possible SGA [small for gestation age, a baby who is smaller than the usual weight expected for the number of weeks of pregnancy]...INDICATIONS FOR PROCEDURE...presented in active labor...the patient [Patient 1] had declined augmentation [the medical process of stimulating the uterus to strengthen or speed up labor which has already started naturally, but has slowed down or stalled] with oxytocin [pitocin] and she had AROM earlier this morning...Thin Meconium was noted with AROM. The patient failed to progress beyond 8 cm. Upon my final exam, the posterior [toward the back of the body] lip of the cervix was noted to be very edematous [swollen] contrary to previous exams when she was 100 % effaced...Fetal heart rate was category 1...shared my concerns about the suspected SGA, thin meconium and arrest of dilation [when a woman’s active labor completely stalls]...I recommended cesarean section...” A review of an untitled facility document titled, “Incident Statement,” dated April 16, 2026, authored by Patient 1’s primary RN, was conducted. The document indicated, “...I was assigned as the labor nurse caring for patient [Name of Patient 1] who presented in active labor and expressed a desire for a natural labor and delivery...[Name of OBGYN 1] arrived early in the shift to assess the patients [Patient 1’s] labor status and progression, noting that he had multiple surgical obligations at another facility that day...I accompanied the provider [OBGYN 1] during his initial bedside assessment. During this interaction, he inquired about the patient’s prenatal care, including where it was received and why she had not presented to her originally planned delivered hospital. The patient stated she did not wish to deliver at that facility...During this discussion, he referenced his scheduled surgeries...The patient also consented to the initiation of Pitocin for labor augmentation. Pitocin was started concurrently with the provider’s third cervical examination, at which time he documented the patient to be 7 [seven] to 8 cm’s dilated with cervical swelling. At that time, I inquired whether administration of diphenhydramine (Benadryl) [a medication used in labor to reduce anxiety and nausea (feeling of wanting to vomit), and induce rest so the birthing parent has energy for active labor} would be appropriate to address the cervical swelling; however, the provider [OBGYN 1] declined and instead stated that the patient would require a cesarean section...after the provider exited the room, the patient expressed that she did not wish to proceed with the cesarean section and prefer to continue laboring. In accordance with my role as a patient advocate, I escalated the situation to the OB director [DLD] to ensure that the patients’ preferences were appropriately addressed. The OB director subsequently came to the bedside to assess the situation and clarify the patient’s wishes. At that time, the provider [OBGYN 1] was again present at the bedside discussing the caesarean section with the patient. The OB director [DLD] directly asked the patient about her preference, and the patient reiterated that she did not want a cesarean section...During this interaction, the patient appeared distressed. I provided reassurance, noting that the fetal heart rate tracing was category 1 and did not indicate fetal distress...based on my clinical assessment and professional experience as a labor and delivery nurse, there was no clear emergent indications necessitating a primary cesarean section at that time. The fetal heart rate tracing remained reassuring overall...Additionally, the patient was primigravida [a women who is pregnant for the first time] and had not been afforded sufficient time for labor progression or adequate trial of augmentation measures. In my professional opinion, the clinical course suggests that the decision to proceed with cesarean delivery may have been influenced by factors unrelated to the patient’s immediate medical condition. This conclusion is based on observed provider [OBGYN 1] behavior and the sequence of events during the patient’s labor course...” During record review, there was no documented evidence OBGYN 1 allowed Patient 1 to continue to labor on her own prior to performing a c-section on Patient 1, as Patient 1 and nursing staff requested. During record review, there was no documented evidence Patient 1 declined labor augmentation with Pitocin. During record review, there was no documented evidence Patient 1 or her unborn child were in distress during labor. On May 11, 2026, at 10:15 a.m., an interview was conducted with the DIC. The DIC stated she spoke with Patient 1 and asked her why she (Patient 1) ultimately agreed to and signed the consent for a c-section. The DIC stated, Patient 1 stated the doctor (OBGYN 1) told her, “If something happens to your baby, it will be your fault, and I have other sections [c-sections] to do at another hospital.” On May 12, 2026, at 1:41 p.m., an interview was conducted with the L&D RN. The L&D RN stated the primary RN and herself were caring for Patient 1. The L&D RN stated she was in the room when the primary RN explained the purpose of having a contraction pattern closer together to continue making cervical change and Pitocin was a medication to help strengthen the contractions to help progress labor. The L&D RN stated she co-signed [to sign jointly with another RN to witness a medication administration] on the Pitocin and walked out of Patient 1’s room. The L&D RN stated, when she walked out of Patient 1’s room, OBGYN 1 was walking in Patient 1’s room. The L&D RN stated the primary nurse was told by OBGYN 1 to stop the Pitocin. The L&D RN stated the primary nurse stated Patient 1 never asked for the Pitocin to be discontinued. The L&D RN stated, “I don’t think she had a sufficient amount of time to labor. It was her first baby.” The L&D RN stated after the rupture of membranes, the patient is given up to 24 hours for self-laboring if there are no signs of infection and the mom and baby were doing good. The L&D RN stated there are several interventions typically used to manage a swollen cervix, such as positioning, applying a cool pad/cloth to the vaginal area, and providing Benadryl as ordered. The L&D RN further stated Patient 1 was requesting more time to labor and that option was not provided for her. On May 13, 2026, at 1:52 p.m., an interview was conducted with OBGYN 1. OBGYN 1 stated he uses a mix of American College of Obstetricians and Gynecologists (ACOG, a nationally recognized organization for obstetricians and gynecologists) and UpToDate (an evidence-based, physician-authored clinical decision support tool used by healthcare professionals) as his guidelines for standards of care. OBGYN 1 stated upon vaginal exam, Patient 1 started to develop a swollen cervix, was not making any cervical change, and slight meconium was present when the membranes were ruptured. OBGYN 1 stated delaying Patient 1’s care was his major concern and since there was no neonatal intensive care unit (NICU, a specialized unit which provides intensive care for newborns who are premature, have low birth weight, or have health conditions requiring close monitoring and specialized treatment) at the facility, he did not want to risk things not going well for the baby. OBGYN 1 stated as a provider, one must also take into consideration the facility one is practicing at, as it can alter one’s plan of care. OBGYN 1 stated he was not aware of Patient 1 not wanting a c-section, and stated, “Of course she did not want a c-section, who does?” OBGYN 1 stated he was looking at the “big picture” and not looking at the amount of progress Patient 1 made. OBGYN 1 further stated, “If I was at a different facility, I probably would have managed her care differently. I would have allowed her to wait a little bit longer because I know NICU and neonatology [a physician who specializes in the medical management, care, and development of newborns] would be right around the corner should we need them.” On May 12, 2026, at 2:44 p.m., an interview was conducted with OBGYN (OBGYN) 2. OBGYN 2 stated it is important to follow a patient’s birthing plan and take into consideration the patient’s wishes. OBGYN 2 stated a physician may have to make appropriate adjustment as needed. OBGYN 2 stated a physician should educate their patient when a concern arises and allow them to make their own decision since a patient has their right to autonomy (the patient’s right to govern oneself, make one’s own choices, and act independently without being controlled by others). OBGYN 2 stated, after reviewing Patient 1’s medical record, and seeing Patient 1 progress from 4 cm to 8 cm (cervical dilatation) sounded very normal. OBGYN 2 stated a Category 1 fetal strip is great and reassuring, and showed the baby was not showing signs of distress. OBGYN 2 stated looking at Patient 1’s overall picture, the listed indications leading to the c-section does not sound like she clinically needed the c-section, and by no actual ACOG (American College of Obstetricians and Gynecologists, leading professional organization for physicians specializing in women’s health) criteria did Patient 1 fall under the category of failure to progress. OBGYN 2 stated Patient 1 was not given enough time to labor on her own and should have been given at least an additional six hours to allow the labor progress. OBGYN 2 stated the standard treatment for a swollen/edematous cervix is repositioning, intravenous Benadryl, and pain control depending on the cause of the cervical swelling. OBGYN 2 further stated she cared for Patient 1 during her post-partum (the period of time immediately following childbirth) stay and she was no longer trusting of medical staff and expressed she did not want to do anything and wanted to leave against medical advice due to feeling traumatized. An article by ACOG titled, “Approaches to Limit Intervention During Labor and Birth,” dated February 2019 and reaffirmed in 2025, was reviewed. The article indicated, “...Obstetrician- gynecologist, in collaboration with midwives [a trained healthcare professional who provides expert care and support to women and birthing people during pregnancy, labor, birth, and the postpartum period], nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction...Data suggest that for women with normally progressing labor and no evidence of fetal compromise [an unborn child in distress], routine amniotomy [a medical procedure where a healthcare provider intentionally punctures the amniotic sac during labor using a specialized tool] need not be undertaken unless required to facilitate monitoring...Obstetrician-gynecologist and other obstetric care providers should be familiar with and consider using low interventional approaches, when appropriate, for the intrapartum [the specific period of time during pregnancy that spans from the onset of labor through the delivery of the baby and the placenta (a flattened circular organ in the uterus of a pregnant mother, nourishing the unborn baby through the umbilical cord) management of low risk women in spontaneous labor...Recommendations and Conclusions...For appropriately counseled women, if concordant with their individual preference and if there are no other maternal or fetal reasons to expedite delivery, the choice of expected management for 12 to 24 hours may be offered...The desire to avoid unnecessary interventions during labor and birth is shared by healthcare providers and pregnant women...Conclusion...Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient-caregiver relationship, and the patients involvement in decision making. Therefore, obstetrician-gynecologist and other obstetric care providers should be familiar with and consider using low interventional approaches, when appropriate, for intrapartum management of low-risk women and spontaneous labor...” A review of the facility’s P&P titled, “Patient Rights,” dated August 2023, was conducted. The document indicated, “... [Name of facility] will ensure each patient’s right to physical and emotional health and safety. All patients have the right to considerate, respectful care at all times and under all circumstances with recognition of their personal dignity and autonomy...Patients have the right to...Considerate and respectful care, and to be made comfortable. You have the right to respect for your culture, psychosocial [a person’s mental, emotional, social, and spiritual health], spiritual, and personal values, beliefs and preferences...You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and foregoing or withdrawing sustaining treatment...Make decision 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 a course of treatment...Request or refuse treatment, to the extent permitted by law...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect exploitation [the act of treating someone unfairly, or using a situation or resource improperly, in order to derive a selfish benefit or profit] or harassment...””

“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: 50454 Based on interview, and record review, the facility failed to ensure a patient’s right was maintained in accordance with the facility’s policies and procedures (P&P), for three of 20 sampled patients (Patients 1, 2, and 11), when; 1. For Patient 1, a birthing plan (a patient’s preferences for labor [process of childbirth, during which uterine contractions cause the cervix to dilate and thin out, ultimately pushing the baby through the birth canal] and delivery [the act of giving birth] of the unborn child) was not followed; 2. For Patient 2, an obstetrics-gynecologist consultation (OBGYN, a physician specializing in women’s reproductive health and childbirth) consultation (the evaluation of a patient being seen at a facility) was ordered by a physician and was not conducted within a timely manner. In addition, a laboratory test was not completed as ordered by the physician and was not documented accurately on Patient 2’s record; and 3. For Patient 11, who was brought to the Emergency Department (ED, a specialized department operating 24 hours a day to provide immediate care for sudden, life-threatening, or severe medical conditions) on a 5150 hold (a temporary involuntary detention of an individual typically for up to 72 hours) hold for being gravely disabled (GD, a condition where a person, due to a mental health disorder, severe substance use disorder, or both, is unable to provide for his own basic needs for food, clothing, shelter, personal safety, or necessary medical care), was left unsupervised and eloped (a patient leaving the facility without authorization or unnoticed) from the ED.. These failures resulted in Patient 1’s having to deliver by cesarean section (c-section, a surgical procedure used to deliver a baby). These failures had the potential for delay of care and treatment for Patient 2, and an increased risk for injury for Patient 11. Findings: 1. On May 11, 2026, at 10:15 a.m., a review of Patient 1’s record was conducted with the Director of Infection Control (DIC). A review of the facility document titled, “OB [obstetrics, the branch of medicine focused on pregnancy, childbirth, and the postpartum (the period immediately following childbirth) period] Triage [the process of quickly sorting and prioritizing patients or tasks based on the urgency of their need and the resources available],” dated April 16, 2026, at 4:01 a.m., was conducted. The document indicated Patient 1 arrived at the Labor and Delivery (L&D, a specialized unit dedicated to the care of pregnant women and their babies during labor, childbirth, and the immediate recovery period) department for intermittent (off and on, not constant) cramping and pressure to her lower abdominal (the region of the body between the chest and pelvis) area. The document indicated, “...Vaginal Exam [ a physical assessment where a physician or midwife gently inserts lubricated, gloved fingers into the vagina to check the progress of labor]...Dilation [the measurement of the opening of the cervix (the neck of the uterus) so the baby can pass through the birth canal. It is measured during vaginal exams using centimeters (cm, unit of measurement), from tightly closed at zero cm to a fully open at ten cm]...4.0 [four point zero] cm...Effacement [the natural thinning, softening, and shortening of the cervix which happens during labor. The goal is to reach 100 percent effacement] (%) [percent]...90...Station [measures how far the baby’s head has descended into the pelvis; vaginal exams are used to determine the baby’s position, scoring them on a scale from -5 [negative five] to +5 [positive five]]...- [minus] 1 [one]...Exam By...[name of registered nurse] Membrane status [the condition of the amniotic sac (the “bag of water”) surrounding the infant]...Intact...Vaginal Bleeding...None...Plan of Care...Plan of care Discussed; Vaginal Delivery...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 6 a.m., was conducted. The document indicated, “Vaginal Exam...Dilation...6 [six].0...Effacement...90...Station...- 1...Exam By...[Name of RN]...Category 1 [a normal fetal tracing (a continuous recording of a baby’s heartbeat alongside the mother’s uterine contractions during pregnancy or labor) which strongly indicates the baby is well-oxygenated (he developing baby is successfully receiving a consistent, healthy supply of oxygen-rich blood from the mother) and thriving in the womb]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 7:30 a.m., was conducted. The document indicated, “...Category 1...07:40 [7: 40 a.m.]...[Name of OBGYN 1] at bedside to assess pt [Patient 1]...07:49 [7:49 a.m.]...Vaginal Exam...Dilation (cm)...8.0 [eight]...Effacement (%)...90...Station...0...Exam by...[name of an OBGYN (a physician trained to manage both pregnancy and general women’s reproductive health) Physician (OBGYN) 1]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 7:50 a.m., was conducted. The document indicated, “...Membrane [amniotic sac, the fluid-filled membranes surrounding the baby in the womb status...Ruptured [water breaking, the tearing of the amniotic sac]...Membranes Ruptured Date/Time...04/16/26 [April 16, 2026]...07:50 [7:50 a.m.]...Membranes Rupture Method...Artificial [AROM, an obstetrical procedure where a healthcare provider intentionally punctures the amniotic sac surrounding the unborn child]...Amniotic Fluid Color...Light Meconium [the baby’s first bowel movement]...Amniotic Fluid Amount...Small...Amniotic Fluid Odor...None...” A review of facility document titled, “OB Admission Note,” dated April 16, 2026, at 8:23 a.m., authored by an OBGYN MD [a physician trained to manage both pregnancy and general women’s reproductive health] (OBGYN) 1, was conducted. The document indicated, “...OBSTETRICS STATUS: Gravida [the total number of times a woman has been pregnant] 2 [two]...Para [the number of times a woman has given birth to a baby past 20 weeks of gestation (how far along a pregnancy is, measured in weeks and days. Pregnancies last an average of 40 weeks)]...0...History of Present Illness...Reason for Admission...normal labor [the presence of regular, painful uterine contractions which result in progressive cervical effacement and dilation]...Presenting symptoms...Uterine Contractions [the rhythmic tightening and relaxing of the uterine muscles to prepare the body for childbirth]...Uterine Contractions...Regular...Uterine Contraction Frequency...3 [three]- [to] 4 minutes...AROM [artificial rupture of membranes, commonly known as “breaking your water” or amniotomy, is a procedure where a doctor or midwife intentionally punctures the amniotic sac surrounding a baby] with slight meconium [a newborn baby’s very first bowel movement]...PROBLEM/ASSESSMENT PLAN...Problem 1: 38 weeks in active labor [the most intense phase of the first stage of labor, during which the cervix opens from about 6 cm to a full 10 cm]...Assessment/Plan 1: Patient [Patient 1] is Progressing well...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 8:30 a.m., was conducted. The document indicated, “...Category 1...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:15 a.m., was conducted. The document indicated, “...Vaginal Exam...Dilation...8.0...Effacement...90...Station...0...Exam By...[Name of OBGYN 1]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:55 a.m., was conducted. The document indicated, “...Vaginal Exam...8.0...Exam By...[Name of OBGYN 1] Annotation: provider did not give full check stated that cervix is starting to swell and recommending a csection [c-section]...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 9:57 a.m., was conducted. The document indicated, “...Pitocin [a synthetic version of oxytocin, a hormone which can help induce labor] (milliunits) [mU, unit of measurement]...Started @ [at] 09:57 [9:57 a.m.]...Annotation: pit [Pitocin] started at 2 [two] mL [millimeters, unit of measurement] = [equal] 2 m unit cosigned with [Name of Labor and delivery RN [L&DRN]]...09:59 [9:59 a.m.]...Pitocin (milliunits)...Discontinued Annotation: pit [Pitocin] stopped per [Name of OBGYN 1] wants to do a c-section...10:00 a.m...Category 1...” (Pitocin medication was administered for two minutes before being discontinued.) A review of facility document titled, “OB Triage,” dated April 16, 2026, at 10 a.m., was conducted. The document indicated, “...Fetus [unborn baby in the later stages of development] A Comments...[Name of OBGYN 1] at bedside wanting to do a c-section for fail to progress [also known as prolonged labor, when labor lasts for approximately 20 hours or more] and swelling of the cervix. Per pt [Patient 1] refusing c-section at this time...Communication...RN at bedside Annotation: pt [Patient 1] is refusing a c-section at this time and wanting more time to labor and requesting an epidural [the most common and effective type of regional pain relief used during childbirth which is administered in the lower back]. MD [OBGYN 1] notified that pt [Patient 1] is not wanting a c-section...” A review of facility document titled, “OB Triage,” dated April 16, 2026, at 10:15 a.m., was conducted. The document indicated, “...Communication Comments...This RN entered the patient room and observed the patient crying while speaking with [Name of OBGYN 1]. The patient [Patient 1] verbalized she did not want a cesarean section and requested additional time to continue labor...This RN asked [Name of OBGYN 1] to clarify the indication [sign, or clue which points to something or suggests it is necessary] for caesarean delivery. From a nursing assessment, the fetal [baby] heart rate tracing was Category 1. [Name of OBGYN 1] stated that a cesarean section was indicated due to fail to progress...This RN asked the patient for consent to perform a vaginal exam to assess current cervical status. The patient [Patient 1] verbally consented...[Name of OBGYN 1] then stated that he did not want this RN to perform a vaginal exam and requested that this RN step outside the room to speak with him...Recorded by: a registered nurse [Name of a RN] and Director of L&D [Name of DLD]...” A review of the facility document titled, “CONSENT TO SURGERY, SPECIAL PROCEDURE AND/OR BLOOD TRANSFUSION,” dated April 16, 2026, at 10:26 a.m., was conducted. The document indicated, “...Your doctors have recommended the following operation or procedure: PRIMARY CESAREAN SECTION and the following type of anesthesia: Spinal or general [anesthesia the relief of pain which results in the loss of sensation and may involve the loss of consciousness]...Name of the practitioner who is performing the procedure or administering the medical treatment: [Name OBGYN 1]...Your signature on this form indicates that...Date: 04/16/26 [April 16, 2026]...Time: 10:26 a.m...Signature: [Name of Patient 1]...Witness Signature: [Name of operating room RN]...Date: 4/16/26...Time: 10:26 a.m...PHYSICIAN CERTIFICATION...Date: 4/16/26...Time 10:26 a.m...Physician’s Signature: [Name of OBGYN 1]...” A review of the facility document titled, “OB Triage,” dated April 16, 2026, at 10:30 a.m., authored by L&D RN, was conducted. The document indicated, “...pt [Patient 1] now amendable to c-section, pt [Patient 1] has been consented and prepped for c-section]...” A review of facility document titled, “LD Delivery Summary [Name of Patient 1],” dated April 16, 2026, at 11:58 a.m., was conducted. The document indicated, “...Delivery Information...Delivery Time: 4/16/26 at 11:58 a.m....Delivery Type: C-Section...Birthweight (lb [pounds, unit of measurement]) 6 lb 0.3 oz [ounces, unit of measurement]...Infant Information...Condition: Stable...” A review of the facility document titled, “Operative Note,” dated April 16, 2026, at 1 p.m., was conducted. The document indicated, “...PROCEDURE: Primary cesarean via low-transverse [horizontal or across] uterine incision [surgical cut]...Surgeon: [Name of OBGYN 1]...PREOPERATIVE DIAGNOSIS: 1-38 gestation...2-Failure to dilate [diagnosed when there has been no progress in cervical dilation for four hours despite adequate uterine contractions or no progress for six hours despite inadequate uterine contractions and oxytocin augmentation]...3-Thin meconium...4-Possible SGA [small for gestation age, a baby who is smaller than the usual amount for the number of weeks of pregnancy]...INDICATIONS FOR PROCEDURE...presented in active labor...the patient [Patient 1] had declined augmentation [the medical process of stimulating the uterus to strengthen or speed up labor which has already started naturally, but has slowed down or stalled] with oxytocin [the generic name for Pitocin] and she had AROM earlier this morning...Thin Meconium was noted with AROM. The patient failed to progress beyond 8 cm. Upon my final exam, the posterior [toward the back of the body] lip of the cervix was noted to be very edematous [swollen] contrary to previous exams when she was 100 % effaced...Fetal heart rate was category 1...shared my concerns about the suspected SGA, thin meconium and arrest of dilation [when a woman’s active labor completely stalls]...I recommended cesarean section...” A review of facility document titled, “Incident Statement,” dated April 16, 2026., authored by the Director of Labor and delivery (DLD) was conducted. The document indicated, “...Upon arrival to the patient room, I observed that patient [Patient 1] visibly distressed and crying. The patient was verbally expressing that she did not want to proceed with a cesarean section at that time. The patient stated, “No, I am scared. I don’t want a c-section. I want more time to deliver normal.”...I reviewed the fetal monitoring strip and did not identify any immediate concerns form a nursing perspective...I asked [Name of OBGYN 1] when the last vaginal exam [examination] had been performed and by whom. He stated that he performed the exam approximately two hours prior. I then asked the patient if she would consent to a vaginal exam for an updated assessment. The patient agreed...At that time, [Name of OBGYN 1] instructed me not to proceed with the exam and asked me to step outside the room...Once outside...I responded that my intent was to advocate for the patient, as she expressed that she did not want a cesarean section and was requesting additional time to labor. [Name of OBGYN 1] then stated, “I will not do this. I have two surgeries at 11 and I’m falling behind. She [Patient 1] can take hours. If this continues, I will have to go to [Name of Chief Nursing Officer]”...After leaving the room, I spoke with [Name of Chief Nursing Officer] regarding the situation. Upon returning, I was informed that the patient had agreed to and signed consent for the caesarean section...” A review of an untitled facility document titled, “Incident Statement,” dated April 16, 2026, authored by Patient 1’s primary RN, was conducted. The document indicated, “...I was assigned as the labor nurse caring for patient [Name of Patient 1] who presented in active labor and expressed a desire for a natural labor and delivery...[Name of OBGYN 1] arrived early in the shift to assess the patients [Patient 1’s] labor status and progression, noting that he had multiple surgical obligations at another facility that day...I accompanied the provider [OBGYN 1] during his initial bedside assessment. During this interaction, he inquired about the patient’s prenatal [occurring or existing before birth] care, including where it was received and why she had not presented to her originally planned delivered hospital. The patient stated she did not wish to deliver at that facility...During this discussion, he referenced his scheduled surgeries...The patient also consented to the initiation of Pitocin for labor augmentation. Pitocin was started concurrently with the provider’s third cervical examination, at which time he documented the patient to be 7 [seven] to 8 cm’s dilated with cervical swelling. At that time, I inquired whether administration of diphenhydramine (Benadryl) [a medication used in labor to reduce anxiety and nausea (feeling of wanting to vomit), and induce rest so the birthing parent has energy for active labor} would be appropriate to address the cervical swelling; however, the provider [OBGYN 1] declined and instead stated that the patient would require a cesarean section...after the provider exited the room, the patient expressed that she did not wish to proceed with the cesarean section and prefer to continue laboring. In accordance with my role as a patient advocate, I escalated the situation to the OB director [DLD] to ensure that the patients’ preferences were appropriately addressed. The OB director subsequently came to the bedside to assess the situation and clarify the patient’s wishes. At that time, the provider [OBGYN 1] was again present at the bedside discussing the caesarean section with the patient. The OB director [DLD] directly asked the patient about her preference, and the patient reiterated that she did not want a cesarean section...During this interaction, the patient appeared distressed. I provided reassurance, noting that the fetal heart rate tracing was category 1 and did not indicate fetal distress...based on my clinical assessment and professional experience as a labor and delivery nurse, there was no clear emergent indications necessitating a primary cesarean section at that time. The fetal heart rate tracing remained reassuring overall...Additionally, the patient was primigravida [a women who is pregnant for the first time] and had not been afforded sufficient time for labor progression or adequate trial of augmentation measures. In my professional opinion, the clinical course suggests that the decision to proceed with cesarean delivery may have been influenced by factors unrelated to the patient’s immediate medical condition. This conclusion is based on observed provider [OBGYN 1] behavior and the sequence of events during the patient’s labor course...” During record review, there was no documented evidence OBGYN 1 allowed Patient 1 to continue to labor on her own prior to performing a c-section on Patient 1, as Patient 1 and nursing staff requested. During record review, there was no documented evidence Patient 1 declined labor augmentation with Pitocin. During record review, there was no documented evidence Patient 1 or her unborn child were in distress during labor. On May 11, 2026, at 10:15 a.m., an interview was conducted with the DIC. The DIC stated she spoke with Patient 1 and asked her why she (patient 1) ultimately agreed to and signed the consent for a c-section. The DIC stated, Patient 1 stated the doctor (OBGYN 1) told her, “If something happens to your baby, it will be your fault, and I have other sections [c-sections] to do at another hospital.” On May 12, 2026, at 1:41 p.m., an interview was conducted with the L&D RN. The L&D RN stated the primary RN and herself were caring for Patient 1. The L&D RN stated she was in the room when the primary RN explained the purpose of having a contraction pattern closer together to continue making cervical change and Pitocin was a medication to help strengthen the contractions to help progress labor. The L&D RN stated she co-signed [requiring two RN’s to witness medication set up and administration] on the Pitocin and walked out of Patient 1’s room. However, when she walked out of the room, OBGYN 1 was walking in Patient 1’s room. The L&D RN stated the primary nurse was told by OBGYN 1 to stop the Pitocin. The L&D RN stated the primary nurse stated Patient 1 never asked for the Pitocin to be discontinued. The L&D RN stated, “I don’t think she had a sufficient amount of time to labor. It was her first baby.”. The L&D RN stated after the rupture of membranes, we usually give up to 24 hours for self-laboring if there are no signs of infection and mom and baby were doing good. The L&D RN stated there are several interventions we typically use to manage a swollen cervix, such as positioning, applying a cool pad/cloth to the vaginal area, and providing Benadryl as ordered. The L&D RN further stated Patient 1 was requesting more time to labor and that option was not provided for her. On May 12, 2026, at 2:44 p.m., an interview was conducted with OBGYN (OBGYN) 2. OBGYN 2 stated it is important to follow a patient’s birthing plan and take into consideration her wishes. OBGYN 2 stated a physician may have to make appropriate adjustment as needed. OBGYN 2 stated a physician should educate their patient when a concern arises and allow them to make their own decision since a patient has their right to autonomy (the power or right to govern yourself, make your own choices, and act independently without being controlled by others). OBGYN 2 stated, after reviewing Patient 1’s medical record, and seeing Patient 1 progress from 4 cm to 8 cm sounded very normal. OBGYN 2 stated a Category 1 fetal strip is great and reassuring, and the baby was not showing signs of distress. OBGYN 2 stated looking at Patient 1’s overall picture, the listed indications leading to the c-section does not sound like she clinically needed the c-section, and by no actual ACOG (American College of Obstetricians and Gynecologists, leading professional organization for physicians specializing in women’s health) criteria did Patient 1 fall under the category of failure to progress. OBGYN 2 stated Patient 1 was not given enough time to labor on her own and should have been given at least an additional 6 hours to allow the labor progress. OBGYN 2 stated the standard treatment for a swollen/edematous cervix is repositioning, IV Benadryl, and pain control depending on the cause of swelling. OBGYN 2 further stated she cared for Patient 1 during her post-partum (the period of time immediately following childbirth) stay and she was no longer trusting of medical staff and expressed she did not want to do anything and wanted to leave against medical advice due to feeling traumatized. On May 13, 2026, at 1:52 p.m., an interview was conducted with OBGYN 1. OBGYN 1 stated he uses a mix of ACOG and UpToDate (an evidence-based, physician-authored clinical decision support tool used by healthcare professionals) as his guidelines for standards of care. OBGYN 1 stated upon vaginal exam, Patient 1 started to develop a swollen cervix, was not making any cervical change, and slight meconium was present when the membranes were ruptured. OBGYN 1 stated delaying Patient 1’s care was his major concern and since there was no neonatal intensive care unit (NICU, a specialized unit which provides intensive medical care for newborns who are premature, have low birth weight or have health conditions requiring close monitoring and specialized treatment) at the facility, he did not want to risk things not going well for the baby. OBGYN 1 stated as a provider, one must also take into consideration the facility you’re practicing at, as it can alter your plan of care. OBGYN 1 stated he was not aware of Patient 1 not wanting a c-section, and stated, “Of course she did not want a c-section, who does?”