Hollywood Presbyterian Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure that one of 34 sampled patients (Patient 16), was notified of their rights as a hospital patient (the fundamental entitlements and protections patients have in healthcare, ensuring they are treated with dignity, involved in decisions [informed consent/refusal], receive quality care, have privacy, and can voice complaints, encompassing rights to be informed, respected, non-discriminated, and have autonomy over their treatment choices), when the facility failed to obtain Patient 16’s signature on the conditions of admission (COA, the contractual terms a person agrees to when entering a facility like a hospital or university, outlining responsibilities like payment, consent for treatment/information release) to indicate Patient 16’s knowledge of and understanding of their rights as a patient, in accordance with the facility’s policy regarding hospital registration/admission process. This deficient practice had the potential to result in Patient 16 not aware of their protections within the healthcare setting, allowing them to make informed decisions about their care, maintain autonomy, and exercise their rights to privacy and respect. (Refer to A-0117) 2. The facility failed to ensure timely and safe care was provided for one of 34 sampled patients (Patient 15), when diagnostic (identifying the nature of an illness) procedure (a medical treatment or operation), neurological consultation (meeting with a specialist in the nervous system), code stroke activation (initiating an emergency response for a brain attack), and physician notification (informing the doctor), were not promptly completed, when Patient 15’s condition changed, in accordance with the hospital’s policies in ensuring timely stroke diagnosis (blockage of blood flow to the brain) and avoiding delay with stroke interventions. This deficient practice resulted in a delay of care for Patient 15, potentially worsening Patient 15’s medical condition and health outcomes and possibly leading to increased risk of complications such as permanent neurological deficit (such as paralysis and speech impairment), prolonged recovery time and even death, and violating Patient 15’s right to receive timely care (the legal and ethical obligation of healthcare facilities to provide prompt and appropriate treatment without unnecessary delay). (Refer to A-0129) 3. The facility failed to ensure one of 34 sampled patients (Patient 19), was treated with courtesy and respect, in accordance with the facility’s policies on Patient Rights and “Standards of Behavior,” when Registered Nurse (RN) 9 placed her (RN 9’s) hand in front of Patient 19’s face and violated Patient 19’s personal space in an attempt to de-escalate (communication and action strategies used to calm intense, agitated, or potentially violent situations by reducing emotional intensity and preventing harm, focusing on empathy, calm self-regulation, and clear, non-confrontational interaction to guide the situation to a safer resolution) Patient 19 on 11/3/2025. This deficient practice resulted in violating Patient 19’s right to be treated with courtesy and receive safe care in the hospital. (Refer to A-0129) 4. The facility failed to ensure that one of 34 sampled patients (Patient 17), was made aware of the discharge order from the acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) to the Emergency Department (ED) and was included in the preparation of her (Patient 17) discharge plan on the day (6/25/2025) Patient 17 was discharged from the facility’s ARU to the Emergency Department after Patient 17 returned to the facility from an outpatient procedure, in accordance with the facility’s policy on Patient Rights. Patient 17 was discharged from the ARU while she (Patient 17) was away from the facility for a procedure, without her (Patient 17) knowledge of the discharge to the ED, without receiving necessary discharge instructions, and without subsequent placement in a skilled nursing facility (SNF, a medical center providing 24/7 care, including skilled nursing (like injections, wound care) and rehabilitation (physical, occupational, speech therapy) by licensed professionals, bridging hospital stays for recovery from surgery, illness, or injury). This deficient practice violated Patient 17’s right (fundamental principles ensuring individuals receive respectful, dignified, and informed care, empowering them to participate in decisions about their health, refuse treatment, maintain privacy, and access care without discrimination, covering everything from consent and understanding diagnoses to appealing insurance denials) to participate in the development and implementation of her (Patient 17) discharge plan, which can negatively impact Patient 17’s care coordination and recovery. (Refer to A-0130) 5. The facility failed to inform one of 34 sampled patients (Patient 17) about the results of diagnostic imaging (non-invasive technologies-such as X-rays and ultrasounds-that create detailed pictures of the body’s internal structures to detect, diagnose, and monitor medical conditions) done, in accordance with the facility’s policy on Patient Rights regarding the right to receive information pertaining to their own care, after Patient 17 reported sustaining a near fall (an unintentional descent to the floor or a lower surface [like a bed or chair], with or without injury, often due to a combination of patient risks [like