. OBGYN 1 stated he was looking at the “big picture” and not looking at the amount of progress Patient 1 made. OBGYN 1 further stated, “If I was at a different facility, I probably would have managed her care differently. I would have allowed her to wait a little bit longer because I know NICU and neonatology [a physician who specializes in pediatric (children) medicine focused on the medical management, care, and development of newborns] would be right around the corner should we need them.” 2a. On May 11, 2026, at 1:15 p.m., a review of Patient 2’s record was conducted with the DIC. A review of the facility document titled, “ED Provider Aware Note,” dated March 18, 2026, at 7:50 p.m., was conducted. The document indicated Patient 2 arrived at the ED with a chief complaint (the reason for which the patient came to the ED) of worsening upper quadrant (the top region of the abdominal area) abdominal pain after having an egg retrieval procedure (a minor surgical procedure used in vitro fertilization, a fertility treatment where an egg and sperm are combined outside the body in a laboratory) and egg freezing (to collect mature eggs from the ovaries to freeze and save them for a later time) done. The document indicated Patient 2 had a past medical history of irritable bowel syndrome (a common, long-term condition which affects the digestive system), polycystic ovarian [pertaining to the ovary, the primary female reproductive organ] syndrome (a condition in where one’s menstrual periods may be very far apart, not regular, or very long), and had a hysteroscopy (a minimally invasive procedure which allows a physician to look inside the uterus using an instrument with a camera) on February 17, 2026. The document indicated, “...21:45 [9:45 p.m.] spoke with [Name of OBGYN 1] from OBGYN- Possible OHSS [ovarian hyperstimulation syndrome, an exaggerated reaction to fertility medications]. Will consult and concurs with admission to hospitalist [a physician who specializes in caring for patients solely while the patients are in the hospital]...Discussion of management: [Name of OBGYN 1] from OBGYN 1...Discussion of need for medical procedure: admission...” A review of the facility document titled, “HISTORY & [and] PHYSICAL, ADULT,” dated March 18, 2026, at 11:23 p.m., was conducted. The document indicated, “...[Name of Patient 2]...with recent transvaginal [through or across the vagina] oocyte [ovarian egg] retrieval on 3/18 [March 18, 2026] presents with acute [sudden] pain beginning after oocyte retrieval this morning...Gynecology [Name of OBGYN 1] was consulted...Patient [Patient 2] was started on continuous IVF [intravenous fluids, fluids delivered directly into the bloodstream through a vein] and admitted for further monitoring, serial H/H [hemoglobin and hematocrit, a standard blood test used to evaluate the amount of red blood cells (part of the blood), and monitor blood loss or hydration], and ongoing gynecologic evaluation [a medical assessment of the female reproductive system.]...” A review of the facility document titled, “Order Summary,” dated March 19, 2026, was conducted. The document indicated, “...Entry Date...19-Mar [March]-2026 at 07:52 [7:52 a.m.]...Consult-Obstetrics-Gynecology-Reason for Consult [consultation]: ovarian hyperstimulation syndrome post procedure [after a procedure. Thanks...provider: [Name of OBGYN 1]...Entry Date...19-Mar-2026 at 20:16 [8:16 p.m.]...Referral-Case Management...Reason for consult comments: Transfer out for HLOC [higher level of care, facilities with more advanced management of illnesses and medical conditions], fertility specialist [an OB-GYN who completes extra training in reproductive endocrinology [hormones specifically related to women’s reproductive health] to diagnose and treat infertility ]/ reproductive endocrinologist [a specialized physician (OB/GYN) who diagnoses and treats hormonal and reproductive issues] for OHSS...” A review of facility document titled, “Progress Note, Nursing,” dated March 19, 2026, at 7:47 p.m. was conducted. The document indicated, “...Narrative...1904 [7:04 p.m.] Good evening [Name of OBGYN 1], wou [sic, will you] be coming to see patient [Name of Patient 2] in [room number of Patient 2] here for ovarian hyperstimulation syndrome?...1905 [7:05 p.m.] Per [Name of OBGYN 1]- I was not even aware that she [Patient 2] has been admitted or that I had been consulted...1910 [7:10 p.m.]...[Name of Patient 2] here for ovarian hyperstimulation syndrome. Pt [Patient 2] told me that she is due for her cetrotide [Cetrotide, a prescription fertility medication used during in vitro fertilization treatments] at 1900 [7 p.m.]. This medication is in her home med [medication] list. Can you add pls [please, add to the physician’s order]...1912 [7:12 p.m.] Per [Name of hospitalist], Please reach out to Ob/Gyn to decide if that should be continued or held...1917 [7:19 p.m.]...the patient was asking for an update, will you be by tomorrow possibly?...1919 [7:19 p.m.] Per [Name of OBGYN 1], At some time tomorrow yes. But I am not sure what I can really offer. This is beyond the scope of what I do. I thought she had been transferred to a higher level of care. I mentioned to the ED physician that I have never dealt with such a problem before. I am not sure she [Patient 2] is in the right place for her problem...1921 [7:21 p.m.]...[Name of Patient 2] here for ovarian hyperstimulation syndrome. Pt told me that she is due for her cetrotide at 1900. This medication is in her home med list. Can you add pls...1922 [7:22 p.m.] I don’t know anything about these medications. Her primary team should handle that. I am NOT an infertility doctor...1939 [7:39 p.m.]...[Name of Patient 2] for ovarian hyperstimulation. I talked with OBGYN [Name of OBGYN 1], he was not aware of the consult. Per [Name of OBGYN 1] he does not know anything about this medication because he is not a fertility doctor. If you are able to talk to the patient...” A review of facility document titled, “Consult Note, Provider-Obstetrics-Gynecology,” dated March 20, 2026, at 4:44 p.m., authored by OBYGN 1, was conducted. The document indicated, “...CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS...[Patient 2] recently underwent oocyte retrieval in [name of a country] earlier this week. She [Patient 2] is a patient of an infertility clinic and presented to the ED via ambulance...and CT scan [computed tomography scan, an imaging procedure] indicated large ovaries with some abdominal fluid and findings of moderate ovarian hyperstimulation ...Given our lack of resources, I had recommended to [Name of ED physician] a transfer for HLOC, ideally to a hospital close to her infertility doctor...” (The OBGYN consultation was completed on March 20, 2026, at 4:44 p.m., approximately 36 hours after the consultation order was placed.) On May 11, 2026, at 2 p.m., an interview was conducted with the DIC. The DIC stated Patient 2 and Patient 2’s family member was upset the OBGYN consultation had not been conducted and wanted to know if and when the patient would be seen. The DIC stated OBGYN 1 stated he was not aware of Patient 2’s admission, however, the nurses reached out to OBGYN 1 and confirmed Patient 2’s admission and need for consultation when they called OBGYN 1 and requested medication for Patient 2. The DIC stated it is also dictated in the ED Providers Note the ED physician spoke with OBGYN 1, and OBGYN 1 agreed to the admission and consult. The DIC stated after she was made aware Patient 2 had still not been seen by OBGYN 1, she went and personally requested OBGYN 1 to come with her to Patient 2’s room and speak with Patient 2 and her family member. The DIC further stated OBGYN 1 was on call on March 19, 2026, and March 20, 2026, and should have seen Patient 2 as soon as possible. On May 12, 2026, at 2:44 p.m., an interview was conducted with OBGYN 2. OBGYN 2 stated when consulted, the expectation is to see the patient within 30 minutes of the consultation order. OBGYN 1 stated sometimes the ED gives the provider a little more grace, however, the 30-minute window is the expectation when you are the OBGYN on call. OBGYN 2 stated, when a consultation comes in, the ordering physician will call, tiger text (in house messaging system), or do both to make the physician aware of the consultation. OBGYN 2 stated in general, the patient should still be seen even if the physician does not understand the patient’s condition and believes the patient would be better served at a higher level of care facility. OBGYN 2 stated the physician should at least assess patient and create a plan even if the physician felt the patient would benefit from a transfer to another facility for higher level of care. OBGYN 2 further stated seeing a patient more than 24 hours after the consultation was ordered is not acceptable. On May 13, 2026, at 1:52 p.m., an interview was conducted with OBGYN 1. OBGYN 1 stated, “In general, I usually see my patients within 30 minutes of being aware of the consultation.” OBGYN 1 stated he had a conversation with the ED physician and informed her he was not familiar with OHSS and suggested Patient 2 should not be managed at this facility and should be transferred to a higher level of care. OBGYN 1 stated he asked the ED provider to let him know if she was going to admit Patient 2. OBGYN 1 stated he was never aware Patient 2 was formally admitted. OBGYN 1 stated no formal request was provided to him. OBGYN 1 denied the ED physician conversation and consultation order placed as being a formal request. OBGYN 1 stated, “I don’t know what happened, physicians need to communicate better because there was a communication breakdown.” OBGYN 1 stated he eventually consulted Patient 2 because the DIC brought him into Patient 2’s room after the DIC was made aware of Patient 2 and Patient 2’s family member’s frustration over the delayed consultation. OBGYN 1 further stated, “If it wasn’t for the DIC, I probably would have not have seen the patient [Patient 2].” 2b. On May 11, 2026, at 1:15 p.m., a review of Patient 2’s record was conducted with the DIC. A review of the facility document titled, “ED Provider Aware Note,” dated March 18, 2026, at 7:50 p.m., was conducted. The document further indicated, “...Hgb [hemoglobin, an iron-rich protein inside red blood cells which carries oxygen from the lungs to the rest of the body] 11.0 [normal range 12.0-16.0]...21:28 [9:28 p.m.] received call from radiology [a branch of medicine which uses imaging technology to look inside the body]: possibly visualized blood within both ovaries as well as free fluid ...21:45 [9:45 p.m.] spoke with OBGYN 1 physician [Name of OBGYN 1] from OBGYN-Possible OHSS [ovarian hyperstimulation syndrome, an exaggerated reaction to fertility medications]. Will consult and concurs with admission to hospitalist [a physician, nurse practitioner, or physician assistant who specializes in caring for patients solely while they are in the hospital]...Discussion of management: [Name of OBGYN 1] from OBGYN...Discussion of need for medical procedure: admission...” A review of the facility document titled, “HISTORY & [and] PHYSICAL, ADULT,” dated March 18, 2026, at 11:23 p.m., was conducted. The document indicated, “...[Patient 2]...with recent transvaginal [through or across the vagina] oocyte [egg] retrieval on 3/18 [March 18, 2026] presents with acute [sudden] pain beginning after oocyte retrieval this morning...Gynecology [Name of OBGYN 1] was consulted...Patient [Patient 2] was started on continuous IVF [intravenous fluids, fluids delivered directly into the bloodstream through a vein] and admitted for further monitoring, serial H/H [hemoglobin/hematocrit, a standard blood test used to evaluate red blood cells, diagnose conditions like anemia, and monitor blood loss or hydration, normal range for hemoglobin is 12-16 g/dL [grams per deciliter, unit of measurement] and normal range for hematocrit is 36 to 44 percent], and ongoing gynecologic evaluation...Repeat Hemoglobin and Hematocrit...From 19-Mar-2026 0800 [8 a.m.] To: 24-Mar-2026 [March 24, 2026,] 02:00 [8 p.m.], Every 6 [six] hours...Source: Blood...Plan...Anticoagulation [the process of preventing or delaying blood clots from forming in the blood vessels] prophylaxis [preventive care or protective treatment] is held in the setting of possible intrabdominal [intra-abdominal, inside of the abdomen] bleed...Home ASA [aspirin, a blood thinning medication] held in setting of possible bleed...” A review of an untitled facility document was conducted. The document indicated, “...19-Mar-2026 at 0815 [8:04 p.m.]...Hemoglobin + Hematocrit...HGB...8.7...HCT...26...20-Mar-2026 [March 20, 2026] at 0210 [2:10 a.m.]...Hemoglobin +Hematocrit...8.7...HCT...27....20-Mar-2026 at 3:50 [3:50 a.m.]...Hemoglobin + Hematocrit...9.5...HCT...29...” A review of facility document titled, “Progress Note, Nursing,” dated March 20, 2026, at 3:15 a.m., was conducted. The document indicated, “...Narrative...0300 [3 a.m.] Patient [Patient 2] called to ask about the blood draw. Went to the patient’s room and [family member] at bedside per patient no one came to draw blood at 0200 [2 a.m.]. Checked the result and there was a result at 0210 [2:10 a.m.] hgb [hemoglobin, an iron-rich protein inside red blood cells which carries oxygen from the lungs to the rest of the body ] 8.7 and hct [hematocrit a blood test which measures the percentage of the blood which is made up of red blood cells] 27...0301 [3: 01 a.m.] Called laboratory and asked if they did it. Per [Name of phlebotomist, a trained healthcare professional whose primary job is to draw blood from patients] she claimed that she went there and drew the blood. [Name of a registered nurse] was informed and went to laboratory and asked for [Name of phlebotomist] but per [Name of laboratory assistant] informed that she already went to draw blood of the patient. Went to patient’s room and informed [Patient 2] that I talked with lab [laboratory] and she claimed she drew the blood at 0210. [Name of registered nurse] informed [Name of house supervisor] and per house supervisor aware and re-order hgb and hct. [Name of registered nurse] placed order...0346 [3:46 a.m.] Lab tech [Name of laboratory technician] at bedside drawing blood. I asked [Name of laboratory technician] where is [Name of phlebotomist] so she cna [sic, can] explain to the patient and wife the incident that happened earlier. Per [Name of laboratory technician], she was just sent out by [Name of phlebotomist] to do the blood draw of the patient...” On May 11, 2026, at 10:15 a.m., an interview was conducted with the DIC. The DIC stated she was made aware of Patient 2’s concerns regarding the alleged falsified laboratory test the following day. The DIC stated she went and spoke with Patient 2 and her (family member) and according to Patient 2’s spouse, she stated, before Patient 2 fell asleep, Patient 2 informed her (family member) and according to her last hgb and hct level, and told her the next laboratory tests should be drawn at 2 a.m. The DIC stated Patient 2’s (family member) noticed the phlebotomist never came to the bedside to draw Patient 2’s blood work and made the primary nurse aware. The DIC stated the primary nurse informed Patient 2’s family member the results populated in Patient 2’s record at 2:10 a.m., and resulted as hgb of 8.7 and hct of 27. The DIC stated Patient 2’s family member reassured the primary nurse no one ever came to the bedside to draw blood for laboratory tests and stated the 2:10 a.m. laboratory test results are almost identical to the 8:04 p.m. labs. The DIC stated a root cause analysis [a problem-solving process used to identify the underlying, core factors that cause a problem] was conducted and during their investigation, the phlebotomist which was assigned to Patient 2’s 2 a.m. laboratory test, admitted she ran the same sample (of blood) from the prior blood draw for Patient 2 and changed the label with a new date and time. The DIC further stated the phlebotomist admitted she did not physically go to Patient 2’s room to draw her blood when she should have. An article by ACOG titled, “Approaches to Limit Intervention During Labor and Birth,” dated February 2019 and reaffirmed in 2025, was reviewed. The article indicated, “...Obstetrician- gynecologist, in collaboration with midwives [a trained healthcare professional who provides expert care and support to women and birthing people during pregnancy, labor, birth, and the postpartum period], nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction...Data suggest that for women with normally progressing labor and no evidence of fetal compromise [an unborn child in distress], routine amniotomy [a medical procedure where a healthcare provider intentionally punctures the amniotic sac during labor using a specialized tool] need not be undertaken unless required to facilitate monitoring...Obstetrician-gynecologist and other obstetric care providers should be familiar with and consider using low interventional approaches, when appropriate, for the intrapartum [the specific period of time during pregnancy that spans from the onset of labor through the delivery of the baby and the placenta (a flattened circular organ in the uterus of a pregnant mother, nourishing the unborn baby through the umbilical cord) management of low risk women in spontaneous labor...Recommendations and Conclusions...For appropriately counseled women, if concordant with their individual preference and if there are no other maternal or fetal reasons to expedite delivery, the choice of expected management for 12 to 24 hours may be offered...The desire to avoid unnecessary interventions during labor and birth is shared by healthcare providers and pregnant women...Conclusion...Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient-caregiver relationship, and the patients involvement in decision making. Therefore, obstetrician-gynecologist and other obstetric care providers should be familiar with and consider using low interventional approaches, when appropriate, for intrapartum management of low-risk women and spontaneous labor...” A review of the facility’s P&P titled, “Patient Rights,” dated August 2023, was conducted. The document indicated, “...[Name of facility] will ensure each patient has the right to physical and emotional health and safety...Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcome of care (including unanticipated outcomes)...Make decision regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent...Receive care in a safe setting...” A review of the facility’s P&P titled, “Legal Record-Contents of a Complete and Accurate Record,” dated November 2024, was conducted. The document indicated, “...All electronic health records (EHR) shall consist of all data elements as required by Centers for Medicare and Medicaid Services (CMS), accrediting agencies and Title 22 [regulations which contains the administrative rules for health, safety, and social services]...Procedure...The EHR must be accurate...The content of the EHR may include but is not limited to...Clinical Assessments/Clinical Data Base...Clinical laboratory studies...” A review of the facility’s P&P titled, “Patient Rights,” dated August 2023, was conducted. The document indicated, “...[Name of facility] will ensure each patient right to physical and emotional health and safety. All patients have the right to considerate, respectful care at all times and under all circumstances with recognition of their personal dignity and autonomy...Patients have the right to...Considerate and respectful care, and to be made comfortable. You have the right to respect for your culture, psychosocial, spiritual, and personal values, beliefs and preferences...You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and foregoing or withdrawing sustaining treatment...Make decision 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 a course of treatment...Request or refuse treatment, to the extent permitted by law...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect exploitation...” 42512 3. On May 11, 2026, at 2 p.m., a review of Patient 11’s record and concurrent interview were conducted with the Chief Nursing Officer (CNO). A facility document titled, “ED Provider Care Note,” dated March 22, 2026, at 12:08 a.m., was reviewed. The document indicated Patient 11 was brought to the ED as a 5150 for being gravely disabled. The document further indicated, “...Upon interview, pt [Patient 11] states she doesn’t know why she’s here. Per EMS [Emergency Medical Services], patient walked into the wrong house and appeared confused...Differential Diagnosis [method doctor uses to distinguish one disease or condition from others that share similar symptoms] included but not limited to...5150, gravely disabled...confusion...” A review of facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION,AND CRISIS INTERVENTION [short-term, ] OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated March 21, 2026, was conducted. The document indicated, “...On 03/21/2026 [March 21, 2026], HOLD [5150 hold] CRITERIA...Gravely disabled adult...” A review of a facility document titled, “Progress Note, Nursing,” dated March 21, 2026, was conducted. The document indicated, “...1915 [7:15 p.m.] Pt [Patient 11] arrived to ER [number of hall in the emergency room]. Pt belongings were inventoried and kept with sitter [staff who provides one-on-one, continuous supervision for high-risk patients, ensuring their safety]...” A review of a facility documents titled, “Progress Note, Nursing,” dated March 22, 2026, was conducted. The document indicated, “...Patient A&O [alert and oriented, a medical abbreviation to describe a patient with four key cognitive areas] X 1 [oriented to person only]...” A review of a facility document titled, “Social Work [a practice-based profession which helps patients and their families navigate the emotional, social, and financial challenges of an illness or injury] Discharge Planning [process in hospitals that coordinates safe transition from hospital to home, or another facility] Note,” dated March 22, 2026, was conducted. The document indicated, “...5150 expires Tuesday 03/24/2026 [March 24, 2026] at 16:51 [4:51 p.m.]...The patient [Patient 11] presented disheveled, her hair was messy and patient appeared disoriented to place and situation. Patient appeared paranoid as evidenced by scanning her environment, making accusatory statements, and not wanting to share information. Patient presents with disorganized speech and thought process...Per chart review, patient has been previously seen at this hospital on 03/2/26 [March 2, 2026] for anxiety [an emotional state characterized by feelings of unease, worry or fear]...Patient was not seen by SW [social worker, trained professional who helps vulnerable individuals] team as patient eloped from the ED...Patient denied visual hallucinations [seeing things that are not real] but reported she has been experiencing auditory hallucinations[hearing things such as murmurs, music, or voices that are not real] for the past four months... Patient could not recall her son or daughter’s name...Plan: Patient continues to meet criteria for 5150 hold due to GD for mental health...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...March-23-2026 [March 23, 2026] 18:15 [6:15 p.m.]...Level of Consciousness...confused...” A review of a facility document titled, “Social Work Discharge Planning Note,” dated March 23, 2026, was conducted. The document indicated, “...SW and Psych NP... In agreement with ED Dr. [doctor] personal property that the patient continues to meet criteria for a 5150 hold...” A review of a facility document titled, “Consult Note, Provider-Emergency/Psychiatric Medicine,” dated March 23, 2026, at 11 a.m., authored by Psychiatric [medical study of mental, emotional, and behavior disorders] Nurse Practitioner (PNP, an advanced practice registered nurse) was conducted. The document indicated, “...consult...involuntary hold...past medical history...cognitive impairment [problem with mental function that affects a person’s ability to think, learn, or remember], denies past psychiatric history. Currently on involuntary hold for gravely disabled after walking to the wrong house, wandering from her home, refusing to leave her car and come into the home, [family member] has to take her food and water she still [sic] not consume it, she’s refusing to take her medical medications and or follow up with her doctors. [Family member] told social worker by phone he can no longer care for [Patient 11] due to her current behaviors. Patient had been previously seen at the hospital on March 2nd [March 2, 2026] for anxiety and stating that there was spiritual warfare and the spirits are trying to kill her...When patient asked if she was staying in her car and refusing to eat or drink she said “probably”, but couldn’t explain why...Patient does not meet criteria for involuntary hold it’s possible as she’s having early signs of dementia [decline in metal ability, memory, reason or problem solving that interferes with daily life] with psychosis [collection of symptoms which indicate a loss of contact with reality]...Patients involuntary hold will be interrupted, case management will find placement for her as her son does not want her to return...” A review of a facility document titled, “Social Work Discharge Planning Note,” dated March 24, 2026, was conducted. The document indicated, “...Social work met with Pt [Patient 11] to discuss DC [discharge] options as Pt’s 5150 hold is expiring today...Pt Does present with confusion and memory loss...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 25, 2026, was conducted. The document indicated, “...SW spoke with pt [Patient 11] and provided clothing at pt’s request...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 28, 2026, was conducted. The document indicated, “...Checked in with patient... Patient was walking down the hallway with her cane... Patient requested to have ED room door open...” A review of facility document titled, “Progress Note, Nursing,” dated March 28, 2026, was conducted. The document indicated, “...1900 [7 p.m.]...Moved pt from [ED Room A] TO ED [Room B] for closed observe with high risk to elope, hx [history] of elopement...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...March-30-2026 [March 30, 2026] 7:04 [a.m.]...Level of Consciousness...confused...Orientation...disoriented...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 30, 2026, was conducted. The document indicated, “...1945 [7:45 p.m.] Pt walk out up to elevator, re direct [redirect] to bed. Needs lots of attention...” A review of facility document titled, “Social Work Discharge Planning Note,” dated April 1, 2026, was conducted. The document indicated, “... [Name of company] may not be appropriate placement for the patient, as she has severe dementia and [Name of company] are for independent individuals...” A review of facility document titled, “Progress Note, Nursing,” dated April 2, 2026, at 12:21 a.m., was conducted. The document indicated, “...Pt transferred to [ED Room C]...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...April-02-2026 [April 2, 2026] 7:00 [a.m.]...Level of Consciousness...confused...” A review of facility document titled, “Progress Note, Nursing,” dated April 2, 2026, at 9:05 p.m., was conducted. The document indicated, “...Receive patient [Patient 11] outside of her room, patient is ambulatory...Patient ask permission if she can walk around since shes [sic] been lying in bed for a long time, patient instructed to stay close to the room or in front of nurses station...” A review of a facility document titled, “Progress Note, Nursing,” dated April 3, 2026, at 11:14 a.m., was conducted. The document indicated, “...@ [at] 1815 [6:15 p.m.] 04/02/2026 [April 2, 2026]...pt [Patient 11] standing in doorway of her room. She seems antsy...Pt stated She wants to walk up and down the hallway...Night shift [7 p.m. to 7 a.m. shift] RN [registered nurse] told her to stay in current hallway...she responded ok that she was going to stay in front of [ED Room C] hallway...” A review of a facility document titled, “Progress Note, Nursing,” dated April 3, 2026, at 11:38 p.m., was conducted. The document indicated, “...Date of Service...02-Apr-2026 [April 2, 2025]19:00 [7 p.m.]...Patient gone missing, last seen was on the hall way [sic] walking. Security guard informed about the situation...” A review of a facility document titled, “ED Nurse Discharge Aware Note,” dated April 2, 2026, at 10:46 p.m., was conducted. The document indicated, “...Disposition Date/Time...Apr-02-2026 [April 2, 2026] 1900 [7 p.m.]...eloped...” A review of a facility document titled, “Incident Disposition,” dated April 2, 2026, at 7:35 p.m., was conducted. The document indicated, “...On April 2, 2026, I, Security Officer...was advised of a possible elopement of a ...patient [Patient 11] from the Emergency Department after being alerted...at 1935 [7:35 p.m.]...Although the nurse initially described the patient...in a white nightgown last seen at 1900 [7 p.m.]...video review...identified the patient...wearing a white sweater and sweatpants...The footage revealed patient officially walked off the property at 1916 [7:16 p.m.]...video review...At 1800 [ 6 p.m.]...[patient] is seen not in a patient room and is wondering back and forth in the hallways...At approximately 1820 [6:20 p.m.]...it was observed...[patient] was walking the ER Hallway...[Patient 11] walked away heading to the mail walkway in the Emergency Department...at approximately 1831 [6:31 p.m.]...it was observed that the patient...exited the Emergency department treatment area and entered the Emergency Department seating Lobby area then proceeded to walk outside the Emergency Department lobby doors, then re-entered approximately 30 seconds later...and remains seated in the Emergency lobby until 1918 [7:18 p.m.]...where the patient...was observed exiting the Emergency Lobby and proceeded to walk towards parking lot E...Observed at 1919 [7:19 p.m.] walking through the tree line parking lot at approximately 1924 [7:24 p.m.]...” A review of facility document titled, “Social Work Discharge Planning Note,” dated April 3, 2026, was conducted. The document indicated, “...According to chart review, the patient eloped...” During a concurrent interview with the CNO, the CNO stated there was no physician’s order for a sitter and there did not have to be. The CNO stated any patient who comes in on a 5150 would automatically get assigned to a sitter. The CNO stated Patient 11 was assigned to a sitter daily until the morning of March 31, 2026. The CNO stated the facility provided clothing for the patient as she did not want to wear a hospital gown. The CNO stated Patient 11 was assigned to ED Room C when she eloped from the emergency department. On May 13, 2026, at 1:30 p.m., an interview was conducted with the Emergency Department Director (EDD). He stated All patients who are in the ED should be changed into a hospital gown or paper scrubs and hospital socks. The EDD stated Patient 11 was given clothing by the hospital. The EDD stated he was not sure why the patient sitter was removed, and this was possibly why she eloped. On May 13, 2026, at 2:09 p.m., an interview was conducted with Registered Nurse Charge Emergency Department (RNCED). RNCED stated she did place a sitter on Patient 11 when she was on shift. RNCED stated Patient 11 was intermittently confused. RNCED stated if the patient had a sitter, she might not have eloped. RNCED stated if Patient 11 had a gown, she also may not have eloped as security may have identified her as a patient. On May 13, 2026, at 2:31 p.m., an interview was conducted with Emergency Technician (ET) 4. ET 4 stated, if a patient attempts to elope, the staff run after the patient and hit a panic button to alarm staff and security that a patient is attempting to elope. On May 13, 2026, at 2:46 p.m., an interview was conducted with Security Officer (SO). SO stated Patient 11 was not wearing a hospital gown and was wearing sweats and a sweater. SO stated he could not see that Patient 11 had a patient arm band. SO stated he noticed Patient 11 walked out of the ED lobby then came back in. SO stated he thought Patient 11 was a family member waiting for a patient. SO stated if Patient 11 had been wearing a hospital gown, he would have inquired why she was in the lobby and could have brought her back to the ED, so she could not elope. On May 13, 2026, at 2:54 p.m., an interview was conducted with Security Lead (SL). SL stated, when a patient comes into the lobby wearing a hospital gown, security will stop the patient to make sure they should be outside the ED. SL stated security would ask the patient who his nurse was and would reach out to the nurse. SL stated if Patient 11 had been wearing a hospital gown, security could have stopped her before eloping. On May 13, 2026, at , an interview was conducted with the Director of ICU (DICU). DICU stated the facility did not have a policy or procedure for a patients who were deemed to be gravely disabled. A facility policy and procedure titled, “Fifty-One Fifty Patients in the Emergency Department,” dated September 2023, was reviewed. The document indicated, “...When a patient on a 5150 hold is brought into the ED...Patient must undress completely with the exception of underwear and be placed in hospital gown/paper scrubs while being observed by as associate for safety...The patient will remain in direct observation of designated associate...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure its policy and procedure was implemented, for one of 20 sampled patients (Patient 13), when Patient 13 was not assessed and the need for continued restraint (a physical method which limits a patient’s ability to move, often to prevent harm to themselves or others) was not conducted every two hours. This failure had the potential to compromise the safety of Patient 13 and for Patient 13 to be placed on unnecessary restraint. Findings: On May 12, 2026, at 10:07 a.m., a review of Patient 13’s record and concurrent interview were conducted with the Director of Intensive Care Unit (ICU, a unit which provides specialized care to critically ill patients). A facility document titled, “History & [and] Physical,” dated April 30, 2026, at 10:37 a.m., was conducted. The document indicated Patient 13 was admitted to the facility on April 30, 2026, at 9 a.m., for shortness of breath with hypoxia (a condition where the body’s tissues do not receive enough oxygen) and dementia (a condition which affects memory, thinking, behavior, and ability to perform everyday activities). A facility document titled, “Behavioral Restraint Clinical Safety,” dated May 1, 2026, was reviewed and indicated, “...Restraints-Safety/Non-Self Destructive Behavior-All Ages...Start Date...May-01-2026 [May 1, 2026]...Start Time...1430 [2:30 p.m.]...Order Expires After...3 [three] Days...Observe and Document...Every 2 [two] hours...” A facility document titled, “Behavioral Restraint Clinical Safety,” dated May 4, 2026, was reviewed and indicated, “...Restraints - Safety/Non-Self Destructive Behavior - All Ages...Start Date...May-04-2026 [May 4, 2026]...Start Time...1400 [2 p.m.]...Order Expires After...3 Days...Observe and Document...Every 2 hours...”” A facility document titled, “Behavioral Restraint Clinical Safety,” dated May 8, 2026, was reviewed and indicated, “...Restraints-Safety/Non-Self Destructive Behavior-All Ages...Start Date...May-08-2026 [May 8, 2026]...Start Time...1300 [1 p.m.]...Order Expires After...3 Days...Observe and Document...Every 2 hours...” A facility document titled, “Flowsheet, Adult Restraint Nonbehavioral Nonviolent,” dated April 30, 2026, through May 12, 2026, was reviewed and indicated Patient 13 was assessed on the following dates and times: - May 3, 2026, at 1 a.m.; - May 3, 2026, at 3 a.m.; - May 3, 2026, at 7 a.m.; - May 3, 2026, at 9 a.m.; - May 3, 2026, at 11 a.m.; - May 5, 2026, at 5 a.m.; - May 5, 2026, at 7 p.m.; - May 8, 2026, 11 p.m.; - May 9, 2026, 1 a.m.; - May 9, 2026, 3 a.m.; and - May 9, 2026, 7:10 a.m. During record review, there was no documented evidence Patient 13 was assessed for the need to continue restraints every two hours, when the assessment was not conducted on May 3, 2026, at 5 a.m., on May 5, 2026, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., and 5 p.m., and on May 9, 2026, at 5 a.m. During a concurrent interview, the DICU verified Patient 13 was not assessed for the need to continue restraints every two hours, when the assessment was not conducted on May 3, 2026, at 5 a.m., on May 5, 2026, at 7 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., and 5 p.m., and on May 9, 2026, at 5 a.m. The DICU stated the registered nurses need to assess the patients on restraint and document their need for continued restraints at a minimum of every two hours. On May 13, 2026, at 3:24 p.m., an interview was conducted with the Charge Nurse of the Medical Surgical [a general care floor in the hospital which cares for patients who are recovering from surgery, or for management of chronic conditions] and Telemetry [unit where the patients’ heart rates and rhythms are continuously monitored remotely] units (CNMST). The CNMST stated, when a patient is placed on restraints, the registered nurses are required to assess the patient and document the patient’s need for restraints every two hours. A review of the facility’s policy and procedure titled, “Restraint Use for Voluntary or Involuntary Immobilization or Seclusion [confinement of a person in a room or area from which they are physically prevented from leaving],” dated February 2026, was conducted. The document indicated, “...Minimum Frequency of Ongoing Assessment of a Patient Placed in Restraint or Seclusion...Patients placed in restraints for safety, non-violent, and non-destructive behavior should be assessed at approximately (within 15 minutes before to 15 minutes after) every two hours...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the needs of one of 20 sampled patients (Patient 11) was met in accordance with the facility’s policy and procedure titled, “Fifty One Fifty Patients in the Emergency Department,” dated September 2023, when Patient 11 was brought to the Emergency Department ( a specialized hospital facility operating 24 hours a day to provide immediate care for sudden, life-threatening, or severe medical conditions) on a 5150 hold (a temporary involuntary detention of an individual typically for up to 72 hours) for being gravely disabled (a condition where a person, due to a mental health disorder, severe substance use disorder, or both, is unable to provide for his own basic needs for food, clothing, shelter, personal safety, or necessary medical care], was left unsupervised and eloped (a patient leaving the facility without authorization) from the ED (Refer to A-1104). This failure resulted in Patient 11 being able to elope from the ED which may place Patient 11 at increased risk for harm and injury. Findings: On May 11, 2026, at 2 p.m., a review of Patient 11’s record and concurrent interview were conducted with the Chief Nursing Officer (CNO). A facility document titled, “ED Provider Care Note,” dated March 22, 2026, at 12:08 a.m., was reviewed. The document indicated Patient 11 was brought to the ED as a 5150 for being gravely disabled. The document further indicated, “...Upon interview, pt [Patient 11] states she doesn’t know why she’s here. Per EMS [Emergency Medical Services], patient walked into the wrong house and appeared confused...Differential Diagnosis [method doctor uses to distinguish one disease or condition from others that share similar symptoms] included but not limited to...5150, gravely disabled [GD, an individual is unable to provide for his basic personal needs due to a severe mental health disorder or substance use disorder]....confusion...” A review of facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION,AND CRISIS INTERVENTION [short-term, ] OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated March 21, 2026, was conducted. The document indicated, “...On 03/21/2026 [March 21, 2026], HOLD [5150 hold] CRITERIA...Gravely disabled adult...” A review of a facility document titled, “Progress Note, Nursing,” dated March 21, 2026, was conducted. The document indicated, “...1915 [7:15 p.m.] Pt [Patient 11] arrived to ER [number of hall in the emergency room]. Pt belongings were inventoried and kept with sitter [staff who provides one-on-one, continuous supervision for high-risk patients, ensuring their safety]...” A review of a facility document titled, “Progress Note, Nursing,” dated March 22, 2026, was conducted. The document indicated, “...Patient A&O [alert and oriented, a medical abbreviation to describe a patient with four key cognitive areas] X 1 [oriented to person only]...” A review of a facility document titled, “Social Work [a practice-based profession which helps patients and their families navigate the emotional, social, and financial challenges of an illness or injury] Discharge Planning [process in hospitals that coordinates safe transition from hospital to home, or another facility] Note,” dated March 22, 2026, was conducted. The document indicated, “...5150 expires Tuesday 03/24/2026 [March 24, 2026] at 16:51 [4:51 p.m.]...The patient [Patient 11] presented disheveled, her hair was messy and patient appeared disoriented to place and situation. Patient appeared paranoid as evidenced by scanning her environment, making accusatory statements, and not wanting to share information. Patient presents with disorganized speech and thought process...Per chart review, patient has been previously seen at this hospital on 03/2/26 [March 2, 2026] for anxiety [an emotional state characterized by feelings of unease, worry or fear]...Patient was not seen by SW [social worker, trained professional who helps vulnerable individuals] team as patient eloped from the ED...Patient denied visual hallucinations [seeing things that are not real] but reported she has been experiencing auditory hallucinations[hearing things such as murmurs, music, or voices that are not real] for the past four months... Patient could not recall her son or daughter’s name...Plan: Patient continues to meet criteria for 5150 hold due to GD for mental health...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...March-23-2026 [March 23, 2026] 18:15 [6:15 p.m.]...Level of Consciousness...confused...” A review of a facility document titled, “Consult Note, Provider-Emergency/Psychiatric Medicine,” dated March 23, 2026, at 11 a.m., authored by Psychiatric [medical study of mental, emotional, and behavior disorders] Nurse Practitioner (PNP, an advanced practice registered nurse) was conducted. The document indicated, “...consult...involuntary hold...past medical history...cognitive impairment [problem with mental function that affects a person’s ability to think, learn, or remember], denies past psychiatric history. Currently on involuntary hold for gravely disabled after walking to the wrong house, wandering from her home, refusing to leave her car and come into the home, [family member] has to take her food and water she still [sic] not consume it, she’s refusing to take her medical medications and or follow up with her doctors. [Family member] told social worker by phone he can no longer care for [Patient 11] due to her current behaviors. Patient had been previously seen at the hospital on March 2nd [March 2, 2026] for anxiety and stating that there was spiritual warfare and the spirits are trying to kill her...When patient asked if she was staying in her car and refusing to eat or drink she said “probably”, but couldn’t explain why...Patient does not meet criteria for involuntary hold it’s possible as she’s having early signs of dementia [decline in metal ability, memory, reason or problem solving that interferes with daily life] with psychosis [collection of symptoms which indicate a loss of contact with reality]...case management will find placement for her as her son does not want her to return...” A review of a facility document titled, “Social Work Discharge Planning Note,” dated March 24, 2026, was conducted. The document indicated, “...Social work met with Pt [Patient 11] to discuss DC [discharge] options as Pt’s 5150 hold is expiring today [5150 expired on March 24, 2026, at 4:51 p.m.]...Pt Does present with confusion and memory loss...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 25, 2026, was conducted. The document indicated, “...SW spoke with pt [Patient 11] and provided clothing at pt’s request...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 28, 2026, was conducted. The document indicated, “...Checked in with patient... Patient was walking down the hallway with her cane... Patient requested to have ED room door open...” A review of facility document titled, “Progress Note, Nursing,” dated March 28, 2026, was conducted. The document indicated, “...1900 [7 p.m.]...Moved pt from [ED Room A] TO ED [Room B] for closed observe with high risk to elope, hx [history] of elopement...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...March-30-2026 [March 30, 2026] 7:04 [a.m.]...Level of Consciousness...confused...Orientation...disoriented...” A review of facility document titled, “Social Work Discharge Planning Note,” dated March 30, 2026, was conducted. The document indicated, “...1945 [7:45 p.m.] Pt walk out up to elevator, re direct [redirect] to bed. Needs lots of attention...” A review of facility document titled, “Progress Note, Nursing,” dated April 2, 2026, at 12:21 a.m., was conducted. The document indicated, “...Pt transferred to [ED Room C]...” A review of facility document titled, “Flowsheets,” dated March 21, 2026, through May 11, 2026, was conducted. The document indicated, “...Cognitive...April-02-2026 [April 2, 2026] 7:00 [a.m.]...Level of Consciousness...confused...” A review of facility document titled, “Progress Note, Nursing,” dated April 2, 2026, at 9:05 p.m., was conducted. The document indicated, “...Receive patient [Patient 11] outside of her room, patient is ambulatory...Patient ask permission if she can walk around since shes [sic] been lying in bed for a long time, patient instructed to stay close to the room or in front of nurses station...” A review of a facility document titled, “Progress Note, Nursing,” dated April 3, 2026, at 11:14 a.m., was conducted. The document indicated, “...@ [at] 1815 [6:15 p.m.] 04/02/2026 [April 2, 2026]...pt [Patient 11] standing in doorway of her room. She seems antsy...Pt stated She wants to walk up and down the hallway...Night shift [7 p.m. to 7 a.m. shift] RN [registered nurse] told her to stay in current hallway...she responded ok that she was going to stay in front of [ED Room C] hallway...” A review of a facility document titled, “Progress Note, Nursing,” dated April 3, 2026, at 11:38 p.m., was conducted. The document indicated, “...Date of Service...02-Apr-2026 [April 2, 2025]19:00 [7 p.m.]...Patient gone missing, last seen was on the hall way [sic] walking. Security guard informed about the situation...” A review of a facility document titled, “ED Nurse Discharge Aware Note,” dated April 2, 2026, at 10:46 p.m., was conducted. The document indicated, “...Disposition Date/Time...Apr-02-2026 [April 2, 2026] 1900 [7 p.m.]...eloped...” A review of a facility document titled, “Incident Disposition,” dated April 2, 2026, at 7:35 p.m., was conducted. The document indicated, “...On April 2, 2026, I, Security Officer...was advised of a possible elopement of a ...patient [Patient 11] from the Emergency Department after being alerted...at 1935 [7:35 p.m.]...Although the nurse initially described the patient...in a white nightgown last seen at 1900 [7 p.m.]...video review...identified the patient...wearing a white sweater and sweatpants...The footage revealed patient officially walked off the property at 1916 [7:16 p.m.]...video review...At 1800 [ 6 p.m.]...[patient] is seen not in a patient room and is wondering back and forth in the hallways...At approximately 1820 [6:20 p.m.]...it was observed...[patient] was walking the ER Hallway...[Patient 11] walked away heading to the mail walkway in the Emergency Department...at approximately 1831 [6:31 p.m.]...it was observed that the patient...exited the Emergency department treatment area and entered the Emergency Department seating Lobby area then proceeded to walk outside the Emergency Department lobby doors, then re-entered approximately 30 seconds later...and remains seated in the Emergency lobby until 1918 [7:18 p.m.]...where the patient...was observed exiting the Emergency Lobby and proceeded to walk towards parking lot E...Observed at 1919 [7:19 p.m.] walking through the tree line parking lot at approximately 1924 [7:24 p.m.]...” A review of facility document titled, “Social Work Discharge Planning Note,” dated April 3, 2026, was conducted. The document indicated, “...According to chart review, the patient eloped...” During a concurrent interview with the CNO, on May 11, 2026, at 2 p.m., the CNO stated there was no physician’s order for a sitter and there did not have to be. The CNO stated any patient who comes in on a 5150 would automatically get assigned to a sitter. The CNO stated Patient 11 was assigned to a sitter daily until the morning of March 31, 2026. The CNO stated the facility provided clothing for the patient as she did not want to wear a hospital gown. The CNO stated Patient 11 was assigned to ED Room C when she eloped from the emergency department. On May 13, 2026, at 1:30 p.m., an interview was conducted with the Emergency Department Director (EDD). He stated All patients who are in the ED should be changed into a hospital gown or paper scrubs and hospital socks. The EDD stated Patient 11 was given clothing by the hospital. The EDD stated he was not sure why the patient sitter was removed, and this was possibly why she eloped. On May 13, 2026, at 2:09 p.m., an interview was conducted with Registered Nurse Charge Emergency Department (RNCED). RNCED stated she did place a sitter on Patient 11. RNCED stated Patient 11 was intermittently confused. RNCED stated if the patient had a sitter, she might not have eloped. RNCED stated if Patient 11 had a gown, she also may not have eloped as security may have identified her as a patient. On May 13, 2026, at 2:31 p.m., an interview was conducted with Emergency Technician (ET) 4. ET 4 stated, if a patient attempts to elope, the staff run after the patient and hit a panic button to alarm staff and security that a patient is attempting to elope. On May 13, 2026, at 2:46 p.m., an interview was conducted with Security Officer (SO). SO stated Patient 11 was not wearing a hospital gown and was wearing sweats and a sweater during the early evening of April 2, 2026, and he he could not see that Patient 11 had a patient arm band. SO stated he noticed Patient 11 walked out of the ED lobby then came back in. SO stated he thought Patient 11 was a family member waiting for a patient. SO stated if Patient 11 had been wearing a hospital gown, he would have inquired why she was in the lobby and could have brought her back to the ED, so she could not elope. On May 13, 2026, at 2:54 p.m., an interview was conducted with Security Lead (SL). SL stated, when a patient comes into the lobby wearing a hospital gown, security will stop the patient to make sure they should be outside the ED. SL stated security would ask the patient who his nurse was and would reach out to the nurse. SL stated if Patient 11 had been wearing a hospital gown, security could have stopped her before eloping. On May 13, 2026, at , an interview was conducted with the Director of ICU (DICU). DICU stated the facility did not have a policy or procedure for a patients who were deemed to be gravely disabled. A facility policy and procedure titled, “Fifty-One Fifty Patients in the Emergency Department,” dated September 2023, was reviewed. The document indicated, “...When a patient on a 5150 hold is brought into the ED...Patient must undress completely with the exception of underwear and be placed in hospital gown/paper scrubs while being observed by as associate for safety...The patient will remain in direct observation of designated associate...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure the patients’ rights were promoted, for two of 28 sampled patients (Patients 6, and 7), when: 1. For Patient 6, the facility document titled, “Condition of Admissions (COA, a facility document giving the facility permission to provide treatment to the patient and indicates the patient’s agreement to the facility’s terms of admission) was not signed by the patient nor the patient’s family member during the patient’s admission to the facility (Refer to A0144); and 2. For Patient 7, blood was transfused (blood transfusion, a medical procedure in which donated blood is administered into the bloodstream through a vein) to Patient 7 without the patient’s consent (Refer to A0144). The cumulative effects of these systemic failures resulted in Patient 7 receiving blood in violation of his religious beliefs and compromise his autonomy, and had the potential for Patient 6 to receive treatment without his informed consent (consent for a treatment or procedure given by the patient after receiving education from a healthcare professional about the risks, benefits, and alternatives of a given procedure or intervention).”

“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: 48776 Based on interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 28 sampled patients (Patients 6, 11, 13, 16, and 19), when: 1. For Patient 6, the documentation of a code blue event (a hospital code for a medical emergency where a patient is experiencing a life-threatening condition which requires immediate cardiopulmonary resuscitation [CPR, an emergency treatment that’s done when someone’s breathing or heartbeat has stopped to restore breathing and blood circulation]) and a care plan (a personalized guide outlining the specific care, goals, and actions nurses will need to care for a patient) addressing restraint (a device, method, or medication used to intentionally limit a patient’s movement, physical activity, or access to his own body) use were not completed. In addition, Patient 6’s restraint was not discontinued at the time of a code blue event and the telemetry (a continuous monitoring of a patient’s heart rate and rhythm) strips (print out) were not printed and retained following a documented change in Patient 6’s heart rate. Furthermore, Patient 6’s nasogastric tube (NGT, a thin, flexible plastic tube inserted through the nose, down the throat, into the stomach and used to administer medications and fluids when a patient is not able to swallow) was not assessed for proper placement prior to the administration of a medication (Refer to A0398); 2. For Patient 11, the physician and Patient 11’s family were not notified after the facility was made aware of an allegation of abuse (Refer to A0398); 3. For Patient 13, care plans were not initiated after the initial admission assessment of the patient was completed (Refer to A0398); 4. For Patient 16, an informed consent (a permission granted by the patient after the possible consequences, risks, and benefits of treatment have been discussed by a physician with the patient) was not signed by the physician (Refer to A0398); and 5. For Patient 19, restraint (devices, medications, or physical holds used to intentionally restrict a patient’s voluntary movement or access to their own body) assessments were not completed while the patient was in restraints (Refer to A0398). The cumulative effects of these systemic failures had the potential to compromise Patients 6, 11, 13, 16, and 19’s safety, wellbeing, and cause delay in the provision of care and/or treatment, and may have contributed to Patient 6’s death.”

“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: 48776 Based on interview and record review, the facility failed to ensure the patients’ rights were promoted, for two of 28 sampled patients (Patients 6, and 7), when: 1. For Patient 6, the facility document titled, “Condition of Admissions (COA, a facility document giving the facility permission to provide treatment to the patient and indicates the patient’s agreement to the facility’s terms of admission) was not signed by the patient nor the patient’s family member during the patient’s admission to the facility; and 2. For Patient 7, blood was transfused (blood transfusion, a medical procedure in which donated blood is administered into the bloodstream through a vein) to Patient 7 without the patient’s consent. These failures resulted in Patient 7 receiving blood in violation of his religious beliefs and compromise his autonomy, and had the potential for Patient 6 to receive treatment without his informed consent (consent for a treatment or procedure given by the patient after receiving education from a healthcare professional about the risks, benefits, and alternatives of a given procedure or intervention). Findings: 1. On February 3, 2026, at 9:20 a.m., a concurrent interview and review of Patient 6’s record were conducted with the Director of Quality (DOQ). A facility document titled, “History & [and] Physical, Adult,” dated November 26, 2025, at 3:43 p.m., was reviewed. The document indicated Patient 6 was admitted to the facility with altered mental status (a sudden or significant change in a person’s normal thinking, awareness, or behavior) which began during dialysis (a treatment to clean the blood by removing extra fluid and waste products). A facility document titled, “Conditions of Admission and Treatment,” dated November 26, 2025, at 12:57 p.m., was reviewed. The document indicated, “...Name [Patient 6]...pt [Patient 6] unable to sign due to medical condition...” During the review of Patient 6’s record, there was no documented evidence Patient 6’s next of kin or family member was contacted by the facility to sign the COA for Patient 6. During a concurrent interview, the DOQ stated Patient 6’s next of kin or family member should have been contacted to sign the COA for Patient 6. On February 3, 2026, at 1:10 p.m., an interview was conducted with the Director of Patient Access (DPS). The DPS stated the COA is obtained when a patient arrives in the emergency department (ED, an area of a hospital used to treat immediate, unscheduled care for patients with severe symptoms). The DPS stated, if the patient is unable to sign due to a medical condition, the admitting clerk is responsible for contacting the patient’s family member. The DPS stated the COA was not signed for Patient 6 and the facility made no attempt to contact Patient 6’s family to have the COA signed. A review of the facility’s policy and procedure (P&P) titled, “Consents,” dated August, 2025, was conducted. The P&P indicated, “...Conditions of Admission are to be signed at the time of Outpatient Registration or Inpatient Admission...The consent must be signed by the patient or by an individual with the authority to make health care decisions for the patient...In addition to verifying consent to treatment, hospital personnel should also obtain the legal representative’s agreement to the ‘Condition of Admission’ form...” 2. On February 3, 2026, at 1:15 p.m., a concurrent interview and review of Patient 7’s record were conducted DOQ. A facility document titled, “Facesheet,” was reviewed. The document indicated Patient 7’s religion was Jehovah Witness (a religion which teaches a non-negotiable religious stand for refusal of transfusion of whole blood or its four primary components). A facility document titled, “History & Physical, Adult,” dated January 5, 2026, at 5:01 a.m., was reviewed. The document indicated Patient 7 was admitted to the intensive care unit (ICU, unit for critically ill patients) for diabetic ketoacidosis (a potentially life-threatening complication of diabetes which is a condition when the blood sugar is too high), and urosepsis (a life-threatening condition where a urinary tract infection spreads to the bloodstream). The document indicated the patient spoke Spanish and was confused. A facility document titled, “Adult Assessment Intervention,” dated January 5, 2026, was reviewed. The document indicated Patient 7’s Glascow Coma Scale (GCS, a scale used to assess a person’s level of consciousness by measuring eye, verbal, and motor responses, with a score of 15 meaning the patient is fully awake) were the following: - On January 5, 2026, at 7 a.m., confused, GCS score was 14; - On January 5, 2026, at 9 a.m., confused, GCS score was 14; - On January 5, 2026, at 11 a.m., oriented, GCS score was 15; - On January 5, 2026, at 3 p.m., confused, GCS score was 14; - On January 5, 2026, at 7 p.m., oriented, GCS score was 15; - On January 5, 2026, at 9 p.m., oriented, GCS score was 14; and - On January 5, 2026, at 11 p.m., oriented, GCS score was 14. An untitled facility document dated January 5, 2026, at 12:28 p.m., was reviewed. The document indicated, “...Order...Transfuse Order...Red Blood Cells [RBC, a component of blood], Qty [quantity] 1 [one] Blood Product ordered...” A facility document titled, “Consent to Blood Transfusion,” dated January 5, 2026, at 2:15 p.m., was reviewed. The document indicated, “...Special Instructions: Blood Transfusions...Signature: phone consent...Name: [Name of Patient 7’s Spouse]...” A facility document titled, “Product Identification Tag,” authored by Registered Nurse (RN) 2, dated January 5, 2026, was reviewed. The document indicated, “...Transfusion Record...Started: 1500 [3 p.m.]...Stopped: 3:15 p.m...Patient and doctor changed their minds, blood transfusion discontinued...” A facility document titled, “Progress Note, Nursing,” authored by the Director of ICU (DICU), dated January 5, 2026, at 4:51 p.m., was reviewed. The document indicated, “...The translation line was accessed to translate to both the patient and his wife...myself and [Name of Director of Surgical Services (DSS)] were witness [sic]...The patient [Patient 7] was adamant that he did not want blood products, but wanted all other care...He also stated that if he became unable to make medical decision that he wanted his wife to make the decision, but was still very adamant that he didn’t want blood products...” A facility document, titled, “Progress Note-Internal Medicine,” dated January 5, 2026, at 4:53 p.m., was reviewed. The document indicated, “...One unit of pRBCs [packed RBC, a component of blood] was ordered in preparation of [sic] percutaneous nephrostomy tube [small, flexible, thin plastic tube placed through the skin directly into the kidney to drain urine]. Pt [Patient 7] adamant that he did not want to receive blood products as he was a Jehovah’s Witness. His wife, at bedside stated that she didn’t know what he was talking about and she had previously made medical decisions for him...Pt had received an estimated 50 cc [cubic centimeter, unit of measurement] of blood at this time...Blood was immediately stopped in accordance with patient [sic] wishes...” On February 3, 2026, at 1:30 p.m., an interview was conducted with the DSS. The DSS stated she was informed by the anesthesiologist (MD 1, a physician who specializes in pain management) Patient 7 did not want any blood products, and she then spoke to the DICU regarding stopping the transfusion. The DSS stated she and the DICU used an interpreter to speak with Patient 7, at which time, Patient 7 informed them he did not want any blood products, and the ongoing blood transfusion was stopped. On February 3, 2026, at 2:20 p.m., an interview was conducted with MD 1. MD 1 stated Patient 7 was Spanish speaking, and she was able to converse with him as she speaks Spanish. MD 1 further stated, Patient 7 was adamant about not receiving a blood transfusion and informed her, “I’m a Jehovah Witness and do not want blood.” On February 3, 2026, at 2:45 p.m., an interview was conducted with the DICU. The DICU stated a facility document titled, “Refusal to Permit Blood Transfusion,” should have been obtained from Patient 7, and an armband labeled, “No Blood Products,” should have been applied on Patient 7 when Patient 7 was admitted to the unit, and these were not done. The DICU further stated the ICU did not have any of these two documents in the unit at the time Patient 7 was admitted to the unit. On February 3, 2026, at 3 p.m., an interview was conducted with the DOQ. The DOQ stated a consent using a facility document titled, “Refusal to Permit Blood Transfusion,” should have been obtained from Patient 7 and an arm band labeled, “No Blood Products,” should have been applied on Patient 7 when the patient first expressed refusal for blood transfusion. The DOQ further stated the facility’s P&P was not followed. On February 3, 2026, at 3:20 p.m., an interview was conducted with RN 2. RN 2 stated he asked Patient 7 if he wanted to receive blood products, and the patient refused, stating he was a Jehovah’s Witness. RN 2 stated there was a conflict between the patient and his wife regarding blood transfusion. RN 2 stated an interpreter was used and it was determined the patient did not want to receive blood products after the transfusion had already been started. RN 2 stated he obtained telephone consent from the patent’s wife, who spoke English. RN 2 further stated the blood transfusion was started and discontinued after approximately 15 minutes after MD 1, the DSS, and the DICU arrived at Patient 7’s bedside. RN 2 stated MD 1 explained Patient 7 was alert and oriented and had the right to refuse treatment, and then the ongoing blood transfusion was discontinued. A review of the facility’s P&P titled, “Refusal of Drugs, Treatments or Procedures,” dated April, 2024, was conducted. The P&P indicated, “...Whenever the patient or their legal representative refuses blood, treatments, or other procedures ordered by the attending provider [sic, the provider] should be contacted immediately... If the refusal is for blood products the patient will be arm banded with a blue armband “No blood Products” for patient safety and notification to healthcare providers [sic]...The patient should be asked to sign the appropriate form “Refusal to Permit Medical Treatment” or “Refusal of Blood Products” attached to this policy; the patient’s signature should be witnessed by a hospital associate...” A review of facility’s P&P titled, “Blood and Blood Products Transfusion,” dated December, 2025, was conducted. The P&P indicated, “...Explain the procedure to the patient. Be sure the blood consent is signed and witnessed. Check arm for a blue ‘No Blood Products’ armband, if present, do not transfuse blood products until a clarification is made with the ordering provider, the patient and/or the patient representative...Transcultural Considerations...Jehovah Witnesses need specific written permission from religious authorities to receive blood products or blood transfusion. Patient’s refusing blood products should have a blue armband ‘No Blood Products’ placed...” A review of facility’s P&P titled, “Patient Rights,” dated August, 2023, was conducted. The P&P indicated, “...Patients have the right to...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 a course of treatment...Request or refuse treatment...””

“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: 48776 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 28 sampled patients (Patients 6, 11, 13, 16, and 19), when: 1. For Patient 6, the documentation of a code blue event (a hospital code for a medical emergency where a patient is experiencing a life-threatening condition which requires immediate cardiopulmonary resuscitation [CPR, an emergency treatment that’s done when someone’s breathing or heartbeat has stopped to restore breathing and blood circulation]) and a care plan (a personalized guide outlining the specific care, goals, and actions nurses will need to care for a patient) addressing restraint (a device, method, or medication used to intentionally limit a patient’s movement, physical activity, or access to his own body) use were not completed. In addition, Patient 6’s restraint was not discontinued at the time of a code blue event and the telemetry (a continuous monitoring of a patient’s heart rate [normal is 60 to 100 beats per minute, bpm] and rhythm) strips (print out) were not printed and retained following a documented change in Patient 6’s heart rate. Furthermore, Patient 6’s nasogastric tube (NGT, a thin, flexible plastic tube inserted through the nose, down the throat, into the stomach and used to administer medications and fluids when a patient is not able to swallow) was not assessed for proper placement prior to the administration of a medication; 2. For Patient 11, the physician and Patient 11’s family were not notified after the facility was made aware of an allegation of abuse; 3. For Patient 13, care plans were not initiated after the initial admission assessment of the patient was completed; 4. For Patient 16, an informed consent (a permission granted by the patient after the possible consequences, risks, and benefits of treatment have been discussed by a physician with the patient) was not signed by the physician; and 5. For Patient 19, restraint assessments were not completed while Patient 19 was in restraints. These failures had the potential to compromise Patients 6, 11, 13, 16, and 19’s safety, wellbeing, and cause delay in the provision of care and/or treatment, and may have contributed to Patient 6’s death. Findings: 1. On February 3, 2026, at 9:20 a.m., a concurrent interview and review of Patient 6’s record were conducted with the Director of Quality (DOQ). A facility document titled, “History & [and] Physical, Adult,” dated November 26, 2025, at 3:43 p.m., was reviewed. The document indicated Patient 6 was admitted to the facility with altered mental status (any sudden or significant change in a person’s normal thinking, awareness, or behavior) which began during dialysis (a procedure which removes extra fluid and waste products from the blood). a. A facility document titled, “Progress Note, Nursing,” authored by Registered Nurse (RN) 1, dated November 29, 2025, at 4:38 p.m., was reviewed. The document indicated, “...[Name of Patient 6]...1245 [12:45 p.m.]...HR [heart rate] 25, went in room, slight breathing, hooked up to monitor [heart rate and rhythm monitor] HR 10, called a code blue...1246 [12:46 p.m.] started code [code blue]...[Name of RN] recorder [person responsible for documenting the entire resuscitation process in real-time and acts as the scribe for the code blue event]...” During the review of Patient 6’s record, there was no documented evidence the code blue event for Patient 6 on November 29, 2025, at 12:46 p.m., was documented. During a concurrent interview, the DOQ stated a facility document titled, “Cardiopulmonary Resuscitation Record,” should have been used to document Patient 6’s code blue event on November 29, 2025, at 12:46 p.m., and this was not done. The DOQ stated the primary RN (RN who is assigned to provide care for the patient) should have been the recorder according to the facility’s per policy. The DOQ stated the facility’s policy and procedure (P&P) was not followed. On February 4, 2026, at 11 a.m., an interview was conducted with RN 1. RN 1 stated she was Patient 6’s primary RN on November 29, 2025. RN 1 stated she did not document the code blue events on the facility document titled, “Cardiopulmonary Resuscitation Record.” RN 1 stated she was not aware of the facility’s P&P on code blue. A review of P&P titled, “Code Blue (Code Blue Resuscitation),” dated October 2024, was conducted. The P&P indicated, “...Patient’s Primary Nurse shall...Serve as the recorder and complete the Cardiopulmonary Resuscitation Record...” b. On February 3, 2026, at 9:20 a.m., an untitled facility document, dated November 28, 2025, at 6:48 p.m., was reviewed. The document indicated, “...Order...Restraints...Requested by [Name of a physician]...Soft Wrist Restraint [device applied to a patient’s wrists to restrict arm movement]...Bilateral [both wrists]...To Support and Promote Physical Healing, Avoid Treatment Interruptions and Enable Active Interventions for the Patient [Patient 6]...” A facility document titled, “Progress Note, Nursing,” authored by RN 1, dated November 29, 2025, at 4:38 p.m., was reviewed. The document indicated, “...1100 [11 a.m.] went to reposition patient [Patient 6] and [Patient 6] tries to grab tube [NGT], restraints remain in place...1250 [12:50 p.m.] no pulse no b/p [blood pressure, the force of blood pushing against the walls of arteries as the heart pumps it throughout the body] cpr started...” A facility document titled, “Adult Plan of Care,” was reviewed. The document indicated a care plan to address Patient 6’s restraints was not initiated and completed since patient 6’s admission to the facility. During the review of Patient 6’s record, there was no documented evidence Patient 6’s restraints were removed at the time of Patient 6’s code blue event on November 29, 2025, at 12:46 p.m., in accordance with the facility’s restraint use P&P. During a concurrent interview, the DOQ stated a care plan to address restraints including remaining free from injury, maintaining skin integrity, and positioning of the patient should have been initiated and completed for Patient 6. The DOQ stated there was no documentation Patient 6’s restraints were removed during the patient’s code blue event on November 29, 2025. The DOQ stated Patient 6’s restraints should have been removed during the code blue. The DOQ stated the facility’s P&Ps on care plan and restraints were not followed. On February 4, 2026, at 11 a.m., an interview was conducted with RN 1. RN 1 stated all patients in restraints should have a care plan in place to address the restraints and this was not done for Patient 6. RN 1 stated she did not document the removal of Patient 6’s restraints during Patient 6’s code blue event on November 29, 2025, and she should have. A review of P&P titled, “Care Plans, Patient,” dated February 2024, was conducted. The P&P indicated, “...The Patient Care Plan will be developed from the assessments and data obtained by the RN, other health care clinicians, and providers in collaboration with the patient or patient’s representative...Care plans are updated relative to patient’s condition/needs changes and patient or patient representative’s input. Care plans are intended to be a fluid document to reflect the patient’s changing condition and needs assessment...” A review of P&P titled, “Restraint Use for Voluntary or Involuntary Immobilization or Seclusion,” dated September 2022, was conducted. The P&P indicated, “...Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely...All patients have the right to be free from restraint...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, an associate, or others and must be discontinued at the earliest possible time...Documenting the Use of Restraints or Seclusion in the Patient’s Plan of Care...The use of restraint or seclusion (including drugs or medications used a restraint as well as physical restraint) must be documented in the patient’s plan of care or treatment plan...The use of a restraint or seclusion intervention should be reflected in the patient’s plan of care or treatment plan based on an assessment and evaluation of the patient...Each episode of restraint or seclusion should contain at least the following documentation in the patient’s EHR [electronic medical record]...Revisions to the plan of care...” c. On February 3, 2026, at 9:20 a.m., a concurrent interview and review of Patient 6’s record were conducted with the DOQ. A facility document titled, “Progress Note, Nursing,” authored by RN 1, dated November 29, 2025, at 4:38 p.m., was reviewed. The document indicated, “...1010 [10:10 a.m.] Tele [Telemetry, central monitoring area where specially trained monitor technicians watch screens for any remotely recorded abnormal heartbeats or changes in the patients’ heart rates] called stating rate [heart rate, normal is 60-100] up to 150 [bpm]...gave metoprolol [a medication used to lower the heart rate]...” A facility document titled, “[Name of facility] - Telemetry Report,” was reviewed. The document indicated, “...[name of Patient 6]...11/28 [November 28, 2025]...1/29 [sic, Novermber 29, 2025]...0931[9:31 a.m.]...HR...140...0955 [9:55 a.m.]...HR 150...” During the review of Patient 6’s record, there was no documented evidence the telemetry strips were printed to capture the change in Patient 6’s heart rate. During a concurrent interview, the DOQ stated telemetry stripes should have been printed when Patient 6’s heart rate increased to 140 at 9:31 a.m., and 150 (bpm, beats per minute) at 9:55 a.m., on November 29, 2025, but this was not done. The DOQ further stated the facility’s P&P was not followed. On February 3, 2025, at 11:50 a.m., a concurrent interview and review of Patient 6’s record were conducted with Monitor Tech (MT, healthcare professional responsible for continuously observing, recording, and interpreting real-time recorded heart rates and rhythms) 1. MT 1 stated any heart rate change is considered a rhythm change and required printing of the telemetry strips and retaining the telemetry strip in the patient’s electronic record (EHR, electronic health record). MT 1 stated telemetry strip were not printed when Patient 6’s heart rate increased to 140 bpm at 9:31 a.m. and 150 bpm at 9:55 a.m. on November 29, 2025. A review of an undated P&P, titled, “Telemetry: Care of the Patient on Centralized Telemetry Monitoring,” was conducted. The P&P indicated, “...Documentation Guidelines...The MT prints out and interprets cardiac strips on the following occasions...Any change in cardiac rhythm...The MT prints the strips and they are scanned into the electronic healthcare record (EHR) where they can be visualized into the computer document for anyone to review...” d. On February 3, 2026, at 9:20 a.m., a concurrent interview and review of Patient 6’s record were conducted with the DOQ. An untitled facility document, dated November 28, 2025, at 2:46 p.m., was reviewed. The document indicated, “...Order...Communication Order to Nurse...Requested by [Name of Physician (MD) 2]...please insert NG tube to administer medications...” A facility document titled, “DRAINS/TUBES,” dated November 29, 2025, at 6:59 a.m., was reviewed. The document indicated, “...[Name of Patient 6]...Naso [inserted through the nose]/Oral [inserted through the mouth] Tube...Location: right nostril...Intended Destination: stomach...Indication: meds [to use for administration of medications]...Placement Check [verification process to check that the NGT is in the correct location]: aspirate [a procedure used to confirm proper tube placement which involves withdrawing the fluid from the stomach by suctioning through the NGT using a syringe] characteristics assessed; x-ray [an imaging procedure] confirmation; at 70 cm [centimeter, unit of measurement] mark [visible indicator on the NGT to show exactly how far it is inserted into a patient’s nose]...” A facility document titled, “Patient Results,” dated November 29, 2025, at 8:09 a.m., was reviewed. The document indicated, “...[Name of Patient 6]...XR [x-ray] Abdomen...Indication: NG tube placement...FINDINGS/IMPRESSION: Nasogastric tube projects towards stomach...” An untitled facility document dated November 29, 2025, at 9 a.m., was reviewed. The document indicated, “...Name of Patient 6]...Order...Communication Order to Nurse...Requested by [Name of MD 2]...okay to use NG tube for meds [for administration of medications]... A facility document titled, “Medication Administration Record,” dated November 29, 2025, at 10:15 a.m. was reviewed. The document indicated lactulose (a medication with thick syrupy consistency used to treat liver disease) was administered to Patient 6 through the NGT. A facility document titled, “Progress Note, Nursing,” authored by RN 1, dated November 29, 2025, at 4:38 p.m., was reviewed. The document indicated, “...0630 [6:30 a.m.]...patient [Patient 6] had pulled out his NG tube...1246 [12:46 p.m.] Started code [code blue]...1307 [1:07 p.m.] Code called [time when the patient is pronounced expired]...” A facility document titled, “Death Pronouncement,” authored by MD 2, dated November 29, 2025, was reviewed. The document indicated, “...Time of Death: Nov-29-2025 [November 29, 2025] 13:07 [1:07 p.m.]...Preliminary Cause of Death: Acute Hypoxic Respiratory Failure [a life-threatening, sudden onset condition where the lungs cannot get enough oxygen]...” During the review of Patient 6’s record, there was no documented evidence the NGT placement was assessed prior to the administration of lactulose to Patient 6 on November 29, 2025, at 10:15 p.m. On February 4, 2026, at 1:30 p.m., an interview was conducted with MD 2. MD 2 stated Patient 6 had altered mental status and was on dialysis. MD 2 stated Patient 6 required a NGT for lactulose administration. MD 2 further stated he believed Patient 6 may have aspirated (when food, liquid, saliva, vomit, or medication enters the airway or lungs instead of the stomach) resulting in a code blue event and subsequent death of Patient 6 on November 29, 2025. On February 4, 2026, at 3:05 p.m., an interview was conducted with the Director of Medical/Surgical/Telemetry (DMST) unit (unit where a patient’s heart is continuously monitored remotely). The DMST stated Lippincott [an evidence-based online resource providing step-by-step instructions, and competency tests for clinical procedures] is used as a reference for nursing skills including NGT placement and use. The DMST further stated Patient 6’s abdominal [stomach area] x-ray required clarification prior to using the NGT for medication administration, as the report indicated the tube was projected toward the stomach, but did not clearly confirm appropriate gastric [stomach] placement or whether further advancement of the NGT was required. On February 4, 2026, at 4:05 p.m., an interview was conducted with RN 1. RN 1 stated MD 2 entered an order to use the NGT and she administered lactulose to Patient 6. RN 1 stated she checked NGT placement by injecting air through the NGT into the patient’s stomach and listening over the abdomen with a stethoscope and verified the mark on the NGT to ensure there was no migration [the unintentional movement of the tube tip form its originally confirmed position in the stomach]. RN 1 stated she did not document NGT placement verification in the EHR prior to the administration of lactulose to Patient 6 on November 29, 2025, at 10:15 a.m. A review of “Lippincott Nursing Procedures,” by Williams and Wilkins, Ninth edition, dated 2022, was conducted. The document indicated. “...Confirm accurate NG tube placement regularly and before instilling any type of solution into the tube using one of these methods. Observe the incremental marking on the tube at the exit site or measure the external tube length and compare it to the baseline documented in the medical records at the time of insertion to assess for tube migration. Review chest and abdominal x-ray reports for notation about the tube’s location. Inspect the visual characteristics of the tube aspirate [the gastric fluid, air, or feeding content withdrawn from a patient’s stomach via the NGT]; fasting gastric secretions [the contents of the stomach removed through the NGT] commonly appear grassy-green, brown, or clear and colorless...” 2. On February 3, 2026, at 9:25 a.m., a review of Patient 11’s record was conducted with the Director of the Intensive Care Unit (DICU) (ICU, a specialized, high-intensity department for patients with severe, life-threatening illnesses or injuries). On February 3, 2026, at 9:30 a.m., a review of a facility document titled, “History and Physical,” dated January 7, 2026, at 11:04 p.m., authored by MD 3 was conducted. The document indicated Patient 11 was admitted to the facility for complaints of nausea (unpleasant sensation of queasiness, discomfort in the stomach, and a conscious urge to vomit), vomiting, and diarrhea with abdominal pain. The document indicated Patient 11 had a medical history of hypertension (high blood pressure), atrial fibrillation (a condition when the heart’s upper chambers beat irregularly and often too fast, causing a chaotic, quivering rhythm instead of a steady pump), and chronic kidney disease (a long-term, progressive loss of kidney function). On February 3, 2026, at 9:35 a.m., a review of a facility document titled, “Progress Note,” dated January 23, 2026, at 7:25 a.m., authored by Certified Nursing Assistant (CNA) 1, was conducted. The document indicated CNA 1 was cleaning Patient 11 with Registered Nurse (RN) 3 present in the room on January 23, 2026. The document indicated, “...Patient [Patient 11] was cooperative with change but once upon her side she accused me of laying on top of her so I put her right side up and made sure she was in a safe position with bed in lowest position...” On February 3, 2026, at 9:45 a.m., a review of a facility document titled, “[Name of Company A],” dated January 23, 2026, at 7:03 a.m., was conducted. The document indicated an incident report (a formal, confidential document used in healthcare to record any unexpected or unusual event that harms, or has the potential to harm, patients, staff, or visitors) was completed by CNA 1 for an incident which occurred on January 23, 2026. The document indicated, “...what type of patient safety event is being reported...Unsafe condition...What type of event...Patient abuse...How was this event discovered...Report by patient [Patient 11]...Provide a brief description of the event or unsafe condition as it occurred...I was cleaning patient in [room number] with RN [name of RN 3] in the room...once upon her side she accused me of laying on top of her...” During the review of Patient 11’s record, there was no documented evidence Patient 11’s family and physician were notified about the allegation of abuse involving Patient 11. On February 3, 2026, at 10 a.m., an interview was conducted with the DICU. The DICU stated she could not find documentation in Patient 11’s record the physician and the family of Patient 11 were notified about the allegation of abuse involving Patient 11 which occurred on January 23, 2026. The DICU stated notification to the patient’s family and physician should have been documented in the patient’s record when it was done. A review of the facility P&P titled, “Abuse- Identification and Reporting of Elder and Dependent Person (Adult),” revised February 2025, was conducted. The P&P indicated, “...All associates are responsible for the reporting of any witnessed or alleged abuse...The reporting procedure is as follows...Notify the patient’s responsible party or family member about the incident...Notify the provider...” 3. On February 3, 2026, at 10:40 a.m., a review of Patient 13’s record was conducted with the DICU. On February 3, 2026, at 10:55 a.m., a review of a facility document titled, “History & Physical,” dated February 2, 2026, at 5:34 p.m., was conducted. The document indicated Patient 13 was admitted to the facility on February 2, 2026, for weakness and loss of appetite. The document indicated Patient 13 had a medical history of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and often with personality change), diabetes (a disorder characterized by high blood sugar levels), chronic obstructive pulmonary disease (a progressive, irreversible lung disease that restricts airflow, making it difficult to breathe), and hypertension (elevated blood pressure). On February 3, 2026, at 10:57 a.m., a review of a facility document titled, “Assessment,” dated February 3, 2026, at 4:46 p.m., authored by RN 4 was conducted. The document indicated an admission assessment for Patient 13 was completed by RN 4. During the review of Patient 13’s record, there was no documented evidence care plans were initiated and completed for Patient 13. On February 3, 2026, at 10:59 a.m., an interview was conducted with the DICU. The DICU stated care plans were not completed on Patient 13’s admission to the facility on February 2, 2026, and they should have been completed. A review of the facility P&P titled, “Care Plans, Patient,” revised February 2024, was conducted. The P&P indicated, “...Care plans are initiated during the admission process to develop a plan of care to meet the individualized needs, care and treatments for the patient...” 4. On February 3, 2026, at 11:40 a.m., a review of Patient 16’s record was conducted with the DICU. On February 3, 2026, at 11:45 a.m., a review of a facility document titled, “History & Physical,” dated January 27, 2026, at 5:28 p.m., was conducted. The document indicated Patient 16 was admitted to the facility with complaints of chest pain with shortness of breath. The document indicated Patient 16 had a medical history of hypertension. On February 3, 2026, at 11:47 a.m. a review of a facility document titled, “Order,” dated January 27, 2026, at 5:23 p.m., was conducted with the DICU. The document indicated a Dobutamine Stress Echocardiogram Test (a non-invasive diagnostic procedure that uses the medication to mimic the effects of exercise on the heart) was ordered by Physician (MD) 4 for Patient 16. On February 3, 2026, a review of a facility document titled, “Consult Cardiology,” dated January 28, 2026, at 1:59 p.m., was conducted. The document indicated, “...Assessment and Plan...She [Patient 13] can do a dobutamine stress echo [echocardiogram] for cardiac risk stratification (heart risk)...Further recommendations can be made pending results...” On February 3, 2026, at 11:48 a.m., a review of a facility document titled, “Consent to Surgery, Special Procedure, and/or Blood Transfusion,” dated January 28, 2026, was conducted. The document indicated, “...Dobutamine Stress Echocardiogram...name of the practitioner who is performing the procedure...[name of a physician]...” On February 3, 2026, at 11:50 a.m., a review of a facility document titled, “Diagnostic Cardiology [a medical field focused on detecting, evaluating, and monitoring heart and blood vessel conditions],” dated January 28, 2026, at 2:34 p.m., was conducted. The document indicated the Dobutamine Stress Echocardiogram test on Patient 13 was completed on January 28, 2026, at 2:33 p.m. During the review of Patient 13’s record, there was no documented evidence the risks and benefits of the Echocardiogram Dobutamine Stress Test was discussed with Patient 13. During the review of Patient 13’s record, there was no documented evidence Patient 13 gave his consent for the Echocardiogram Dobutamine Stress Test. During the review of Patient 13’s record, there was no documented evidence a physician signed the consent for Patient 13’s Echocardiogram Dobutamine Stress Test (a physician’s signature on the consent form signifies the physician discussed the risk and benefits of the procedure with the patient). On February 3, 2026, at 11:55 a.m., an interview was conducted with the DICU. The DICU stated, “...the physician should have signed the consent form...it is important so that the patient is aware of the risks and benefits of the procedure...” A review of the P&P titled, “Consents,” revised August 2025, was conducted with the DICU. The P&P indicated, “...The provider must document, in the patient’s electronic healthcare record (HER) that the risks, possible complications, benefits and alternatives have been explained to the patient or the patient’s legal representative. This can be documented in the progress note, in the history and physician or by dating, timing, and signing the preprinted Physician Certificate of Informed Consent declaration at the bottom of the consent form...” 5. On February 3, 2026, at 12:30 p.m., a review of Patient 19’s record was conducted with the DICU. On February 3, 2026, at 12:40 p.m., a review of a facility document titled, “ED Provider Aware Note,” dated December 25, 2025, at 12:15 p.m., was conducted. The document indicated Patient 19 was admitted on December 25, 2025, at 12:14 p.m., to the Emergency Department (ED, a specialized hospital unit providing 24 hours a day, unscheduled care for patients with sudden, severe, or life-threatening injuries and illnesses) for bizarre behavior and was previously put on a 5150 hold (an involuntary 72-hour hold as a result of a mental health disorder, being a danger to others, or to themselves, or being gravely disabled [unable to care for oneself]) by law enforcement due to being a danger to others. On February 3, 2026, at 12:45 p.m., a review of a facility document titled, “Order,” dated December 25, 2025, at 4:44 p.m., was conducted. The document indicated a physician’s order for bilateral soft wrist for Patient 19 due to “...physical attack...” to staff by the patient. On February 3, 2026, at 12:50 p.m., a review of a facility documents titled, “Progress Note, Nursing,” dated December 25, 2025, at 5 p.m., was conducted. The document indicated, “...Pt [Patient 19] is not able to calm down and repeats behaviors to elope [an unauthorized departure or escape of a patient from a facility]. Pt is agitated and is pushing staff at the doorway. [Name of MD 5] informed and orders received to restrain the patient...” During the review of Patient 19’s record, there was no documented evidence assessments and monitoring were performed while Patient 19 was on restraints. On February 3, 2026, at 12:52 p.m., an interview was conducted with the DICU. The DICU stated, “...the nurse should have documented assessments while the patient was in restraints for safety and to make sure they are not causing harm to the patient in restraints...” A review of the facility P&P titled, “Restraint Use for Voluntary or Involuntary Immobilization or Seclusion,” dated September 2022, was conducted. The P&P indicated, “...Patients placed in restraint or seclusion for violent or self-destructive behavior should be monitored at least every 60 minutes with an increase in monitoring based on patient’s individualized needs...””

“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: 48326 Based on interview and record review, the facility failed to ensure nursing services were provided in accordance with the facility’s policy and procedure (P&P) for fetal heart rate monitoring and provider notification, for one of 28 sampled patients (Patient 11), when the physician was not notified by nursing staff regarding a non-reassuring (the reading of the baby’s heart rate does not look normal) fetal heart rate (the baby’s heartbeat in the womb, normal is 110-160 beats per minute [bpm, how many times the heart beats in one minute]) finding (Refer to A-0398). The cumulative effects of this systemic failure had the potential to result in delayed identification and intervention for an emergency medical condition for Patient 11 who was pregnant and her undelivered baby, and could have contributed to Patient 11 being admitted to the intensive care unit (unit for critically ill patients) and her baby’s fetal demise (when the baby has died before birth while still in the uterus).”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 48326 Based on interviews and record review, the facility failed to ensure an adverse event was reported to the California Department of Public Health (CDPH, a state agency), for one of 28 sampled patients (Patient 11), within the mandated time-frame of reporting an adverse event to the Department, when Patient 11 who was 35 weeks pregnant and a type 1 diabetic (a condition with high blood sugar) returned eleven (11) hours and two (2) minutes after being discharged from the facility with diabetic ketoacidosis (DKA, a life-threatening medical emergency) and suffered fetal demise [the baby died before birth in the uterus]. This failure resulted in an 85-day delay in reporting an adverse event and had the potential to delay regulatory oversight and corrective action, placing current and future obstetric [pertaining to the care of the pregnant woman and the delivery of her child] patients at risk for similar adverse maternal-fetal [mother and baby] outcomes, including fetal demise. Findings: On November 19, 2025, a review of Patient 11’s record was conducted with the Director of Risk Management and Quality Assurance (DRMQA). A facility document titled, “Physicians Orders,” dated August 20, 2025, was reviewed. The document indicated physician orders for Patient 11 to “...admit to OB [obstetric, pertaining to the care of the pregnant woman and the delivery of her child] outpatient...” for “...vomiting...NST [non-stress test, a fetal heart rate test] for fetal wellbeing...” A facility document titled, “Triage Information Form,” dated August 20, 2025, was reviewed. The document indicated, “...reason for being seen...35 weeks pregnant [full term pregnancy is 38 to 40 weeks] I can’t stop vomiting or hold water down/dehydrated [not enough fluids in the body]...” An undated facility document titled, “Audit Trail Print,” was reviewed. The document indicated Patient 11 had a past medical history of type 1 diabetes [a condition with high blood sugar]. A facility document titled, “OB [Obstetrics, medical care for pregnancy and childbirth] Triage [the process of determining how urgent the patients’ needs are],” dated August 20, 2025, at 6:08 p.m., was reviewed. The document indicated Patient 11 was experiencing irregular contractions [tightening of the uterus (organ where baby grows)]. The document indicated, “...pain location...pelvic [the lower belly between the hips] pressure and pelvic pain...fetal assessment...external US [external ultrasound, a device used to monitor the baby’s heart beat]...FHR baseline rate: 155...Variability [beat to beat changes in baby’s heart rate, absent means no change; minimal means 5 [five] bpm or less; moderate means normal change, 6-25 bpm; and marked means very large change, more than 25 bpm]: moderate 6-25 bpm...accelerations [brief increases in the baby’s heart rate, normal is a rise of at least 10 beats per minute above the usual rate for at least 10 seconds that returns to the baseline]: 10 x 10...decelerations [drops in the baby’s heart rate, normal is no sudden or repeated drops in the baby’s heart rate]: none...category...category II (2) [meaning FHR tracings are unclear or uncertain]...communication comments: orders received for discharge home...” A facility document titled, “Medication Reconciliation Record,” dated August 20, 2025, at 6:29 p.m., was reviewed. The document indicated, “...BG [blood glucose, blood sugar level, normal is 70-100 milligrams/deciliter [mg/dL, unit of measurement] 99 at home this pm [evening] prior to coming into the hospital...” A facility document titled, “Discharge Summary,” dated August 20, 2025, was reviewed. The document indicated Patient 11 was discharged home on August 20, 2025, at 7:25 p.m. A facility document titled, “OB Triage,” dated August 21, 2025, at 6:27 a.m., was reviewed. The document indicated Patient 11 returned to the OB department on August 21, 2025. The document indicated, “...c/o [sic: complaining of] contractions, nausea and vomiting with pain 10/10 [ten out of ten, pain scale score from zero to 10, 10 being worst pain]. Patient [Patient 11] abdomen palpated [to feel with hands] hard and 10/10 pain with touch. Patient reports that she feels that her pain is getting progressively worst [sic]. Patient placed on monitor no fetal heart tones [baby’s heartbeat] found...” The document further indicated at 7:45 a.m., “...patient reported that she felt like fainting. Patient noted in decline [progressive decrease or deterioration in physical or mental health] no longer answering questions with eyes rolling back...rapid [rapid response, a hospital code for a medical emergency designed to identify and respond to patients with early signs of clinical deterioration] called...provider [Medical Doctor (MD) 1] at bedside. Updated Patient 11...of fetal demise and options...” A facility document titled, “Rapid Response Record,” dated August 21, 2025, was reviewed. The document indicated, “...patient [Patient 11] came in with contractions, nausea [inclination to vomit], and pain. Patient declined and was lethargic [a state of unusual drowsiness, lack of energy, and mental sluggishness]. Rapid [rapid response] called suspected DKA [diabetic ketoacidosis, a life-threatening complication of having very high blood sugar]. BS [blood sugar] 347, continued tachypnea [fast breathing], EKG [electrocardiogram, a test which records the electrical activity of the heart], sinus tach [sinus tachycardia, a type of fast heart rate]. Fluids [intravenous fluids, fluid administered through the vein], insulin [a medicine which lowers blood sugar], mag [sic: magnesium, a medicine to treat pre-eclampsia, a medical emergency in a pregnant patient which could cause convulsion] done. Prepped [prepared] for C/S [sic: cesarean section, surgery to deliver a baby by making a cut in the mother’s abdomen and uterus]...” A facility document titled, “Operative Report,” dated August 21, 2025, authored by MD 1, was reviewed. The document indicated, “...history of presenting illness...approximately 35-week gestation. She had initially presented on 8/20/2025 [sic: August 20, 2025]...she had come in complaining of nausea and contractions every 3 [three] minutes...there was some mention that she was diabetic and on a lot of medication to control it. I was not told anything regarding the fetal status...I gave orders to try terbutaline [a medication which relaxes the uterus to slow or stop contractions and reduce stress on the baby] and Zofran [a medication for nausea]...if she improved...she could be discharged and at that point there was no notification regarding her status or fetal status. The following morning the patient re-presented with contractions that were closer together. The patient was in a lot of discomfort. Also had a blood pressure [normal blood pressure 120/80] that was in the 160 systolic range [top blood pressure number, normal is 120], as well as worsening shortness of breath...I was notified that there was difficulty obtaining fetal heart tones...I ordered a biophysical profile [an ultrasound that checks how well the baby is doing in the womb by looking at movement, breathing, motions, muscle tones and fluid, a score of 8-10 is normal, a score of 4 or less is abnormal, requiring urgent medical care, including possible delivery of the baby] to which there was no fetal heart rate or movement the baby scored 0/0 [zero]...I recommended calling a rapid response given her shortness of breath...the patient blood sugar check was found to be in the 300’s. Her blood gases [a blood test which shows how much oxygen (the gas that is breathed in) and carbon dioxide (the gas that is breathed out) to see how well the lungs and body are working] were also drawn at the time which showed that she was in diabetic ketoacidosis...given the contractions that the patient was having I was concerned for uterine rupture [when the walls of the uterus tear open]...which is why I deemed it necessary to proceed with urgent...cesarean section...” The document further indicated, “...intraoperative findings...there was a true knot [a knot which forms in the baby’s umbilical cord, the lifeline between the baby and the placenta, an organ that grows in the uterus during pregnancy] in the umbilical cord. Baby had no heartbeat or pulse at the time of delivery...” A facility document titled, “Critical Care Medicine,” dated August 22, 2025, was reviewed. The document indicated Patient 11 was admitted to the ICU for management of DKA and was intubated [a breathing tube inserted through the airway to help the patient breathe]. The document indicated, “...Admit date: 21 Aug 2025 [sic: August 21, 2025]...length of stay 2 [days]...endotracheal tube [breathing tube]...she has been managed in the ICU for multi-organ dysfunction [ failure of two or more organ systems to function properly] including acute kidney injury [a condition when the kidneys are damaged], acute hypoxic respiratory failure [a condition when the lungs are not getting enough oxygen into the blood], and severe metabolic derangements [a serious, life-threatening complications that disrupt the body’s normal chemical processes]...” A facility document titled, “Discharge Summary,” dated August 23, 2025, was reviewed. The document indicated, “...hospital course...she [Patient 11] underwent a cesarean by [name of MD 1] and was admitted to the ICU in DKA...” There was no documented evidence a physician order to check Patient 11’s blood sugar level was obtained on August 20, 2025, when Patient 11 first came to the facility. There was no documented evidence Patient 11’s blood sugar level was obtained on August 20, 2025. There was no documented evidence intravenous (IV, through the vein) fluids (fluids administered into the vein using a catheter ) was started, oxygen was administered, Patient 11 was repositioned, or a pelvic examination (a physical examination of the female reproductive organs which include the uterus) were performed for the management of a Category II FHR on August 20, 2025, in accordance with the facility policy. On November 19, 2025, at 1:40 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware she had to check Patient 11’s blood glucose herself on August 20, 2025, when Patient 11 first came to the OB department, because Patient 11 told her she (Patient 11) checked her blood sugar prior to coming to the hospital. RN 1 stated she did not have to check the blood glucose of the patient. She stated she does not remember asking Patient 11 if the patient took any insulin on August 20, 2025. RN 1 further stated she gave Patient 11 water to drink as an intervention and was then able to recategorize the fetal heart rate from category II (two) to Category I (one, normal) but did not notify the doctor that she initially categorized the FHR as a two. On November 20, 2025, at 3:37 p.m., a telephone interview was conducted with MD 1. MD 1 stated the RN should have checked Patient 11’s blood glucose level on August 20, 2025. MD 1 stated the RN should have called him to notify him the FHR was initially categorized as two. MD 1 stated he would have ordered a Biophysical Profile which he stated was an ultrasound to determine the baby’s movement. On November 19, 2025, at 1:22 p.m., an interview was conducted with the Women-Child Health Director (WCD). The WCD stated the nurse should check the blood sugar of a patient who is a known diabetic and is pregnant. The WCD stated this is the standard of practice. On November 19, 2025, at 2 p.m., an interview was conducted with the WCD. The WCD stated, when the nurse gave the FHR a category two, the physician should have been called and notified of the assessment. The WCD stated the nurse did not notify the physician of the category two FHR for Patient 11 on August 20, 2025. On October 21, 2025, at 2:21 p.m., an interview was conducted with the DRMQA. The DRMQA stated this was an adverse event and was not reported to the California Department of Public Health (CDPH). The facility’s P&P titled, “[Name of Facility] Electronic Fetal Monitoring,” dated May 2024, was reviewed. The P&P indicated, “...EMF (Electronic Fetal Monitoring) is used to provide evaluation of the fetal heart response during labor, pregnancy related illness, and to describe interventions aimed at maximizing fetal perfusion [how well blood is flowing to the baby] and oxygenation [how well blood oxygen is getting into the blood and out to the body’s tissues]...categorization of FHR patterns...a three tier system for categorization of FHR patters will be utilized...Category II: FHR tracings are indeterminate are not predictive of abnormal fetal acid-base status and there is inadequate evidence to categorize them as a Category 1(normal) or Category III (abnormal)...management of Category II or III: Notify provider immediately...start IV with 1000 ml [milliliters, a unit of measurement] LR [Lactated Ringers, a type of IV fluid] bolus with 150 ml/hr [milliliters per hour, a unit of measurement]...initiate [start] oxygen at 8-10 L/min [liters per minute, a unit for measurement for volume oxygen for each hour] via simple face mask [a mask worn over the nose and mouth to deliver oxygen to the patient]...reposition patient - left side or knee-chest...vaginal exam [pelvic exam] to rule out prolapsed cord [an obstetric emergency where the umbilical cord descends into the birth canal before or alongside the baby’s presenting part ]...” The facility’s P&P titled, [Name of Facility] “Disclosure of Adverse Outcomes or Unanticipated Events” dated August 2024, was reviewed. The document indicated “...types of events that must be reported...”adverse events” include...care management...examples of adverse/unanticipated outcome...a result that differs significantly from what was anticipated...care management...maternal death or serious disability associated with labor or delivery...while being cared for in a facility...all...adverse events shall be reported to California Department of Public Health (CDPH) no later than five (5) calendar days after the adverse event is detected...” This failure resulted in an 85-day delay in reporting an adverse event to the Department.”

“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: 48326 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) for fetal heart rate (FHR, the baby’s heartbeat in the womb, normal is 110-160 beats per minute [bpm, how many times the heart beats in one minute]) monitoring and provider notification was implemented when the physician was not notified by nursing staff regarding a non-reassuring (the reading of the baby’s heart rate does not look normal) FHR finding, for one patient of 28 sampled patients (Patient 11). This failure had the potential to result in delayed identification and intervention for an emergency medical condition for Patient 11 who was pregnant and her undelivered baby, and could have contributed to Patient 11 being admitted to the intensive care unit (ICU, unit for critically ill patients) and her baby’s fetal demise (when the baby has died before birth while still in the uterus). Findings: On November 19, 2025, a review of Patient 11’s record was conducted with the Director of Risk Management and Quality Assurance (DRMQA). A facility document titled, “Physicians Orders,” dated August 20, 2025, was reviewed. The document indicated physician orders for Patient 11 to “...admit to OB [obstetric, pertaining to the care of the pregnant woman and the delivery of her child] outpatient...” for “...vomiting...NST [non-stress test, a fetal heart rate test] for fetal wellbeing...” A facility document titled, “Triage Information Form,” dated August 20, 2025, was reviewed. The document indicated, “...reason for being seen...35 weeks pregnant [full term pregnancy is 38 to 40 weeks] I can’t stop vomiting or hold water down/dehydrated [not enough fluids in the body]...” An undated facility document titled, “Audit Trail Print,” was reviewed. The document indicated Patient 11 had a past medical history of type 1 diabetes [a condition with high blood sugar]. A facility document titled, “OB [Obstetrics, medical care for pregnancy and childbirth] Triage [the process of determining how urgent the patients’ needs are],” dated August 20, 2025, at 6:08 p.m., was reviewed. The document indicated Patient 11 was experiencing irregular contractions (tightening of the uterus [organ where baby grows]). The document indicated, “...pain location...pelvic [the lower belly between the hips] pressure and pelvic pain...fetal assessment...external US [external ultrasound, a device used to monitor the baby’s heart beat]...FHR baseline rate: 155...Variability [beat to beat changes in baby’s heart rate, absent means no change; minimal means 5 [five] bpm or less; moderate means normal change, 6-25 bpm; and marked means very large change, more than 25 bpm]: moderate 6-25 bpm...accelerations [brief increases in the baby’s heart rate, normal is a rise of at least 10 beats per minute above the usual rate for at least 10 seconds that returns to the baseline]: 10 x 10...decelerations [drops in the baby’s heart rate, normal is no sudden or repeated drops in the baby’s heart rate]: none...category...category II (2) [meaning FHR tracings are unclear or uncertain]...communication comments: orders received for discharge home...” A facility document titled, “Medication Reconciliation Record,” dated August 20, 2025, at 6:29 p.m., was reviewed. The document indicated, “...BG [blood glucose, blood sugar level, normal is 70-100 milligrams/deciliter [mg/dL, unit of measurement] 99 at home this pm [evening] prior to coming into the hospital...” A facility document titled, “Discharge Summary,” dated August 20, 2025, was reviewed. The document indicated Patient 11 was discharged home on August 20, 2025, at 7:25 p.m. A facility document titled, “OB Triage,” dated August 21, 2025, at 6:27 a.m., was reviewed. The document indicated Patient 11 returned to the OB department on August 21, 2025. The document indicated, “...c/o [sic: complaining of] contractions, nausea and vomiting with pain 10/10 [ten out of ten, pain scale score from zero to 10, 10 being worst pain]. Patient [Patient 11] abdomen palpated [to feel with hands] hard and 10/10 pain with touch. Patient reports that she feels that her pain is getting progressively worst [sic]. Patient placed on monitor no fetal heart tones [baby’s heartbeat] found...” The document further indicated at 7:45 a.m., “...patient reported that she felt like fainting. Patient noted in decline [progressive decrease or deterioration in physical or mental health] no longer answering questions with eyes rolling back...rapid [rapid response, a hospital code for a medical emergency designed to identify and respond to patients with early signs of clinical deterioration] called...provider [Medical Doctor (MD) 1] at bedside. Updated Patient 11...of fetal demise and options...” A facility document titled, “Rapid Response Record,” dated August 21, 2025, was reviewed. The document indicated, “...patient [Patient 11] came in with contractions, nausea [inclination to vomit], and pain. Patient declined and was lethargic [a state of unusual drowsiness, lack of energy, and mental sluggishness]. Rapid [rapid response} called suspected DKA [diabetic ketoacidosis, a life-threatening complication of having very high blood sugar]. BS [blood sugar] 347, continued tachypnea [fast breathing], EKG [electrocardiogram, a test which records the electrical activity of the heart], sinus tach [sinus tachycardia, a type of fast heart rate]. Fluids [intravenous fluids, fluid administered through the vein], insulin [a medicine which lowers blood sugar], mag [sic: magnesium, a medicine to treat pre-eclampsia, a medical emergency in a pregnant patient which could cause convulsion] done. Prepped [prepared] for C/S [sic: cesarean section, surgery to deliver a baby by making a cut in the mother’s abdomen and uterus] ...” A facility document titled, “Operative Report,” dated August 21, 2025, authored by MD 1, was reviewed. The document indicated, “...history of presenting illness...approximately 35-week gestation. She had initially presented on 8/20/2025 [sic: August 20, 2025]...she had come in complaining of nausea and contractions every 3 [three] minutes...there was some mention that she was diabetic and on a lot of medication to control it. I was not told anything regarding the fetal status...I gave orders to try terbutaline [a medication which relaxes the uterus to slow or stop contractions and reduce stress on the baby] and Zofran [a medication for nausea]...if she improved...she could be discharged and at that point there was no notification regarding her status or fetal status. The following morning the patient re-presented with contractions that were closer together. The patient was in a lot of discomfort. Also had a blood pressure [normal blood pressure 120/80] that was in the 160 systolic range [top blood pressure number, normal is 120], as well as worsening shortness of breath...I was notified that there was difficulty obtaining fetal heart tones...I ordered a biophysical profile [an ultrasound that checks how well the baby is doing in the womb by looking at movement, breathing, motions, muscle tones and fluid, a score of 8-10 is normal, a score of 4 or less is abnormal, requiring urgent medical care, including possible delivery of the baby] to which there was no fetal heart rate or movement the baby scored 0/0 [zero]...I recommended calling a rapid response given her shortness of breath...the patient blood sugar check was found to be in the 300’s. Her blood gases [a blood test which shows how much oxygen (the gas that is breathed in) and carbon dioxide (the gas that is breathed out) to see how well the lungs and body are working] were also drawn at the time which showed that she was in diabetic ketoacidosis...given the contractions that the patient was having I was concerned for uterine rupture [when the walls of the uterus tear open]...which is why I deemed it necessary to proceed with urgent...cesarean section...” The document further indicated, “...intraoperative findings...there was a true knot [a knot which forms in the baby’s umbilical cord, the lifeline between the baby and the placenta, an organ that grows in the uterus during pregnancy] in the umbilical cord. Baby had no heartbeat or pulse at the time of delivery...” A facility document titled, “Critical Care Medicine,” dated August 22, 2025, was reviewed. The document indicated Patient 11 was admitted to the ICU for management of DKA and was intubated [a breathing tube inserted through the airway to help the patient breathe]. The document indicated, “...Admit date: 21 Aug 2025 [sic: August 21, 2025]...length of stay 2 [days]...endotracheal tube [breathing tube]...she has been managed in the ICU for multi-organ dysfunction [ failure of two or more organ systems to function properly] including acute kidney injury [a condition when the kidneys are damaged], acute hypoxic respiratory failure [a condition when the lungs are not getting enough oxygen into the blood], and severe metabolic derangements [a serious, life-threatening complications that disrupt the body’s normal chemical processes]...” A facility document titled, “Discharge Summary,” dated August 23, 2025, was reviewed. The document indicated, “...hospital course...she [Patient 11] underwent a cesarean by [name of MD 1] and was admitted to the ICU in DKA...” There was no documented evidence a physician order to check Patient 11’s blood sugar level was obtained on August 20, 2025, when Patient 11 first came to the facility. There was no documented evidence Patient 11’s blood sugar level was obtained on August 20, 2025. There was no documented evidence intravenous (IV, through the vein) fluids (fluids administered into the vein using a catheter ) was started, oxygen was administered, Patient 11 was repositioned, or a pelvic examination (a physical examination of the female reproductive organs which include the uterus) were performed for the management of a Category II FHR on August 20, 2025, in accordance with the facility’s policy. On November 19, 2025, at 1:22 p.m., an interview was conducted with the Women-Child Health Director (WCD). The WCD stated the nurse should check the blood sugar of a patient who is a known diabetic and is pregnant. The WCD stated this is the standard of practice. On November 19, 2025, at 1:40 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware she had to check Patient 11’s blood glucose herself on August 20, 2025, when Patient 11 first came to the OB department, because Patient 11 told her she (Patient 11) checked her blood sugar prior to coming to the hospital. RN 1 stated she did not have to check the blood glucose of the patient. She stated she does not remember asking Patient 11 if the patient took any insulin on August 20, 2025. RN 1 further stated she gave Patient 11 water to drink as an intervention and was then able to recategorize the fetal heart rate from category II (two) to Category I (one, normal) but did not notify the doctor that she initially categorized the FHR as a two. On November 19, 2025 at 1:45 p.m., an interview was conducted with the WCD. The WCD stated RN 1 is one of six nurses competent to perform MSE in the facility’s OB department. On November 19, 2025, at 2 p.m., an interview was conducted with the WCD. The WCD stated, when the nurse gave the FHR a category two, the physician should have been called and notified of the assessment. The WCD stated the nurse did not notify the physician of the category two FHR for Patient 11 on August 20, 2025. On November 20, 2025, at 3:37 p.m., a telephone interview was conducted with MD 1. MD 1 stated the RN should have checked Patient 11’s blood glucose level on August 20, 2025. MD 1 stated the RN should have called him to notify him the FHR was initially categorized as two. MD 1 stated he would have ordered a Biophysical Profile which he stated was an ultrasound to determine the baby’s movement. The facility’s P&P titled, “[Name of Facility] Electronic Fetal Monitoring,” dated May 2024, was reviewed. The P&P indicated, “...EMF (Electronic Fetal Monitoring) is used to provide evaluation of the fetal heart response during labor, pregnancy related illness, and to describe interventions aimed at maximizing fetal perfusion [how well blood is flowing to the baby] and oxygenation [how well blood oxygen is getting into the blood and out to the body’s tissues]...categorization of FHR patterns...a three tier system for categorization of FHR patters will be utilized...Category II: FHR tracings are indeterminate are not predictive of abnormal fetal acid-base status and there is inadequate evidence to categorize them as a Category 1(normal) or Category III (abnormal)...management of Category II or III: Notify provider immediately...start IV with 1000 ml [milliliters, a unit of measurement] LR [Lactated Ringers, a type of IV fluid] bolus with 150 ml/hr [milliliters per hour, a unit of measurement]...initiate [start] oxygen at 8-10 L/min [liters per minute, a unit for measurement for volume oxygen for each hour] via simple face mask [a mask worn over the nose and mouth to deliver oxygen to the patient]...reposition patient - left side or knee-chest...vaginal exam [pelvic exam] to rule out prolapsed cord [an obstetric emergency where the umbilical cord descends into the birth canal before or alongside the baby’s presenting part ]...””

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure patient placement was completed prior to discharge, for one of 28 sampled patients (Patient 1), in accordance with the facility’s policies and procedures. This failure resulted in Patient 1 being discharged to the home where she was told not to return. Findings: On November 19, 2025, at 11 a.m., an interview and review of Patient 1’s record were conducted with the Director of Intensive Care Unit (DICU). A facility document titled, “ED [Emergency Department] Provider Aware Noted,” dated August 20, 2025, at 3:18 a.m., was reviewed. The document indicated, “...Patient [Patient 1] is...complaining of altered mental status [a state of confusion, disorientation]. Chief Complaint ...patient altered unable to answer basic questions. Lives with a friend ...friend does not want her there anymore...” A facility document titled, “Case Management Discharge Planning,” dated August 20, 2025, at 9:43 a.m., was reviewed. The document indicated, “...CM [Case Management] consult received for patient that was kicked out by her friend [name of friend] who she was staying with again. PT [Patient 1] has been seen in our ER [Emergency Room] multiple times with similar circumstances. She is very emotional, tearful, a&ox4 [alert, oriented times four, oriented to person, place, time, and event)]. She said that she hasn’t drank etoh [alcohol] in over 6 [six] months, which is why she is originally kicked out by her friend [name of friend]. Asked patient if she would be ok [okay] with me looking for a room and board [a facility which provides both housing and meals for residents in exchange for payment] for her and she gave permission. Contacted [Name of person assisting with placement] who has helped with placement in the past...” A facility document titled, “Social Work Discharge Planning Note,” dated August 20, 2025, at 2:39 p.m., was reviewed. The document indicated, “...SS [Social Services] Consult Reason: Transportation home...Intervention to address: SW [Social Worker] met with the patient to confirm her home address and phone number. SW scheduled ride home with [Name of insurance company]...” An untitled facility document, dated November 20, 2024, authored by Emergency Department Registered Nurse (EDRN), was reviewed. The document indicated, “...My understanding was that the social worker was going to set up transport for this patient [Patient 1]. When I rounded on the patient, the social worker was in the room with her. When she came out, she told me she was going to set up for transportation. I went in and told her she [Patient 1] was going to be going home and began going over ...discharge instructions, prescriptions, etc [etcetera, and others]. The patient said to me ‘My [family member] doesn’t want me to go back to her house,’ then she said, ‘The social worker is working on it.’ I trusted that the social worker had verified where the patient was going. The social worker came back and told me the transport [transportation] was ready. The patient was sitting on the gurney and was fully dressed in her own clothing...” There was no documented evidence the case manager followed up with Patient 1’s placement and communicated Patient 11’s discharge plan with the social worker. There was no documented evidence the social worker verified discharge disposition and housing resources were given to Patient 1, in accordance with the facility’s policy and procedure. On November 20, 2025, at 9:43 a.m., an interview and concurrent record review were conducted with the Registered Nurse Case Manager (RNCM). The RNCM stated a referral was made to her for a room and board for Patient 1 because she knew Patient 11 could not go back to the home she (Patient 1) was asked not to return to but she (the RNCM) did not follow up. THE RNCM stated, when she went back down to the unit, Patient 1 was gone. The RNCM stated, “ I am not sure if the social worker was aware, I don’t believe I told her.” The RNCM further stated the expectation would be to follow up with the patient’s placement and communicate this with the team. On November 20, 2025, at 3:25 p.m., an interview and concurrent record review were conducted with Associate Social Worker (ASW). The ASW stated she” I got a referral to set up transportation for Patient 11 and the referral was not for Patient 11’s placement. The ASW stated she did not know Patient 11 could not return to her listed address. The ASW stated she did not get report from the nurse nor did she verify the address where Patient 11 will be transported to. The SW stated the address she set up for transportation for Patient 1 when Patient 1 was discharged was that of Patient 1’s friend. A review of the facility Policy and Procedure (P&P) titled, “Discharge Planning and Implementation,” dated November 2025, was conducted. The policy indicated, “...Review past medical records...Communicate findings to the disciplinary team ...Gather the findings and recommendations of the multidisciplinary team...Keep the provider and multidisciplinary team informed of implementation activities...Communicate with patient...Agreement with the updated plans among all parties ...Actions to implement the plan...” A review of the P&P titled, “Core Social Worker (SW) Process and Responsibilities,” dated November 2025, was conducted. The policy indicated, “...Referrals from case managers made on the basis of the discharge planning evaluation results ...To address complex psychosocial issues such as...where family dynamics or prior living arrangements creates barriers to discharge, frequent hospitalizations and Emergency Department (ED) encounters due to social situations, where long-term placement is needed...referral to community support resources...Living Arrangements...House-type...unhoused...Document psycho-social barriers to optimal wellness and health management...Collaboration with nurse case managers and other members of the treatment team, sharing SW findings and plan recommendations...””

“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: 44871 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR §489.24(a), §489.24(c), and § 489.24(d) (1-3), when the facility failed to ensure the facility’s’s policy and procedure was not implemented, for one of 20 sampled patients (Patient 11), who. Patient 11 was not stabilized before the patient was discharged from the facility. This failure had the potential to delay recognition and treatment of an emergency medical condition and placed Patient 11, who was pregnant, and the baby in the patient’s womb at risk for further deterioration, including intrauterine demise(when the baby has died before birth while still in the uterus) and admission to the Intensive Care Unit (ICU, unit for critically ill patients).”

“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: 48326 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) was implemented, for one of 20 sampled patients (Patient 11), when Patient 11 was not appropriately screened before the patient was discharged from the facility. This failure had the potential to delay recognition and treatment of an emergency medical condition and could have contributed to Patient 11 having diabetic ketoacidosis (DKA, a life-threatening complication of having very high blood sugar) and and to her baby’s fetal demise (when the baby has died before birth while still in the uterus). Findings: On November 19, 2025, a review of Patient 11’s record was conducted with the Director of Risk Management and Quality Assurance (DRMQA). A facility document titled, “Physicians Orders,” dated August 20, 2025, was reviewed. The document indicated physician orders for Patient 11 to “...admit to OB [obstetric, pertaining to the care of the pregnant woman and the delivery of her child] outpatient...” for “...vomiting...NST [non-stress test, a fetal heart rate test] for fetal wellbeing... A facility document titled, “Triage Information Form,” dated August 20, 2025, was reviewed. The document indicated, “...reason for being seen...35 weeks pregnant [full term pregnancy is 38 to 40 weeks] I can’t stop vomiting or hold water down/dehydrated [not enough fluids in the body]...” An undated facility document titled, “Audit Trail Print,” was reviewed. The document indicated Patient 11 had a past medical history of type 1 diabetes [a condition with high blood sugar]. A facility document titled, “OB [Obstetrics, medical care for pregnancy and childbirth] Triage [the process of determining how urgent the patients’ needs are],” dated August 20, 2025, at 6:08 p.m., was reviewed. The document indicated Patient 11 was experiencing irregular contractions (tightening of the uterus [organ where baby grows]). The document indicated, “...pain location...pelvic [the lower belly between the hips] pressure and pelvic pain...fetal assessment...external US [external ultrasound, a device used to monitor the baby’s heart beat]...FHR baseline rate: 155...Variability [beat to beat changes in baby’s heart rate, absent means no change; minimal means 5 [five] bpm or less; moderate means normal change, 6-25 bpm; and marked means very large change, more than 25 bpm]: moderate 6-25 bpm...accelerations [brief increases in the baby’s heart rate, normal is a rise of at least 10 beats per minute above the usual rate for at least 10 seconds that returns to the baseline]: 10 x 10...decelerations [drops in the baby’s heart rate, normal is no sudden or repeated drops in the baby’s heart rate]: none...category...category II (2) [meaning FHR tracings are unclear or uncertain]...communication comments: orders received for discharge home...” A facility document titled, “Medication Reconciliation Record,” dated August 20, 2025, at 6:29 p.m., was reviewed. The document indicated, “...BG [blood glucose, blood sugar level, normal is 70-100 milligrams/deciliter [mg/dL, unit of measurement] 99 at home this pm [evening] prior to coming into the hospital...” A facility document titled, “Discharge Summary,” dated August 20, 2025, was reviewed. The document indicated Patient 11 was discharged home on August 20, 2025, at 7:25 p.m. On November 20, 2025, a review of Patient 11’s records dated August 21, 2025, was conducted with the DQRMA. The facility document titled “OB Triage” dated August 21, 2025 at 6:27 a.m., indicated Patient 11 returned to the facility in distress 11 hours and 2 minutes after discharge from the facility on August 20, 2025 at 7:25 p.m., and she required emergency medical attention and experienced fetal demise. There was no documented evidence a physician order to check Patient 11’s blood sugar level was obtained on August 20, 2025, when Patient 11 first came to the facility. There was no documented evidence Patient 11’s blood sugar level was obtained on August 20, 2025. There was no documented evidence intravenous (IV, through the vein) fluids (fluids administered into the vein using a catheter ) was started, oxygen was administered, Patient 11 was repositioned, or a pelvic examination (a physical examination of the female reproductive organs which include the uterus) were performed for the management of a Category II FHR on August 20, 2025, in accordance with the facility’s policy. On November 19, 2025, at 1:40 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware she had to check Patient 11’s blood glucose herself on August 20, 2025, when Patient 11 first came to the OB department, because Patient 11 told her she (Patient 11) checked her blood sugar prior to coming to the hospital. RN 1 stated she did not have to check the blood glucose of the patient. She stated she does not remember asking Patient 11 if the patient took any insulin on August 20, 2025. RN 1 further stated she gave Patient 11 water to drink as an intervention and was then able to recategorize the fetal heart rate from category II (two) to Category I (one, normal) but did not notify the doctor that she initially categorized the FHR as a two. On November 19, 2025, at 1:40 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware she had to check Patient 11’s blood glucose herself on August 20, 2025, when Patient 11 first came to the OB department, because Patient 11 told her she (Patient 11) checked her blood sugar prior to coming to the hospital. RN 1 stated she did not have to check the blood glucose of the patient. She stated she does not remember asking Patient 11 if the patient took any insulin on August 20, 2025. RN 1 further stated she gave Patient 11 water to drink as an intervention and was then able to recategorize the fetal heart rate from category II (two) to Category I (one, normal) but did not notify the doctor that she initially categorized the FHR as a two. On November 19, 2025, at 2 p.m., an interview was conducted with the WCD. The WCD stated, when the nurse gave the FHR a category two, the physician should have been called and notified of the assessment. The WCD stated the nurse did not notify the physician of the category two FHR for Patient 11 on August 20, 2025. The facility’s P&P titled, “[Name of Facility] Electronic Fetal Monitoring,” dated May 2024, was reviewed. The P&P indicated, “...EMF (Electronic Fetal Monitoring) is used to provide evaluation of the fetal heart response during labor, pregnancy related illness, and to describe interventions aimed at maximizing fetal perfusion [how well blood is flowing to the baby] and oxygenation [how well blood oxygen is getting into the blood and out to the body’s tissues]...categorization of FHR patterns...a three tier system for categorization of FHR patters will be utilized...Category II: FHR tracings are indeterminate are not predictive of abnormal fetal acid-base status and there is inadequate evidence to categorize them as a Category 1(normal) or Category III (abnormal)...management of Category II or III: Notify provider immediately...start IV with 1000 ml [milliliters, a unit of measurement] LR [Lactated Ringers, a type of IV fluid] bolus with 150 ml/hr [milliliters per hour, a unit of measurement]...initiate [start] oxygen at 8-10 L/min [liters per minute, a unit for measurement for volume oxygen for each hour] via simple face mask [a mask worn over the nose and mouth to deliver oxygen to the patient]...reposition patient - left side or knee-chest...vaginal exam [pelvic exam] to rule out prolapsed cord [an obstetric emergency where the umbilical cord descends into the birth canal before or alongside the baby’s presenting part ]...” 44871”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48326 Based on interview and record review, the facility failed to comply with their policy and procedure (P&P) when the facility’s policies were not implemented, for one of 20 sample patients (Patient 11). Patient 11 was not appropriately stabilized before the patient was discharged home. This failure had the potential to delay recognition and treatment of an emergency medical condition and placed Patient 11 and her fetus at risk for further deterioration, including intrauterine demise. Patient 11 later experienced fetal death in utero (when the baby has died before birth while still in the uterus) and was admitted to the Intensive Care Unit (ICU, unit for critically ill patients). Findings: On November 19, 2025, a review of Patient 11’s record was conducted with the Director of Risk Management and Quality Assurance (DRMQA). A facility document titled, “Physicians Orders,” dated August 20, 2025, was reviewed. The document indicated physician orders for Patient 11 to “...admit to OB [obstetric, pertaining to the care of the pregnant woman and the delivery of her child] outpatient...” for “...vomiting...NST [non-stress test, a fetal heart rate test] for fetal wellbeing...” A facility document titled, “Triage Information Form,” dated August 20, 2025, was reviewed. The document indicated, “...reason for being seen...35 weeks pregnant [full term pregnancy is 38 to 40 weeks] I can’t stop vomiting or hold water down/dehydrated [not enough fluids in the body]...” An undated facility document titled, “Audit Trail Print,” was reviewed. The document indicated Patient 11 had a past medical history of type 1 diabetes [a condition with high blood sugar]. A facility document titled, “OB [Obstetrics, medical care for pregnancy and childbirth] Triage [the process of determining how urgent the patients’ needs are],” dated August 20, 2025, at 6:08 p.m., was reviewed. The document indicated Patient 11 was experiencing irregular contractions (tightening of the uterus [organ where baby grows]). The document indicated, “...pain location...pelvic [the lower belly between the hips] pressure and pelvic pain...fetal assessment...external US [external ultrasound, a device used to monitor the baby’s heart beat]...FHR baseline rate: 155...Variability [beat to beat changes in baby’s heart rate, absent means no change; minimal means 5 [five] bpm or less; moderate means normal change, 6-25 bpm; and marked means very large change, more than 25 bpm]: moderate 6-25 bpm...accelerations [brief increases in the baby’s heart rate, normal is a rise of at least 10 beats per minute above the usual rate for at least 10 seconds that returns to the baseline]: 10 x 10...decelerations [drops in the baby’s heart rate, normal is no sudden or repeated drops in the baby’s heart rate]: none...category...category II (2) [meaning FHR tracings are unclear or uncertain]...communication comments: orders received for discharge home...” A facility document titled, “Medication Reconciliation Record,” dated August 20, 2025, at 6:29 p.m., was reviewed. The document indicated, “...BG [blood glucose, blood sugar level, normal is 70-100 milligrams/deciliter [mg/dL, unit of measurement] 99 at home this pm [evening] prior to coming into the hospital...” A facility document titled, “Discharge Summary,” dated August 20, 2025, was reviewed. The document indicated Patient 11 was discharged home on August 20, 2025, at 7:25 p.m. There was no documented evidence a physician order to check Patient 11’s blood sugar level was obtained on August 20, 2025, when Patient 11 first came to the facility. There was no documented evidence Patient 11’s blood sugar level was obtained on August 20, 2025. There was no documented evidence intravenous (IV, through the vein) fluids (fluids administered into the vein using a catheter ) was started, oxygen was administered, Patient 11 was repositioned, or a pelvic examination (a physical examination of the female reproductive organs which include the uterus) were performed for the management of a Category II FHR on August 20, 2025, in accordance with the facility policy. On November 19, 2025, at 1:22 p.m., an interview was conducted with the Women-Child Health Director (WCD). The WCD stated the nurse should check the blood sugar of a patient who is a known diabetic and pregnant. The WCD stated this is the standard of practice. On November 19, 2025, at 1:40 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware she had to check Patient 11’s blood glucose herself on August 20, 2025, when Patient 11 first came to the OB department, because Patient 11 told her she (Patient 11) checked her blood sugar prior to coming to the hospital. RN 1 stated she did not have to check the blood glucose of the patient. She stated she does not remember asking Patient 11 if the patient took any insulin on August 20, 2025. RN 1 further stated she gave Patient 11 water to drink as an intervention and was then able to recategorize the fetal heart rate from category II (two) to Category I (one, normal) but did not notify the doctor that she initially categorized the FHR as a two. On November 19, 2025, at 2 p.m., an interview was conducted with the WCD. The WCD stated, when the nurse gave the FHR a category two, the physician should have been called and notified of the assessment. The WCD stated the nurse did not notify the physician of the category two FHR for Patient 11 on August 20, 2025. On November 20, 2025, at 1:42 p.m., a review of Patient 11’s records dated August 21, 2025, was conducted with the DQRMA. The facility document titled “OB Triage,” dated August 21, 2025 at 6:27 a.m., indicated Patient 11 returned to the facility in distress 11 hours and 2 minutes after discharge from the facility on August 20, 2025 at 7:25 p.m., and she required emergency medical attention and experienced fetal demise. On November 20, 2025, at 3:37 p.m., a telephone interview was conducted with MD 1. MD 1 stated the RN should have checked Patient 11’s blood glucose level on August 20, 2025. MD 1 stated the RN should have called him to notify him the FHR was initially categorized as two. MD 1 stated he would have ordered a Biophysical Profile which he stated was an ultrasound to determine the baby’s movement. The facility’s P&P titled, “[Name of Facility] Electronic Fetal Monitoring,” dated May 2024, was reviewed. The P&P indicated, “...EMF (Electronic Fetal Monitoring) is used to provide evaluation of the fetal heart response during labor, pregnancy related illness, and to describe interventions aimed at maximizing fetal perfusion [how well blood is flowing to the baby] and oxygenation [how well blood oxygen is getting into the blood and out to the body’s tissues]...categorization of FHR patterns...a three tier system for categorization of FHR patters will be utilized...Category II: FHR tracings are indeterminate are not predictive of abnormal fetal acid-base status and there is inadequate evidence to categorize them as a Category 1(normal) or Category III (abnormal)...management of Category II or III: Notify provider immediately...start IV with 1000 ml [milliliters, a unit of measurement] LR [Lactated Ringers, a type of IV fluid] bolus with 150 ml/hr [milliliters per hour, a unit of measurement]...initiate [start] oxygen at 8-10 L/min [liters per minute, a unit for measurement for volume oxygen for each hour] via simple face mask [a mask worn over the nose and mouth to deliver oxygen to the patient]...reposition patient - left side or knee-chest...vaginal exam [pelvic exam] to rule out prolapsed cord [an obstetric emergency where the umbilical cord descends into the birth canal before or alongside the baby’s presenting part ]...” 44871”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 42512 Based on observations, interviews, and document reviews, the hospital failed to ensure they had an effective, active system wide infection control program for the prevention, control, and investigation of infections and communicable diseases. The infection control program did not meet the needs of all patients receiving care and supportive healthcare in the hospital, as evidenced by: 1. Clean GI (gastrointestinal, pertaining to the esophagus, stomach, and intestines) scopes (flexible, lighted tube with a camera to visually examine the esophagus, stomach, and first part of the intestines) were stored in a procedure room and not compliant with National Infection Control Standards the hospital followed (refer to A-0749 finding 1); 2. There was no documented evidence to demonstrate the storage cabinet used to store flexible scopes was cleaned and maintained according to the manufacture instructions for use (IFUs) (refer to A-0749 finding 2); 3. The hospital SPD decontamination room (a room used to clean and disinfect re-usable patient surgical instruments) did not consistently maintain negative pressure (the air pressure inside the room is lower than the air pressure outside the room which means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room cannot flow outside into non-contaminated areas). The doors were opened frequently, which opened directly into the Operating Room (OR) corridor which faced OR 3 (a room that was in use during a patient surgical procedure). In addition, the doors had gaps beneath and between the doors and the doors did not open in a unidirectional workflow pattern (refer to A-0749 finding 3); 4. Surgical brushes used to clean soiled surgical instruments were not cleaned between use (refer to A-0749 finding 4); 5. Two of two surgical processing staff (SPD Tech 1 & 2) did not adhere to the contact time (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs and achieve the desired level of sanitation) of the Super Sani wipes (cleaning and disinfectant wipes) (refer to A-0749 finding 5); 6. Three of three SPD staff employee files did not contain documented evidence they received job specific competencies (refer to A-0749 finding 6); 7. The Infection Control Director’s (ICD) employee file did not contain documented evidence to demonstrate she was appointed by the hospital’s Governing Body (group of directors responsible for overseeing the hospital’s operations) & that the appointment was based off of Medical & Nursing Leadership (refer to A-0748 finding 1); 8. Four (4) sterilized and ready to use surgical instruments contained the following: one (1) instrument contained black non-smooth matter, 1- contained sticky residue, and two (2) instruments contained non-manufacture etching that was course to touch (refer to A-0749 finding 7); 9. The autoclave (a machine used to sterilize surgical instruments) was not cleaned and maintained according to manufacture IFU (refer to A-0749 finding 8); 10. The hospital Sterile Processing Department Prep & Pack (an area used to prepare clean surgical instruments for sterilization and reuse) area did not receive terminal cleaning (a thorough, hospital cleaning focused on eliminating all pathogens from a room, especially in healthcare settings, after use to prevent the spread of infections) (refer to A-0749 finding 9); and 11. Cleaning and disinfection of endoscopy gastrointestinal (GI) flexible scopes (thin flexible tubes with a camera and light used to visualize the interior of the digestive tract) was not performed in a unidirectional workflow pattern and the GI processing room was not designed to contain contaminants and did not facilitate the highest level of infection control (refer to A-0749 finding 10). The cumulative effects of these systemic problems resulted in the hospital’s inability to provide an effective hospital wide Infection Control Program. Resulting in the hospitals inability to provide patient care in a safe and effective manner and in accordance with §482.42 Condition of Participation for Infection Control Services. §482.42 Condition of Participation for Infection Prevention/Control/Antibiotics Stewardship Program, NOT MET. The cumulative effects of these systemic problems resulted in the hospital’s inability to provide an effective hospital wide infection control program, resulting in the hospitals inability to provide patient care in a safe and effective manner and in accordance with §482.42 Condition of Participation for Infection Prevention/Control/Antibiotics Stewardship Program. The seriousness of which, resulted in an Immediate Jeopardy (IJ), which was identified by the survey team. Immediate Jeopardy On March 4, 2025, at 10:25 a.m., the survey team identified significant concerns in the hospital’s Infection Control Program, when clean GI scopes were stored in a procedure room, there was no documented evidence the scope cabinet was cleaned according to manufacture IFUs, and (&) surgical brushes used to clean soiled surgical instruments were not cleaned between use. Due to the seriousness of the situation, an Immediate Jeopardy (IJ) was declared for failing to maintain an environment to prevent the risk of cross contamination. The IJ was called in the presence of the Chief Executive Officer, Director of Risk and Quality, Infection Control Director, Chief Human Resources Officer, Chief Nurse Executive, Chief Human Resource Officer, and Vice President and Ancillary Services (Refer to A-0749 findings 1, 2, & 4). On March 4, 2025, at 1 p.m., the hospital’s Director of Risk & Quality (DRQ) provided the team an acceptable corrective action plan (CAP) to lift the immediacy of the IJ. The CAP indicated: - Scope cabinet relocated to GI (gastrointestinal) Hallway. The new location is in designated secure, clean, positive pressure space outside of procedure rooms and OR (operating room) suites; - Process in place for maintaining sterility of scopes being moved from cabinet to special procedure room; - Associates responsible for cleaning the scope cabinet will receive training and have competency on file. Training will include use of required personal protective equipment (PPE, equipment which includes surgical masks, gloves, and gowns) and use of only the EPA (Environmental Protection Agency, a national agency) registered disinfectants per cabinet IFUs (instruction for use). Training will also include frequency of cleaning per cabinet IFUs, minimum of weekly and as needed. The training process will include any new hires and an annual review of process per cabinet IFUs; - New process will include clean/sterile scopes being removed from cabinet by trained GI Tech prior to any cabinet cleaning. A gown and gloves will be worn during removal of scopes prior to cleaning process as well as during return to cabinet. Scopes will be maintained in a clean field while the cabinet is cleaned. Tech will return scopes to the cabinet after the cleaning process is complete wearing required PPE; - All surgical brushes will be one time use; and - In service of all Sterile Processing Department (SPD) techs will include new process and notification that this is effective immediately. This training process will include any new hires. On March 5, 2025, at 3:44 p.m., the CAP for the immediate jeopardy was reviewed and was found acceptable. On March 6, 2025, at 12 p.m., the immediate jeopardy was abated, after the team validated, through onsite observations, interviews, and record reviews, the hospital’s corrective action plan was implemented. The IJ was removed in the presence of the DRQ and the DIP.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 42512 Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner and in accordance with acceptable standards of practice. This failure had the potential of transmission of infectious agents and foreign material from reusable instruments to patients and staff. The hospital failed to comply with the §482.51 Condition of Participation for Surgical Services when: 1. Surgical brushes used to clean soiled surgical instruments were not cleaned between use (refer to A-0951 finding); 2. Two of two surgical processing staff (SPD Tech 1 & 2) did not adhere to the contact time (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs and achieve the desired level of sanitation) of the Super Sani wipes (cleaning and disinfectant wipes) (refer to A-0951 finding 2); 3. Three of three SPD staff employee files did not contain documented evidence they received job specific competencies (refer to A-0951 finding 3); 4. Four sterilized and ready to use surgical instruments contained the following: one instrument contained black non-smooth matter, 1- contained sticky residue, & two instruments contained non-manufacture etching that was coarse to touch (refer to A-0951 finding 4); 5. The autoclave (a machine used to sterilize surgical instruments) was not cleaned and maintained according to manufacture IFU (refer to A-0951 finding 5); 6. The hospital Sterile Processing Department Prep & Pack (an area used to prepare clean surgical instruments for sterilization and reuse) area did not receive terminal cleaning (a thorough, hospital cleaning focused on eliminating all pathogens from a room, especially in healthcare settings, after use to prevent the spread of infections) (refer to A-0951 finding 6); 7. The hospital SPD decontamination room (a room used to clean and disinfect re-usable patient surgical instruments) did not consistently maintain negative pressure, (the air pressure inside the room is lower than the air pressure outside the room. Which means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room cannot flow outside into non-contaminated areas). The doors were opened frequently, which opened directly into the Operating Room (OR) corridor which faced OR 3 (a room that was in use during a patient surgical procedure). In addition, the doors had gaps beneath and between the doors and the doors did not open in a unidirectional workflow pattern (refer to A-0951 finding 7); and 8. The Director of Surgical Services was qualified by training and experience to manage the Surgical Service Department in accordance with nationally recognized perioperative practices, guidelines, and regulations (Refer A-0942). The cumulative effects of these systemic problems resulted in the hospital’s inability to provide effective hospital wide surgical services and failed to ensure patient care requiring surgical services were provided in a safe and effective manner and in accordance with the §482.51 Condition of Participation for Surgical Services. These deficient practices resulted in the Condition of Participation for Surgical Services being NOT MET.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the facility failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality when: 1. Disposable surgical instruments were not disposed of properly at the bedside in accordance with the facility’s policy and procedure; and 2. Multiple expired supplies and equipment were readily available for use. These failures had the potential to delay patient care and services or cause patient harm. Findings: 1. On March 3, 2025, 10:31 a.m., an observation and concurrent interview were conducted with the ICU Registered Nurse (ICURN) 2 in the Intensive Care Unit (ICU, unit for patients who are critically ill and kept under constant observation). An uncovered small three compartment blue tray was observed on the counter in the soiled utility room. The container was observed to contain two metal tweezers, three metal clamps, and one pair of metal scissors. The container and the metal instruments were observed to have reddish brownish stains. ICURN 2 stated reusable surgical instruments were not used on patient floors. He stated he was not sure why they were there. On March 3, 2025, at 10:35 a.m., an interview was conducted with the Graduate Medical Education Coordinator (GMEC). She stated reusable instruments are not used on patient floors. The GMEC stated all instruments used on patient floors are disposable instruments. She stated after use, the instruments should have been discarded in the sharps container (specialized, puncture resistant waste receptacle) in the patient’s room. She further stated the disposable surgical instruments should not have been placed in the dirty utility room. A review of the policy and procedure (P&P) titled, “External Departments - Instrument Transportation/Reprocessing,” dated August 2021, was conducted. The document indicated, “...All single use items will be used only once and then disposed of in the correct manner...Each department/unit is responsible for sharps removal...” 2a. On March 3, 2025, 9:55 a.m., an observation and concurrent interview were conducted with the Director of Emergency Department (DED) and the Graduate Medical Education Coordinator (GMEC) in the ICU. During the observation the following expired products and supplies were observed: - 41 grey top vacutainers, with expiry date of April 7, 2024; - 10 red top vacutainers, with expiry date of December 11, 2023; - One dressing change kit, with expiry date of October 26, 2024; - One dressing change kit, with expiry date of January 1, 2025; - One dressing change kit, with expiry date of February 22, 2025; - Two Safe-T-Centesis (instrument used for thoracentesis [a procedure of removing fluid from area between the lungs and chest wall] and paracentesis [a procedure in which a thin needle or tube is put into the abdomen to remove fluid]) Plus 8 (eight) Fr (french, outer diameter circular devices equivalent to 2.67 centimeter [unit of measurement]) Catheter (a thin plastic tube) Drainage Tray, with expiry date of February 28, 2025; - One Acute High Pressure Triple Lumen Catheter (a type of tubing with three separate channels, which when inserted into a vein would allow for simultaneous administration of multiple medications or fluids) Tray, with expiry date of February 28, 2025; and - Two Radial Artery Catheterization (a thin tube inserted through a blood vessel in the arm into the heart and its blood vessels) kits, with expiry date of October 31, 2024. A concurrent interview with the DED was conducted. She stated the materials management department stocks the supply room. She further stated the certified nursing assistants restock the small supply room from the large supply room when needed. The DED stated registered nurses were responsible for checking the expiration dates prior to patient use. The DED stated expired products should have been removed and not be available for patient use. On March 6, 2025, at 3:06 p.m., an interview was conducted with the Director of Materials (DOM). The DOM stated materials management was in charge of stocking supplies in the ICU. The DOM stated supplies were stocked every three days. The DOM stated materials management staff would check for expired items when they stock and if the items are found expired, these will be discarded. The DOM stated the expectation would be to remove any expired items, discard them, and replace them with new ones. 2b. On March 3, 2025, 11:05 a.m., an observation was conducted with the Director of Obstetrics (DOB) in the Obstetrics unit (OB, unit which focuses on pregnancy and childbirth). During the observation, four sterile tubing kits, with expiry date of December 31, 2024, were observed. During a concurrent interview, the DOB stated expired supplies should have been removed from the supply room and replaced with unexpired supplies. 2c. On March 3, 2025, at 11:08 a.m., an observation was conducted with the Director of Risk and Quality (DRQ) in the Pre-Operative Unit (unit where patients are prepared for surgery). During the observation the following expired products and supplies were observed: - Two intravenous (IV, inserted through a vein) start kits, with expiry date of January 28,2025; - One IV start kit, with expiry date of August 22, 2024; and - One IV start kit, with expiry date of September 9, 2024. During a concurrent interview, the DRQ stated registered nurses were responsible for checking expiration dates prior to patient use. The DRQ stated expired products should have been removed and not be readily available for patient use. 2d. On March 3, 2025, at 2:48 p.m., an observation was conducted with the DRQ in Operating Room 3. During the observation, a bougie (a thin, flexible surgical instrument) was on top of an anesthesia cart and was observed labeled with an expiry date January 1, 2024. The DRQ stated anesthesia technicians were responsible for checking expiration dates prior to patient use. The DRQ stated expired products should have been removed and not be available for patient use. A review of the policy and procedure titled, “Sterile Processing - Event Related Sterility/Shelf Life,” dated August 202,4 was conducted. The policy indicated, “...All items are marked with the date of sterilization...Any item that has a manufacturer indicated expiration date will not be used past the indicated expiration date...Staff will be assigned on a monthly basis to search for and remove any items (commercially or internally processed) displaying an expired or soon to expire (within the month) date...Commercially expired items will be sent back to Material Management for disposal/return...””

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure the Director of Infection Prevention (DIP) was appointed by the governing body as the Infection Preventionist when the Infection Control Director’s (ICD) employee file did not contain documented evidence to demonstrate she was appointed by the hospital’s Governing Body (GB - group of directors responsible for overseeing the hospital’s operations) and that the appointment was based off of Medical & Nursing Leadership. This failure ahs the potential for infection preventio and control practices to not be implemented appropriately. Finding: 1. On March 4, 2025, at 11:50 a.m., the employee file of the DIP was reviewed with the Human Resources Generalist (HRG), the employee file did not have documented evidence to indicate DIP was appointed by the hospital’s Governing Body. On March 4, 2025, at 3:40 p.m., during an interview with the DIP, she validated the above findings and stated that she was hired by the Chief Nurse Executive (CNE) and was not appointed by the GB. In addition, she stated she was not aware that the regulation required her to be appointed by the GB.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 42512 Based on observation, interview, and record review, the hospital failed to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases when: 1. Clean GI (gastrointestinal, pertaining to the esophagus, stomach, and intestines) scopes (flexible, lighted tube with a camera and light used to visualize the interior of the digestive tract) were stored in a procedure room and not compliance with National Infection Control Standards the hospital followed (refer to A-0749 finding 1); 2. There was no documented evidence to demonstrate the storage cabinet used to store flexible scopes was cleaned and maintained according to the manufacture instructions for use (IFUs) (refer to A-0749 finding 2); 3. The hospital Sterile Processing Department (SPD) decontamination room (a room used to clean and disinfect re-usable patient surgical instruments) did not consistently maintain negative pressure (the air pressure inside the room is lower than the air pressure outside the room which means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room cannot flow outside into non-contaminated areas). The doors were opened frequently, which then opened directly into the Operating Room (OR) corridor which faced OR 3 (a room that was in use during a patient surgical procedure). In addition, the doors had gaps beneath and between the doors and the doors did not open in a unidirectional workflow pattern (refer to A-0749 finding 3); 4. Surgical brushes used to clean soiled surgical instruments were not cleaned between use (refer to A-0749 finding 4); 5. Two of two surgical processing staff (SPD Techs 1 and 2) did not adhere to the contact time (the amount of time a disinfectant requires to remain wet on a surface to effectively kill germs and achieve the desired level of sanitation) of the Super Sani wipes (cleaning and disinfectant wipes) (refer to A-0749 finding 5); 6. Three of three SPD staff employee files did not contain documented evidence they received job specific competencies (refer to A-0749 finding 6); 7. Four sterilized and ready to use surgical instruments contained the following: one instrument contained black non-smooth matter, 1 instrument contained sticky residue, & two instruments contained non-manufacture etching that was coarse to touch (refer to A-0749 finding 7); 8. The autoclave (a machine used to sterilize surgical instruments) was not cleaned and maintained according to manufacture IFU (refer to A-0749 finding 8); 9. The hospital SPD Prep & Pack (an area used to prepare clean surgical instruments for sterilization and reuse) area did not receive terminal cleaning (a thorough, hospital cleaning focused on eliminating all pathogens from a room, especially in healthcare settings, after use to prevent the spread of infections) (refer to A-0749 finding 9); 10. Cleaning and disinfection of endoscopy GI flexible scopes was not performed in a unidirectional workflow pattern and the GI processing room was not designed to contain contaminants and did not facilitate the highest level of infection control (refer to A-0749 finding 10); 11. Hand hygiene practices were not followed, in two of three medication pass observations (refer to A-0749 finding 11); and 12. Aseptic technique was not followed in one of three medication pass observations (refer to A-0749 finding 12). Findings 1. On March 3, 2025, at 9:45 a.m., a tour was conducted of the GI Special Procedure room (a dedicated procedure room in a hospital where medical procedures are performed using endoscopes) in the presence of the Director of Surgical Services (DSS) and the Director of Infection Prevention (DIP). The DSS stated the hospital followed Nationally Recognized Infection Control Standards from AAMI (Association for the Advancement of Medical Instrumentation, an organization for advancing the development, and safe and effective use of medical technology). They also followed SGNA (Society of Gastroenterology Nurses and Associates, a professional organization of nurses and associates dedicated to the safe and effective practice of gastroenterology and endoscopy nursing), and AORN (Association of periOperative Registered Nurses, a national organization that supports operating room nurses and defines standards for patient safety). During the continued tour at 10:14 a.m., a cabinet which contained clean scopes was stored in the procedure room. During a concurrent interview with DSS and DIP, they both stated they did not know the scopes could not be stored in a procedure room and were not aware that the National Standards stipulated they could not be stored in a procedure room. On March 3, 2025, at 12 p.m., a document review of the National Standards the hospital followed, “ANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities”. The Standards stipulated, “...11.2.2 Storage Cabinets, cabinets used for storage of flexible endoscopes should be situated in a secure location such as in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room (AORN, 2018e, IX.a [39]). Situating the storage cabinet in a secure location helps protect inventories of flexible endoscopes and supplies that are vulnerable to misappropriation. Locating the storage cabinet in the clean workroom or in a clean area outside of the procedure room helps prevent contamination of processed endoscopes...” 2. On March 3, 2025, at 10:25 a.m., during the tour of the GI Special Procedure room, a concurrent observation and interview were conducted with a Lead Surgical Aide (LSA) who was responsible for cleaning the GI scope storage cabinet located in the procedure room. LSA stated he cleaned the cabinet on a weekly basis, and that he did not remove the clean scopes as he cleaned the interior of the cabinet. LSA stated that to clean the interior of the cabinet, he moved one scope onto a scope hook located within the cabinet while he cleaned the hook that the scope was hanging from. In addition, LSA touched the cleaned scopes with bare hands as he demonstrated the cleaning procedure, and the drip tray beneath the scopes was not removed. LSA stated he did not remove the drip tray to clean it, was not aware what the manufacture cleaning IFUs stipulate and did not have a cleaning log to provide documented evidence when the cabinet was cleaned. During the same observation, LSA was asked to remove the drip tray, the bottom of the tray contained black particles and the top shelf of the cabinet (the area above the scopes) contained black particles. On March 3, 2025, at 11:30 a.m., the Scope Cabinet Manufacture IFUs was provided by the facility. The manufacture IFU stipulated, “...Maintenance and Cleaning...Removable Drip Tray: Remove scopes from the cabinet. Then remove drip tray and clean with a non-abrasive liquid cleaner...” On March 3, 2025, at 12 p.m., a document review of the National Standards the hospital followed, “ANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities,” was conducted. The Standards stipulated, “...11.2.2 Storage Cabinets...”Cabinets and endoscopes shall be visually inspected to ensure cleanliness when the endoscope is placed into the storage cabinet and also when the endoscope is removed for patient use. An endoscope that is removed from a visibly dirty cabinet or is not dry shall be processed before use (SGNA, 2018 [297]). Storage cabinets should be cleaned in accordance with the manufacturer’s IFU, or at least weekly and when visibly soiled...” 3. On March 3, 2025, at 10:40 a.m., during a tour of GI Special Procedure Room and the Operating Room (OR) Main Corridor, an observation was made of a set of double doors located in the OR Corridor, the doors had gaps between the doors and beneath the doors. The doors were directly across from OR 3 where a patient surgical procedure was in process. The DSS who was present during the tour stated behind the doors was the decontamination room of SPD (an area where soiled surgical instruments and GI endoscope cleaning are performed). The DSS and the DIP stated SPD is a negative pressure area. On March 3, 2025, at 10:40 a.m., the Director of Facilities (DF) was asked to verify the pressure in SPD. DF placed a vacuum pressure gauge (a device used to obtain the pressure in a room) under the door. The vacuum pressure gauge did not consistently maintain a negative pressure reading, the pressure showed a neutral and positive reading. The DF stated, “the pressure changes, it depends on what is happening behind the closed doors,” referring to the SPD procedures occurring inside and if the door at the opposite end of SPD was opened. On March 3, 2025, at 11:30 a.m., a record review of the document titled, “Sterile Processing - Infection Surveillance,” provided by the hospital was conducted. The document indicated, “...3. Sterile Processing Environmental Requirement: A. Within the Sterile Processing area, the air exchange must be (a) Negative pressure in the decontamination area...” An interview with DF was conducted on March 6, 2025, at 4:22 p.m. The DF stated they followed the guidelines from ASHRAE (an international society of heating, refrigerating and air-conditioning professionals). On March 6, 2925, at 4:30 p.m., a review of ASHRAE 7.1 stipulated, “...Pressure Relationship to Adjacent Areas... Endoscope cleaning room negative pressure)...” 4. On March 3, 2025, at 10:45 a.m., during a tour of the hospital SPD decontamination room, an interview was conducted with a Sterile Processing Technician (SPDT I). SPDT I was asked to explain the brushes that were placed on top of a sink used to clean soiled surgical instruments. SPDT I stated the brushes were used to clean “dirty” surgical instruments. SPDT I was asked how the brushes get cleaned. SPDT I stated, “We don’t ever clean the brushes,” they use them throughout the day and at the end of the day they get disposed. On March 3, 2025, at 11:30 a.m., a document review was conducted of the manufacture IFU for the cleaning brushes used by SPD staff to clean soiled surgical instruments. The document was provided by the facility and stipulated, “Cleaning & Disinfection: New, unused brushes are provided non-sterile. Clean brushes after each use and disinfect between cases or daily, at a minimum ...” On March 4, 2025, at 9:10 a.m., an interview was conducted with SPDT III who verified above interview and stated they do not clean the brushes between use, they dispose them at the end of the day. 5. On March 3, 2025, at 11:10 a.m., SPDT I was asked to explain what the contact time was of the disinfectant (Super Sani Cloth) she used to wipe down a soiled instrument transport cart. She was unable to explain what the contact time was and after surveyor explained it to her, SPDT I stated, “Wow, I never knew that I learned something new.” On March 5, 2025, at 10:50 a.m., a Surgical Technician (ST I) was asked to explain what the contact time was of the Super Sani Cloth the hospital used to clean and disinfect the plastic bins she used to transport GI scopes. ST I was not familiar with the contact time and stated, “It can dry and as long as the 2 minutes is up they can use the plastic bins.” On March 5, 2025, at 3 p.m., a record review of the manufacture IFU of the Super Sani Cloth provided by the DIP stipulated “allow treated surface to remain wet for two (2) minutes. Let air dry.” 6. On March 4, 2025, at 11:50 a.m., on March 6, 2025, at 11:55 a.m., multiple employee files were reviewed with the hospital’s Human Resources Generalist (HRG). The employee files of SPDT 1, SPDT II, and SPDT III were reviewed. There was no documented evidence that the employees received job specific competencies since 2020. On March 6, 2025, at 12:45 p.m., a document provided by HRG read, “Associate Competency Policy: it is the policy of (name of facility) to ensure that all associates are competent to perform their job responsibilities. (hospital) will assess the competence of its staff on an on-going basis through a variety of means...”...C. Competence Assessment/Annual Performance Evaluation: Annual evaluation of staff performance will be based on the competency-based performance expectations outlined in the job description...Completion of annual competencies is documented and forwarded to HR...” On March 6, 2025, at 1 p.m., a review of AAMI ST 79 (the National Standards the hospital followed) stipulated, “...4.2.2 Sterile processing personnel The responsibility for sterile processing should be assigned to qualified individuals who have demonstrated competence in all aspects of sterile processing, including biohazard transportation, decontamination, preparation, packaging, sterilization, sterile storage, and distribution of sterile medical devices. Qualifications include demonstrated knowledge of and documented competence in a) all aspects of decontamination, including sorting, disassembly/reassembly, manual and mechanical cleaning methods, microbicidal processes, equipment operation, standard and transmission-based precautions, and engineering and work-practice controls; “4.3 Education and training 4.3.1 Sterile processing personnel Sterile processing personnel should receive...b) continuing education at regular intervals to review and update knowledge and skills and to maintain competency and certification; and c) in-service training on all new instrumentation, devices, and equipment. The health care facility should have a written standardized program that includes 1) aspects of education and training related to facility policies and procedures; 2) tools to document that education and training were performed and competency was verified; and 3) the facility’s policies and procedures, accepted standards of practice, and manufacturers’ recommendations...” 7. On March 5, 2025, at 9:40 a.m., a tour of the hospital SPD Prep and Pack area (a clean area where clean instruments are packaged, prepared for sterilization and patient use), was conducted in the presence of DSS, DIP, and SPDT II. Inspection of sterilized instruments ready for use was performed and revealed the following: During a concurrent observation and interviews with SPDT II, one Richardson retractor (a handheld surgical instrument with a right-angle blade used to retract, expose, or push tissues, organs, muscles, and bones during surgeries) contained coarse black matter. SPDT II stated, the instrument should have been pulled out of use. One Straight Kelly (a surgical instrument used to clamp blood vessels and tissues, control bleeding, and manipulate tissues during surgery) contained coarse non-manufacture etching. SPDT II stated it should have been pulled out of use. One Babcock (a type of surgical instrument used to grasp and hold delicate tissues during surgical procedures) contained coarse non-manufacture etching. SPDT II stated it should have been pulled out of use. One Curved Metz (an instrument used for fine dissection and cutting of delicate tissues, particularly in areas where precise movements are needed) contained sticky tape residue. SPDT II stated the tape residue should have been completely removed. On March 5, 2025, at 3 p.m., a document provided by DIP titled, “Sterile Processing - Preparation and Assembly of Surgical Instrumentation” stipulated, “...9. Instruments are carefully inspected for cleanliness, flaws or damage before packaging. (a) Items noted as dirty will be returned for adequate cleaning before proceeding. (b) Damaged items will be removed from service and sent in for repair or replacement...” 8. On March 5, 2025, at 9:50 a.m., during a tour of SPD Prep & Pack, SPDT II was asked for the cleaning log of the autoclave machine (a machine that sterilizes reusable patient surgical instruments). The autoclave chamber contained brown/orange matter. SPDT II stated they did not have a log and they do not clean or maintain the interior chamber. On March 3, 2025, at 10:15 a.m., a review of the autoclave manufacture IFU was conducted. The document stipulated, “Chamber Routine Cleaning Procedure...Chamber Cleaning Frequency Due to differences in water quality, steam quality, frequency of use and boiler additives, no specific frequency interval is recommended for chamber cleaning. Operators must determine the appropriate cleaning interval based on the local water conditions and chamber appearance...” The document provided a 21 step “Chamber Cleaning Procedure” detailed guide. During a concurrent interview with the Peri-Op Material Coordinator (MMM), who verified the manufacture IFUs and stated they did not have a cleaning frequency of the autoclave. 9. On March 5, 2025, at 10:25 a.m., during the tour of the SPD Prep and Pack Area, SPDT II was asked when SPD gets terminally cleaned. SPDT II stated it did not get terminally cleaned. During a concurrent interview on 3/5/25 at 10:25 AM, DSS confirmed that SPD did not get terminally cleaned at the end of the workday. On March 5, 2025, at 2:30 p.m., an interview was conducted with the Director of Environmental Services (EVSD), who confirmed that terminal cleaning is not performed in SPD. A review of the National Standards the hospital followed was conducted, standards stipulated, “AORN 2012-2025, 6 Sterile Processing Areas 6.2 Terminally clean sterile processing areas each day the areas are used. Sterile processing personnel conduct critical processes, such as decontaminating, assembling, and sterilizing surgical instrumentation, in support of operating and invasive procedure rooms. As such, the recommendations for terminal cleaning apply in sterile processing areas as in areas where surgical and other invasive procedures are performed. Furthermore, sterile processing areas where decontamination occurs have some of the highest risks for environmental contamination of all perioperative areas. Environmental cleaning in sterile processing areas is critical for reducing the risk of disease transmission from reservoirs of bloodborne pathogens and microorganisms in the decontamination environment.” 10. On March 5, 2025, at 10:50 a.m., during a tour of the hospital Special Procedure Unit, a Surgical Technician (ST I) explained the hospital process for disinfecting GI scopes. During the interview the following concerns were identified: a. The path of travel from SPD, where the disinfection of the GI scopes is performed was not unidirectional. The path of travel required staff to exit the GI procedure room with soiled GI scopes across the OR (a restricted clean area), in through doors that swung out to the OR corridor and across an OR room. Staff then exit through the same doors with soiled GI scopes across the OR unit and to the medivator room (a room used to perform high level disinfection of the GI scopes); b. Prior to the GI scopes receiving thorough cleaning and disinfecting, the scopes are transported soiled out of double doors into the main corridor of the OR Unit (a restricted, clean area); c. The soiled scopes are transported through the OR Unit to the medivator room; d. ST I did not know the contact time of the Super Sani Clothes used to clean and disinfect the plastic bins used to transport the soiled GI scopes; and c. There was no documented evidence to demonstrate the plastic bins used to transport the GI scopes were re-usable and could be properly disinfected. During a concurrent interview on 3/5/25 at 10:55 AM, DIP and DSS both agreed the path of travel of transporting the soiled GI scopes from SPD was not unidirectional and not the best infection control practice. In addition, the hospital staff did not provide a policy or a process to guide staff with the GI scope disinfecting process. On March 5, 2025, at 11:30 a.m., a document titled “Sterile Processing - Infection Surveillance approved 8/2024 (August 2024),” was reviewed and stipulated, “Procedures: 2. Separation of Processing Areas: 1. The flow of processing shall be from contaminated to clean and sterile.” On March 5, 2025, at 12 p.m., a review of the National Infection Control Standards the hospital followed AAMI ST 91 stipulated, “...4.1 General considerations: The processing area should be physically separated from the patient care areas and procedure rooms. The processing area should be designated for processing only and designed to allow for the unidirectional flow of devices from the receipt of new and/or used endoscopes to storage prior to next patient use, including: a) receipt of devices, leak testing; b) cleaning (decontamination); c) inspection; d) storage; and e) disinfection and drying or packaging and sterilization. In all cases, facilities should ensure a unidirectional flow from dirty to clean; conduct an analysis to identify risks; and minimize these risks by policies, procedures, education, and training of processing personnel...” In addition, the National Standards stipulated, 4.2 Workflow 4.2.1 General considerations: Workflow should be unidirectional from the decontamination area to the clean area and then to the storage area. Workflow patterns should be designed to contain contaminants, prevent damage to endoscopes, and minimize employee exposure to pathogens and toxic chemicals. 11.a. During a medication pass observation on March 4, 2025 at 8:36 a.m., Registered Nurse 2 (RN 2) was observed preparing and administering two medications to Patient 6. RN 2 entered Patient 6’s room, performed hand hygiene, donned gloves, and then logged into the computer at Patients 6’s bedside. RN 2 proceeded to adjust the window blinds, use the computer, check Patient 6’s blood pressure, and scan medications wearing the same pair of gloves. RN 2 then prepared and administered an intravenous (IV, into the vein) medication into Patient 6’s IV access line wearing the same pair of gloves. During an interview on March 4, 2025 at 8:49 a.m., RN 2 verified she did not perform hand hygiene or change gloves before administering the IV medication to Patient 6. 11.b. During a medication pass observation on March 4, 2025 at 9:30 a.m., RN 1 was observed preparing and administering four medications to Patient 7. RN 1 performed hand hygiene and donned gloves outside Patient 7’s room. RN 1 proceeded to use the computer and scan medication wearing the same pair of gloves. RN 2 then prepared and administered three IV medications into Patient 7’s IV access line wearing the same pair of gloves. During an interview on March 4, 2025 at 10:09 a.m., RN 1 verified he did not perform hand hygiene or change gloves before administering IV medications to Patient 7. RN 1 stated he was not aware of any hospital policy to do hand hygiene before administering IV medications. 12. During a medication pass observation on March 4, 2025 at 8:36 a.m., Registered Nurse 2 (RN 2) was observed preparing and administering two medications to Patient 6. RN 2 prepared famotidine (generic for Pepcid, a medication to treat acid reflux) 20 milligrams (mg) injection by adding normal saline (NS, salt water) to the famotidine vial. RN 2 did not wipe the vial top with alcohol before adding NS to the vial. During an interview on March 4, 2025 at 8:49 a.m., RN 2 verified she did not wipe the famotidine vial top with an alcohol swab. RN 2 stated she was supposed to wipe the vial top with an alcohol swab before inserting the needle. During an interview on March 6, 2025 at 11:57 a.m., the Director of Infection Prevention and Control (IP) stated her expectation is for nurses to perform hand hygiene and put on new gloves before administering IV medications. IP stated her expectation is for the nurse to wipe the vial top with an alcohol swab, allow to dry, and then insert the needle when preparing IV medications. A review of the facility’s policy and procedures titled “Intravenous Site & Device Care,” revised April 2024, indicated: “ ...Observe standard precautions: wash your hands before and after, wear gloves ...” and, “ ...Swab port with...alcohol swab...” A review of the facility’s policy and procedures titled “Intravenous Therapy,” revised January 2025, indicated: “...Intravenous Administration of Medication...Aseptic technique must be followed when giving direct IV injection to prevent contamination of the IV system...” and, “...Aseptic technique must be followed in the preparation of the solution and its administration...” and, “Starting the IV Infusion: Wash hands and put on gloves...” A review of the Association for Professionals in Infection Control and Epidemiology (APIC) “Position Paper: Safe Injection, Infusion, and Medication Practices in Health Care,” published 2016, indicated: “...Aseptic Technique...Disinfect the rubber stopper of medication vials with sterile 70% alcohol before inserting a needle...””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedure for maintaining a central venous catheter (CVC, a thin, flexible tube inserted into a large vein near the heart) was implemented, for two of 31 sample patients (Patients 15 and 16) when: 1. For Patient 15, the CVC catheter dressing was not labeled with the date and time the dressing was applied, and the initials of the staff who performed the dressing application. In addition, there was no physician’s order for the insertion and use of the CVC; and 2. For Patient 16, the CVC dressing was not changed every seven days. These failures had the potential for unnecessary line placement, risk for central line-associated bloodstream infections, and other complications for the patients. Findings: A tour of the Intensive Care Unit (ICU, a specialized unit where critically ill or injured patients receive intensive medical care and monitoring) was conducted on March 3, 2025, at 10 a.m., with the Director of Risk and Quality (DRQ). 1. A concurrent observation and interview were conducted on March 3, 2025, at 10:02 a.m., in Patient15’s room, with the DRQ and ICU Registered Nurse (ICURN) 1. Patient 15 was observed to have a triple lumen CVC (central venous catheter, a thin plastic tubing inserted through a vein) on his right neck. The CVC was observed to have a chlorhexidine (a type of antiseptic) patch and dressing which was observed to not be labeled with the date and time the dressing was applied, and the initials of the staff who performed the dressing application. ICURN 1 stated the CVC is being used to infuse medications to Patient 15. ICURN 1 further stated the dressing of the CVC should have been labeled with the date and time of application and should indicate the initials of the staff who performed the dressing application. The DRQ stated the CVC dressing should have a date and time of application, and the initial of the staff who applied it, in accordance with the facility policy. A review of Patient 15’s record was conducted on March 6, 2025, at 11:45 a.m. with the DRQ. A facility document titled, “History and Physical,” dated March 1, 2025, was reviewed. The document indicated Patient 15 was admitted to the facility on March 1, 2025, with a diagnosis of cardiogenic shock (a life-threatening condition where the heart is unable to pump enough blood to meet the body’s needs). A facility document titled, “KBC [Knowledge Based Charting] Adult Assessment Interventions,” dated March 1, 2025, was reviewed. The document indicated, “ ...Access/Monitoring Devices...Central Line...Site: Right IJ [internal jugular] CVC...Site Day 1...lumen triple...Indication...meds/IV [intravenous] solutions...securement...secured with adhesive dressing...” A facility document titled, “History and Physical,” dated March 1, 2025, was reviewed. The document indicated, “...patient remained hypotensive requiring pressors (a class of drugs which increases the blood pressure) and a Central line was placed in the ED (Emergency Department) and pt [Patient 15] was started on [brand name of norepinephrine, a medication used to treat life-threatening low blood pressure)...” There was no documented evidence physician’s order was obtained prior to the insertion and use of the CVC on Patient 15. An interview was conducted on March 6, 2025, at 11:56 a.m., with the DRQ. The DRQ stated a physician’s order should have been obtained for the insertion of the CVC in accordance the facility’s policy. A review of the facility’s policy and procedure titled, “Intravenous Site & Device Care,” dated April 2024, was conducted. The policy indicated, “...IV site access...Obtain or review the provider’s order for intravenous (IV) therapy...IV site assessment, maintenance, and documentation...Date and time and initial the dressing...” 2. A concurrent observation and interview were conducted with the DRQ and ICURN 2 on March 3, 2025, at 10:11 a.m., in Patient 16’s room. Patient 16 was observed to have a triple lumen CVC on his right neck. The CVC was observed to have a chlorhexidine patch and dressing which was observed to not be labeled with the date and time of application and the initials of the staff who performed the dressing application. ICURN 2 stated the CVC is being used to infuse medications. ICURN 2 was unable to state when the CVC dressing was changed. The DRQ stated the dressing should have been labeled with the application date and time, and the initial of the staff who applied the dressing in accordance with the facility’s policy. A review of Patient 16’s record was conducted on March 6, 2025, at 11:13 a.m. with the DRQ. A facility document titled, “History and Physical,” dated January 31, 2025, was reviewed. The document indicated Patient 16 was admitted to the facility on January 31, 2025, with a diagnosis of septic shock (a widespread life-threatening infection) likely due to pneumonia (an infection of the lungs). A facility document titled, “ED Aware Note,” dated January 31, 2025, was reviewed. The document indicated, “...Central Line Insertion...The indications for the procedure are volume resuscitation and hemodynamic monitoring...” A facility document titled, “KBC Adult Assessment Interventions,” dated January 31, 2025, through March 4, 2025, was reviewed. There was no documented evidence the dressing for Patient 16’s CVC was changed on the following dates: - On February 8, 2025; - On February 15, 2025; - On February 21, 2025; and - On February 28, 2025. A concurrent interview and policy review was conducted on March 6, 2025, at 11:40 a.m. with the DRQ and the Intensive Care Unit Director (ICUD). The ICUD stated the facility’s policy was not followed when the CVC dressing for Patient 16 was not changed every seven days. A facility policy and procedure titled, “Prevention of Central Line Associated Infections,” dated December 2020, was reviewed. The document indicated, “...Catheter Dressing Changes...Catheter site dressing changes shall occur as follows...Chlorhexidine patch under a clear occlusive dressing (without gauze) should be changed at least every 7 [seven] days and PRN (as needed) if wet, bloody or loose...””

“OPERATING ROOM SUPERVISION CFR(s): 482.51(a)(1) The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to ensure the Director of Surgical Services was qualified by training and experience to manage the Surgical Service Department in accordance with nationally recognized perioperative practices, guidelines, and regulations. This failure had the potential for operational inefficiencies and lack of oversight in the Surgical Service Department which may result in the provision of unsafe patient care practices. Findings: An interview was conducted on March 3, 2025, at 2:50 p.m., with the Director of Surgical Services (DSS). The DSS stated they follow the AORN (Association of Perioperative Registered Nurses, nationally accepted guidelines for the Operating Room [OR]), American Society of Peri Anesthesia Nurses (ASPAN, a professional specialty nursing organization for nurses practicing in pain management) guidelines for the Post Anesthesia (branch of medicine specializing in pain management) Care Unit (PACU, unit where patients recover after surgery). The DSS stated she but does not know the guidelines they follow for the Sterile Processing Department (SPD, an area in the facility where used medical devices are cleaned, disinfected, sterilized, assembled, packaged, stored, and distributed) and Gastroenterology Laboratory (GI Lab, a specialized unit within a hospital focused on diagnosing and treating conditions affecting the digestive system). The DSS further stated she had no experience working in the OR as a registered nurse (RN). The DSS stated her managerial experience in the OR started when she was an interim director in 2024. The DSS stated she has no experience working or managing SPD and GI lab. A concurrent interview and record review were conducted on March 4, 2025, at 10:46 a.m., with the Human Resources Generalist (HRG). The employee file of the DSS was reviewed and indicated the following: - On July 11, 2016, the DSS was initially hired by the facility as an RN in the Definitive Observation Unit (DOU, a specialized unit in the facility that provides close monitoring and care to patients who require more attention than a general medical ward but not as intensive as an Intensive Care Unit (ICU, a specialized unit intensive treatment to patients with severe or life-threatening illnesses or injuries, often requiring life support); - On July 2, 2018, the DSS transferred to the ICU as an ICU RN; - On February 2, 2020, the DSS transferred to the PACU as Pre-Admission Nurse; - On March 22, 2022, the DSS transferred to the PACU as a PACU RN; - On December 12, 2022, the DSS was hired as a Charge nurse in the PACU; - On April 15, 2024, the DSS was hired as an Interim Director for the Surgical Services; and - On August 15, 2024, the DSS was hired as the Director for the Surgical Services. A facility document titled, “Director,” dated August 15, 2024, was reviewed with the HRG. The document indicated, “...Job Description: Director...Position Name Director Surgery...The Director of Surgical Services coordinates the nursing care given in all aspects of management for the Surgical Services department. This includes the Operating Room, Post Anesthesia Care Unit, Pre-Operative Preparation Area, Sterile Processing Unit and G.I. Lab...Regulatory Requirement (Licensure and Credentials)...Experience...Minimum of three years of prior managerial experience required with demonstrated administrative and leadership ability. Minimum of five year’s operating room experience with the ability to scrub or circulate when needed.” During a concurrent interview, the HRG stated there was no documentation the DSS was trained or precepted to scrub or circulate in the OR. The HRG stated there was no documentation the DSS had three years of managerial experience and five years of operating room experience. The HRG stated there was no documentation the DSS had experience working or managing the OR, SPD and GI Lab. The HRG further stated there was no documentation the DSS was onboarded, trained, nor precepted (the process through which a provider gains experience and/or training on new skills and knowledge) on the care of patients in the OR and GI lab. A concurrent interview and record review was conducted on March 4, 2025, at 11:08 a.m., with the Chief Nurse Executive (CNE) and HRG. A facility document titled, “Director,” dated August 15, 2024, was reviewed. The CNE stated DSS is not qualified to be the Surgical Services Director based on the requirements stated on the job description. A review of the AORN’s Position Statement titled, “Guiding Principles for the Surgical Services Director Role,” dated 2023, was conducted. The document indicated, “...AORN believes that the Director of Surgical Services should be a registered nurse with perioperative experience...The role of the Director is multi-faceted, requiring clinical experience, knowledge of the art and science of nursing, expertise that supports broad-level thinking, and an understanding of the fiduciary responsibilities of providing safe, quality patient care in the surgical arena...Principles...The Director of Surgical Services should have clinical perioperative experience and expert skills and knowledge in the practice of perioperative nursing...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 42512 Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner, in accordance with acceptable standards of practice and in a manner to prevent the risk of cross contamination, when: 1. Surgical brushes used to clean soiled surgical instruments were not cleaned between use; 2. Two of two surgical processing staff (SPD Tech 1 & 2) did not adhere to the contact time (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs and achieve the desired level of sanitation) of the Super Sani wipes (cleaning and disinfectant wipes); 3. Three of three SPD staff employee files did not contain documented evidence they received job specific competencies; 4. Four sterilized and ready to use surgical instruments contained the following: one instrument contained black non-smooth matter, 1- contained sticky residue, & two instruments contained non-manufacture etching that was course to touch; 5. The autoclave (a machine used to sterilize surgical instruments) was not cleaned and maintained according to manufacture IFU; 6. The hospital Sterile Processing Department Prep & Pack (an area used to prepare clean surgical instruments for sterilization and reuse) area did not receive terminal cleaning (a thorough, hospital cleaning focused on eliminating all pathogens from a room, especially in healthcare settings, after use to prevent the spread of infections); and 7. The hospital SPD decontamination room (a room used to clean and disinfect re-usable patient surgical instruments) did not consistently maintain negative pressure, (the air pressure inside the room is lower than the air pressure outside the room. Which means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room cannot flow outside into non-contaminated areas). The doors were opened frequently, which opened directly into the Operating Room (OR) corridor which faced OR 3 (a room that was in use during a patient surgical procedure). In addition, the doors had gaps beneath and between the doors and the doors did not open in a unidirectional workflow pattern. Findings: 1. On March 3, 2025, at 10:45 a.m., during a tour of the hospital SPD decontamination room, an interview was conducted with a Sterile Processing Technician (SPDT I). SPDT I was asked to explain the brushes that were placed on top of a sink used to clean soiled surgical instruments. SPDT I stated the brushes were used to clean “dirty” surgical instruments. SPDT I was asked how the brushes get cleaned. SPDT I stated, “We don’t ever clean the brushes”, they use them throughout the day and at the end of the day they get disposed. On March 3, 2025, at 11:30 a.m., a document review was conducted of the manufacture IFU for the cleaning brushes used by SPD staff to clean soiled surgical instruments. The document was provided by the facility and stipulated, “Cleaning & Disinfection: New, unused brushes are provided non-sterile. Clean brushes after each use and disinfect between cases or daily, at a minimum...” On March 4, 2025, at 9:10 a.m., an interview was conducted with SPDT III who verified above interview and stated they do not clean the brushes between use, they dispose them at the end of the day. 2. On March 3, 2025, at 11:10 a.m., SPDT I was asked to explain what the contact time was of the disinfectant (Super Sani Cloth) she used to wipe down a soiled instrument transport cart. She was unable to explain what the contact time was and after surveyor explained it to her, SPDT I stated, “Wow, I never knew that I learned something new.” On March 5, 2025, at 10:50 a.m., a Surgical Technician (ST I) was asked to explain what the contact time was of the Super Sani Cloth the hospital used to clean and disinfect the plastic bins she used to transport GI scopes. ST I was not familiar with the contact time and stated, “It can dry and as long as the 2 minutes is up they can use the plastic bins.” On March 3, 2025, at 3 p.m., a record review of the manufacture IFU of the Super Sani Cloth provided by the DIP stipulated “allow treated surface to remain wet for two (2) minutes. Let air dry.” 3. On March 3, 2025, at 11:50 a.m., and on March 6, 2025, at 11:55 a.m., multiple employee files were reviewed with the hospital’s Human Resources Generalist (HRG). The employee files of SPDT 1, SPDT II, and SPDT III were reviewed. There was no documented evidence that the employees received job specific competencies since 2020. On March 6, 2025, at 12:45 p.m., a document provided by HRG read, “Associate Competency Policy: it is the policy of (name of facility) to ensure that all associates are competent to perform their job responsibilities. (hospital) will assess the competence of its staff on an on-going basis through a variety of means...C. Competence Assessment/Annual Performance Evaluation: Annual evaluation of staff performance will be based on the competency-based performance expectations outlined in the job description...Completion of annual competencies is documented and forwarded to HR...” On March 6, 2025, at 1 p.m., a review of AAMI ST 79 (the National Standards the hospital followed) stipulated, “...4.2.2 Sterile processing personnel The responsibility for sterile processing should be assigned to qualified individuals who have demonstrated competence in all aspects of sterile processing, including biohazard transportation, decontamination, preparation, packaging, sterilization, sterile storage, and distribution of sterile medical devices. Qualifications include demonstrated knowledge of and documented competence in a) all aspects of decontamination, including sorting, disassembly/reassembly, manual and mechanical cleaning methods, microbicidal processes, equipment operation, standard and transmission-based precautions, and engineering and work-practice controls...4.3 Education and training 4.3.1 Sterile processing personnel Sterile processing personnel should receive...b) continuing education at regular intervals to review and update knowledge and skills and to maintain competency and certification; and c) in-service training on all new instrumentation, devices, and equipment. The health care facility should have a written standardized program that includes 1) aspects of education and training related to facility policies and procedures; 2) tools to document that education and training were performed and competency was verified; and 3) the facility’s policies and procedures, accepted standards of practice, and manufacturers’ recommendations...” 4. On March 5, 2025, at 9:40 a.m., a tour of the hospital SPD Prep and Pack area (a clean area where clean instruments are packaged, prepared for sterilization and patient use), was conducted in the presence of DSS, DIP, and SPDT II. Inspection of sterilized instruments ready for use was performed and revealed the following: - During a concurrent observation and interviews with SPDT II, one Richardson retractor (“a handheld surgical instrument with a right-angle blade used to retract, expose, or push tissues, organs, muscles, and bones during surgeries”) contained coarse black matter. SPDT II stated, the instrument should have been pulled out of use; - One Straight Kelly (“a surgical instrument used to clamp blood vessels and tissues, control bleeding, and manipulate tissues during surgery”) contained coarse non-manufacture etching. SPDT II stated it should have been pulled out of use; - One Babcock (“a type of surgical instrument used to grasp and hold delicate tissues during surgical procedures”) contained coarse non-manufacture etching. SPDT II stated it should have been pulled out of use; and - One Curved Metz (“used for fine dissection and cutting of delicate tissues, particularly in areas where precise movements are needed”) contained sticky tape residue. SPDT II stated the tape residue should have been completely removed. On March 5, 2025, at 3 p.m., a document provided by DIP titled, “Sterile Processing - Preparation and Assembly of Surgical Instrumentation” stipulated, “...9. Instruments are carefully inspected for cleanliness, flaws or damage before packaging. (a) Items noted as dirty will be returned for adequate cleaning before proceeding. (b) Damaged items will be removed from service and sent in for repair or replacement...” 5. On March 5, 2025, at 9:50 a.m., during a tour of SPD Prep & Pack, SPDT II was asked for the cleaning log of the autoclave machine (a machine that sterilizes reusable patient surgical instruments). The autoclave chamber contained brown/orange matter. SPDT II stated they did not have a log and they do not clean or maintain the interior chamber. On March 5, 2025, at 10:15 a.m., a review of the autoclave manufacture IFU was conducted. The document stipulated, “...Chamber Routine Cleaning Procedure...Chamber Cleaning Frequency Due to differences in water quality, steam quality, frequency of use and boiler additives, no specific frequency interval is recommended for chamber cleaning. Operators must determine the appropriate cleaning interval based on the local water conditions and chamber appearance...” The document provided a 21 step “Chamber Cleaning Procedure” detailed guide. During a concurrent interview with the Peri-Op Material Coordinator (MMM), who verified the manufacture IFUs and stated they did not have a cleaning frequency of the autoclave. 6. On March 5, 2025, at 10:25 a.m., during the tour of the SPD Prep and Pack Area, SPDT II was asked when SPD gets terminally cleaned. SPDT II stated it did not get terminally cleaned. During a concurrent interview on March 5, 2025, at 10:25 a.m., the DSS confirmed that SPD did not get terminally cleaned at the end of the workday. On March 5, 2025, at 2:30 p.m., an interview was conducted with the Director of Environmental Services (EVSD), who confirmed that terminal cleaning is not performed in SPD. A review of the National Standards the hospital followed was conducted, standards stipulated, “...AORN 2012-2025, 6 Sterile Processing Areas 6.2 Terminally clean sterile processing areas each day the areas are used. Sterile processing personnel conduct critical processes, such as decontaminating, assembling, and sterilizing surgical instrumentation, in support of operating and invasive procedure rooms. As such, the recommendations for terminal cleaning apply in sterile processing areas as in areas where surgical and other invasive procedures are performed. Furthermore, sterile processing areas where decontamination occurs have some of the highest risks for environmental contamination of all perioperative areas. Environmental cleaning in sterile processing areas is critical for reducing the risk of disease transmission from reservoirs of bloodborne pathogens and microorganisms in the decontamination environment...” 7. On March 3, 2025, at 10:40 a.m., during a tour of GI Special Procedure Room and the Operating Room (OR) Main Corridor, an observation was made of a set of double doors located in the OR Corridor, the doors had gaps between the doors and beneath the doors. The doors were directly across from OR 3 where a patient surgical procedure was in process. DSS who was present during the tour stated behind the doors was the decontamination room of SPD (an area where soiled surgical instruments and GI endoscope cleaning are performed). DSS and DIP stated SPD is a negative pressure area. On March 3, 2025, at 10:40 a.m., the Director of Facilities (DF) was asked to verify the pressure in SPD. DF placed a vacuum pressure gauge (a device used to obtain the pressure in a room) under the door. The vacuum pressure gauge did not consistently maintain a negative pressure reading, the pressure showed a neutral and positive reading. DF stated, “the pressure changes, it depends on what is happening behind the closed doors” referring to the SPD procedures occurring inside and if the door at the opposite end of SPD was opened. On March 3, 2025, at 11:30 a.m., a record review was provided by the hospital, the document titled, “Sterile Processing - Infection Surveillance...3. Sterile Processing Environmental Requirement: A. Within the Sterile Processing area, the air exchange must be (a) Negative pressure in the decontamination area...” An interview with DF was conducted on March 6, 2025, at 4:22 p.m., the DF stated they followed the guidelines from ASHRAE (an international society of heating, refrigerating and air-conditioning professionals). On March 6, 2025, at 4:30 p.m., a review of ASHRAE 7.1 stipulated “...Pressure Relationship to Adjacent Areas...Endoscope cleaning room negative pressure)...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for six of 30 sample patients (Patients 2, 4, 5, 23, 27, and 29), when: 1. For Patients 2, 4, 5, and 23, individualized care plans were not developed nor implemented (Refer to A 0130); 2. For Patients 2, 4, 27, and 29, the blood transfusion consents were not signed by the physician prior to the surgery (Refer to A 0131); and 3. For Patient 23, the alleged involved staff was not placed on administrative leave while an investigation of an alleged abuse was ongoing (Refer to A0144). The cumulative effects of these systemic failures resulted in the patients’ safety to be put at risk, and had the potential to delay the treatment and care of patients in the facility.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure an individualized plan of care was developed and implemented, for four of 30 sample patients (Patients 2, 4, 5, and 23). These failures had the potential to cause a delay in patient care and harm for the patients. Findings: 1. A review of Patient 2’s record was conducted on October 30, 2024, at 10:55 a.m., with the Director of Risk and Quality (DRQ). A facility document titled, “History and Physical [H&P],” dated October 28, 2024, was reviewed and indicated Patient 2 was admitted to the facility on October 28, 2024, for right hip osteoarthritis (a degenerative disease of the joint) and a right total hip arthroplasty (a surgical procedure that replaces the damaged parts of the hip joint with artificial components). A facility document titled, “[Facility name] Adult Plan of Care-Flowsheet Summary,” dated October 28, 2024, was reviewed and indicated, “...Rehabilitation Goals...transfer training goal...date established...Oct-28-2024 [October 28, 2024]...by discharge...Gait training goal...date established Oct-28-2024...by discharge...” The facility document titled, “[Facility Name] HIM [Health Information Management] Orders,” dated October 28, 2024, at 6:11 a.m., was reviewed and indicated, “...SURG. [surgery] Post Op [operative] Orders for Hip or Knee Replacement...order entered: 10/25/2024 [October 25, 2024]...oxyCodone [a narcotic for pain management]...10 milligrams [unit of measurement] oral every 4 [four] hours, PRN [as needed] for pain level 4-6 [four to six]...” A facility document titled, “[Facility Name] HIM MAR [Medication Administration Record],” dated October 28, 2024, at 6 p.m., was reviewed and indicated, “...oxyCodone...every 4 hours...10 milligrams...oral...10/29/24 [October 29, 2024] 10:37 a.m...” There was no documented evidence a care plan for pain management was developed for Patient 2. An interview was conducted on October 30, 2024, at 11:43 a.m., with the Director of Risk and Quality (DRQ). The DRQ stated she did not have find care plans except for the rehabilitation goals for Patient 2. The DRQ stated there was no care plan for pain developed for Patient 2. The DRQ stated Patient 2 was prescribed and administered pain medications. 2. On October 29, 2024, at 11:45 a.m., Patient 4’s record was reviewed with the DRQ. A facility document titled, “H&P,” dated October 28, 2024, was reviewed. The document indicated Patient 4 was admitted to the facility on October 28, 2024, for status post [after a procedure] total replacement of right hip. A facility document titled, “[Name of facility] Adult Plan of Care-Flowsheet Summary” dated October 28, 2024, indicated, “...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education...” There was no documented evidence interventions were included in Patient 4’s care plans. There was no documented evidence Patient 4 or Patient 4’s family members were involved in the development of Patient 4’s care plan. On October 30, 2024, at 2:56 p.m., an interview was conducted with the Director of the Intensive Care (DID). The DID stated there were no interventions nor patient or family involvement documented in Patient 4’s care plan. The DID stated the nurses should have completed these. The DID stated documentation of plan of care and patient involvement is important to show that the care plan is being implemented. She further stated, “Care plans are meant to fully guide nurses in the care they are giving.” 3. Patient 5’s record was reviewed on October 30, 2024, at 1:36 p.m., with the DRQ. A facility document titled, “H&P,” dated October 29, 2024, was reviewed and indicated Patient 5 was admitted to the facility on October 29, 2024, for septic shock (a life-threatening condition that occurs when a severe infection leads to dangerously low blood pressure) due to urinary tract infection (an infection in the bladder and or the urethra where urine passes out of). A facility document titled, “[Facility name] Adult Plan of Care-Flowsheet Summary,” dated October 28, 2024, was reviewed and indicated, “...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education...” There was no documented evidence an individualized care plan was developed for Patient 5. An interview was conducted on October 30, 2024, at 1:50 p.m., with the DRQ. The DRQ stated an individualized care plans were not developed for Patient 5. The DRQ further stated the nurse should have developed individualized care plans for Patient 5 once the assessment was completed, as it is the nurse’s responsibility to initiate the care plans. 50304 4. A review of Patient 23’s record was conducted on October 30, 2024, at 1:31 p.m., with the Director of Intensive Care Unit (DID). The facility document titled, “H&P,” dated October 15, 2024, indicated Patient 23 was admitted to the facility on October 15, 2024, for hip fracture (a break in the bone). The facility document titled, “KBC Adult Plan of Care-Flowsheet Summary” dated October 16, 2024, indicated, “...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education...” There was no documented evidence interventions were developed in Patient 23’s care plan. On October 30, 2024, at 2:56 p.m., an interview was conducted with the DID. DID stated there were no interventions documented for Patient 23’s care plans, which the nurses should have done. DID stated documentation of plan of care and patient involvement is important to show that the care plan is being followed. She further stated, “care plans are meant to fully guide nurses in the care they are giving.” A review of the facility’s policy and procedure (P&P) titled, “[Facility Name] Care Plans, Patient,” revised February 2024, was conducted. The P&P indicated, “...The patient or patient’s representative has the right to participate in the development, implementation and revision of their plan of care to meet their medical and psychological needs. The plan of care is to include at a minimum, the right to: pain management plan...inpatient treatment...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for four of 30 sample patients (Patients 2, 4, 27, and 29), when the blood transfusion (medical procedure that involves transferring blood or blood components into a patient’s bloodstream through the vein) consents were not signed by the physician/s. These failures had the potential to cause a delay in Patients 2, 4, 27, and 29’s surgical procedures, and may cause harm for the patients. Findings: 1. A review of Patient 2’s medical record was conducted on October 29, 2024, at 10:55 a.m., with the Director of Risk and Quality (DRQ). A facility document titled, “History and Physical [H&P],” dated October 28, 2024, was reviewed. The document indicated Patient 2 was admitted to the facility on October 28, 2024, for right hip osteoarthritis (a degenerative disease of the joint) and a right total hip arthroplasty (a surgical procedure that replaces the damaged parts of the hip joint with artificial components). An untitled facility document was reviewed. The document indicated, “...Consent to Blood Transfusion Date...Time...Provider Signature...” There was no documented evidence the physician signed the blood transfusion consent prior to Patient 2’s surgical procedure. On October 29, 2024, at 11:19 a.m., an interview with the Director of the Post Anesthesia (a branch of medicine which specializes in the use of medication to prevent pain during surgery and other procedures) Care Unit (DPACU) and the Charge of the Operating Room (COR) were conducted. The COR stated the Physician did not sign the Consent to Blood Transfusion for Patient 2. She stated the surgeon should have signed the consent prior to the surgical procedure. The COR stated, if the blood would have been required during the surgery, the surgeon would have had to scrub out of the surgery, sign the consent, and then scrub back (scrubbing hands for five minutes, doffing [taking off] then donning [putting on] a sterile surgical gown and sterile gloves) which could delay the surgery and the administration of the blood to the patient. 2. A review of Patient 4’s record was conducted on October 29, 2024, at 11:45 a.m., with the DRQ. A facility document titled, “H&P,” dated October 28, 2024, was reviewed. The document indicated Patient 4 was admitted to the facility on October 28, 2024, for right hip osteoarthritis and a right total hip arthroplasty. An untitled facility document was reviewed. The document indicated, “...Consent to Blood Transfusion...Date...Time...Provider Signature...” There was no documented evidence the physician signed the blood transfusion consent prior to Patient 2’s surgical procedure. An interview was conducted on October 29, 2024, at 11:45 a.m., with the DPACU and the COR. The COR stated the physician did not sign the consent to blood transfusion for Patient 4. She stated the surgeon should have signed the consent prior to the surgical procedure. The COR stated, if the blood would have been required during Patient 4’s surgery, the surgeon would have had to scrub out of the surgery, sign the consent, and then scrub back in, which would delay the surgery and the administration of the blood to the patient. 50304 3. A review of Patient 27’s record was conducted on October 29, 2024, at 11 a.m., with the DRQ. A facility document titled, “H&P,” dated October 28, 2024, was reviewed. The document indicated Patient 27 was admitted to the facility on October 28, 2024, for right total hip replacement. An untitled facility document was reviewed. The document indicated, “...Consent to Blood Transfusion...Date...Time...Provider Signature...” There was no documented evidence the physician signed the blood transfusion consent prior to Patient 27’s surgery. 4. A review of Patient 29’s record was conducted on October 29, 2024, at 11:15 a.m., with the DRQ. A facility document titled, “H&P,” dated October 28, 2024, was reviewed. The document indicated Patient 29 was admitted to the facility on October 28, 2024, for left total hip replacement. An untitled facility document was reviewed. The document indicated, “...Consent to Blood Transfusion...Date...Time...Provider Signature...” There was no documented evidence the physician signed the blood transfusion consent prior to Patient 29’s surgery. An interview was conducted on October 29, 2024, at 11:35 a.m., with the DRQ. The DRQ stated Patients 27 and 29’s blood transfusion consents were not completed and did not have a physician signature. The DRQ further stated the physician must sign the section for the physician informed consent documentation of the facility document titled, “Consent for Blood Transfusion” before the surgery. She stated the staff would need this form signed to get blood from the laboratory. She further stated if the form is not signed by the physician prior to surgery, this will cause delay of the surgery and the administration of blood to the patient. A review of the P&P titled, “[Facility Name] Consents,” dated May 2022, was conducted. The P&P indicated, “...an [authorization for and consent to surgery or special diagnosis or therapeutic procedures] is completed on every patient undergoing surgery, an invasive procedure or blood transfusion...the informed consent is obtained by the physician...if a consent form is filled out incorrectly, a new form must be completed and signed...””

“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: 50304 Based on interview and record review, the facility failed to ensure the facility’s policy for abuse was implemented, for one of 30 sampled patients (Patient 23), when Registered Nurse (RN) 2, who was allegedly involved in an abuse allegation, was not removed from patient care while the investigation of alleged abuse was ongoing. This failure had the potential for the patients to be subjected to abuse. Findings: On October 24, 2024, at 8:08 p.m., the facility sent a report by facsimile (a telephonic transmission) indicating, “...at approx. [approximately] 0730 [7:30 a.m.] [name of Patient 23’s roommate heard his roommate [Patient 23] being slapped by 2 [two] night shift nurses when being cleaned up during the night shift. This nurse [asked if he witnessed this being done and he stated he did not since the curtain was closed, but heard it happening...” A review of Patient 23’s record was conducted on October 25, 2024, at 4 p.m., with the Director of Medical Surgical Unit (DMS). A facility document titled, “Progress Notes,” dated October 25, 2024, at 11:28 a.m., authored by RN 1, was reviewed. The document indicated, “...Late Entry: 10/24/24 [October 24, 2024] Approx [approximately] 0800 [8 a.m.] LVN [Licensed Vocational Nurse] [LVN’s Name] notified me of report that pt [Patient 23] was “slapped” in the middle of the night by night shift CNA’s [Certified Nurses Assistants]. Upon report, I assessed pts [patient’s] condition, pt had no physical signs of abuse present. Minor scratches were seen on the pts upper L [left] chest where the tele [telemetry, continuous remote heart monitoring] lead [wires that connect electrodes to a telemetry unit] was present. Bruising on pts upper right arm and left side that was reported to have been caused by pts falls at home. Pt showed nor verbalized any signs or symptoms of distress. Charge nurse [charge nurse’s name] notified, pt was moved to another another [sic] room and police were notified...” A review of a facility document titled, “[Name of Facility] Medical Surgical Telemetry Unit Assignment Sheet,” dated October 28, 2024, was conducted. The document indicated, “...[Name of RN 2]...Patient room assignment...” A review of RN 2’s timecard, dated October 23, 2024, through October 28, 2024, was conducted. The document indicated, “...Monday [October 28, 2024]...In 17:56 [5:56 p.m.]...out 0:41 [12:41 a.m.]...in 1:11 [1:11 a.m.]...out 08:06 [8:06 a.m.]...” On October 25, 2024, at 4:01 p.m., an interview was conducted with the DMS. The DMS stated the LVN came in and reported to her that the roommate of Patient 23 had told her two black people were cleaning Patient 23 up and he heard a slap but could not see who the staff were because the privacy curtain was closed. The DMS stated the local police department was notified, did their investigation, and reported to her that “there was no abuse.” The DMS stated she thought the investigation was over because the local police department had come to investigate. The DMS stated she had been told if the investigating police officer said there’s no evidence of abuse and patient is safe, the facility did not have to suspend staff allegedly involved or the staff allegedly involved would not be assigned to the alleged abused patient. The DMS stated she did not place any nursing staff on administrative leave after receiving report about the alleged abuse on Patient 23 on October 24, 2024. The DMS further stated she did not interview the night shift staff who was allegedly involved in the abuse. The DMS stated the alleged victim was not able to talk so she did not interview him. The DMS stated she was unable to provide documentation of an investigation which was conducted related to the allegation abuse on Patient 23. On October 29, 2024, at 1:23 p.m., an interview was conducted with the DMS. The DMS stated she finished talking to staff regarding the alleged abuse incident on Patient 23 on October 28, 2024, at 1 a.m. The DMS stated she was unable to provide documentation of an investigation which was conducted related to the allegation abuse on Patient 23. The DMS stated, “[Name of RN 2] came to work on Monday [October 28, 2024].” On October 30, 2024, at 9:25 a.m., an interview was conducted with the DMS. The DMS stated she interviewed LVN 1 on the night of October 29, 2024. The DMS stated LVN 1 told her she and RN 2 changed Patient 23 at 6 a.m., on October 24, 2024, and both staff were “black” women. On October 30, 2024, at 9:42 a.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated no one was placed on administrative leave during the investigation of the alleged abuse on Patient 23. The CNO stated they could not identify the staff involved in the alleged abuse. The CNO stated Patient 23’s roommate had reported that there two African nurses who slapped Patient 23 but he did not know who the staff were. The CNO stated she was not aware that two African American female staff took care of Patient 23 on the night of the alleged abuse incident on Patient 23. On October 30, 2024, at 4:18 p.m., LVN 1 was interviewed. LVN 1 stated Patient 23’s roommate told her two African American nurses were changing Patient 23 and he heard a slap but could not see who the staff were because the privacy curtain was closed. On October 30, 2024, at 4:29 p.m., an interview was conducted with RN 2. RN 2 stated, around 6 a.m. on October 24, 2024, she repositioned and cleaned up Patient 23 with LVN 1. RN 2 denied the slapping incident involving Patient 23 happened. A review of policy and procedure titled, “Abuse-Prevention Elder and Dependent Adult,” revised June 2022, was conducted. The policy indicated, “...[Name of facility] prohibits and takes measures to prevent the mistreatment...and abuse of patients...Patients have the right to be free of mistreatment...abuse...Patients have the right to be free from...physical abuse...All allegations of abuse identifying an associate [staff] as the suspect will be...thoroughly investigated. Further potential abuse will be prevented while the investigation is in progress...Patients will immediately be protected from further potential abuse while incidents are investigated and until abuse has been ruled out...If the accused abuser is an associate, they will immediately be placed on Administrative Leave by the Director or House Supervisor. Assessments and interviews will be done to identify special needs or interventions required for the alleged victim (patient)...””

“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: 47071 Based on observation and interview, the facility failed to ensure the facility’s policy and procedure (P&P) for medication storage was implemented, when several 10 ml (milliliters, unit of measurement) 0.9% (percent) normal saline (a type of fluid) intravenous (IV, administered through the vein) flushes (a sterile injection of a salt solution that cleans out intravenous (IV) catheters, central lines, or arterial lines) were observed in a clear plastic container on the countertop to the right and left side of the sink in an unlocked storage room. This failure had the potential to cause a contamination to the normal saline flushes and increased risk of infection for the patients. Findings: A tour of the Intensive Care Unit (ICU, unit with patients with life-threatening injuries and illnesses) and the Definitive Observation Unit (DOU, unit for patients with less than critical care needs where close monitoring is provided for patients) was conducted on October 29, 2024, at 10:38 a.m., with the Director of Risk and Quality (DRQ), and the Director of the Intensive Care (DID). The supply room was observed to not be locked. Inside the supply room, several 10 ml 0.9% normal saline intravenous flushes were observed in a clear plastic container on the countertop to the right and left side of the sink. On October 29, 2024, at 10:44 a.m., an interview with the DID was conducted. The DID stated the nurses were preparing for an IV and left the supplies on the countertop. The DID stated the countertop by the sink is not the best place to store the supplies. On October 30, 2024, at 2:10 p.m., an interview with the Director of Pharmacy (DOP) was conducted. The DOP stated 0.9% normal saline is considered a medication. The DOP stated the 0.9% normal saline 10 ml syringe flushes should not be stored in the unlocked ICU/DOU storage room. The DOP stated the normal saline syringe flushes should be stored in the locked medication room. A review of the P&P titled, “[Facility Name] In Transit Management of Medications,” dated August 2024, was conducted. The P&P indicated, “...medications will be maintained in a secure manner during transit storage...Placing the medication in an area that is under continuous visual observation of authorized staff...storing the medication in a locked medication storage room...” A review of the P&P titled, “[Facility Name] Medication Storage,” dated August 2024, was conducted. The P&P indicated, “...medication will be stored in such a manner as to prevent moisture, condensation, contamination, mold growth, or spoilage...””