confusion, weakness, age] and environmental hazards [like poor lighting or slippery floors], leading to potential serious harm) on 6/24/2025. This deficient practice violated Patient 17’s right to stay informed about her (Patient 17) health condition and to make decisions about her (Patient 17) care, including the ability to request or refuse treatment. (Refer to A-0131) 6. The facility failed to ensure two of 34 sampled patients (Patient 19 and Patient 28), had their call light (a remote control at the bedside used by a patient to signal his or her need for assistance from professional staff) within their reach, in accordance with the facility’s policy regarding call light system. This deficient practice had the potential to result in a delay of care and accommodation of Patient 19’s and Patient 28’s care needs which may cause physical and emotional distress for Patient 19 and Patient 28. (Refer to A-0144) 7. The facility failed to protect four (4) of 34 sampled patients (Patient 31, Patient 32, Patient 33, and Patient 34) from potential physical abuse (as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish), when an alleged nursing staff (Registered Nurse [RN] 9) was allowed to continue to work before the investigation of an alleged physical abuse, was completed. RN 9 was placed on investigatory suspension on 11/4/2025 following an allegation of abuse by a patient (Patient 19) and was released from suspension and worked on 11/7/2025 morning shift while the facility’s Human Resources (HR) Department was still performing investigation the same day (11/7/2025). RN 9 was assigned to take care of four of 34 sampled patients (Patient 31, Patient 32, Patient 33 and Patient 34) before the investigation was completed by HR department. This deficient practice had the potential to put Patient 31, Patient 32, Patient 33 and Patient 34 at risk for emotional and/or physical distress, and place other patients at risk for potential abuse. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assessment and Performance Improvement (QAPI, a hospital?wide program that uses data to identify problems, test solutions, and improve patient safety and quality) was met, as evidenced by: 1. The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a hospital?wide program that uses data to identify problems, test solutions, and improve patient safety and quality) program collected and analyzed sufficient data during the root cause analysis (RCA, a structured process to identify underlying causes of an adverse event) of an operating room (OR, the hospital surgical suite where operations are performed) fire for one (1) of four (4) sampled patients (Patient 1), in accordance with the facility’s QAPI plan,. The QAPI program did not identify contributing factors or implement corrective actions, including preoperative patient education (instructions given to a patient before surgery to reduce risk and prepare for the procedure), use of non?flammable, water?soluble surgical jelly (a fire?resistant gel applied to hair/skin near the surgical site to reduce ignition risk), staff training (education on policies and procedures), adherence to manufacturer instructions (device or product use directions provided by the maker), and preventive maintenance (PM, scheduled safety and performance inspections per manufacturer specifications). This deficient practice left the facility unable to prevent recurrence of similar events because QAPI did not collect, analyze, or act on critical data. (Refer to A-0273) 2. The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team performed a thorough review and analysis regarding a patient’s death for one of 34 sampled patients (Patient 7) to identify its root cause and plan for corrective actions, when there was a delay of escalating care for Patient 7’s evolving (progressive, getting worse) stroke (happens when blood flow to part of the brain is blocked or a blood vessel bursts, depriving brain cells of oxygen and nutrients, causing them to die within minutes) on 7/17/2024, in accordance with the facility’s QAPI plan. This deficient practice had the potential to result in increasing the likelihood of similar events from recurring and put stroke (damage to the brain from interruption of its blood supply) patients’ safety at risk. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure its Registered Nurses (RNs) provided adequate monitoring and took action to manage one of 34 sampled patients (Patient 7), who had an acute (new onset) stroke (a sudden disruption of blood flow to the brain), when Patient 7 presented progressive deterioration (getting worse) in neurological status (the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) on 7/17/2024 as indicated by: 1.a. Inadequate and incomplete neurological (neuro) assessment (assessment performed by nurse to check for patient’s mental status and alertness) on 7/17/2024 1.b. Failure to activate Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) when Patient 7 experienced a change in neuro status on 7/17/2024 at 10:47 a.m. and progressively deteriorated throughout the day. RRT was not called until 7/18/2024 at 12:05 a.m. 1.c. Failure to follow up and carry out STAT (a medical abbreviation for immediately or without delay) computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) ordered on 7/17/2024 at 9:37 p.m. CT head scan was done on 7/18/2024 at 12:51 a.m. These deficient practices resulted in a delay in Rapid Response Team (RRT) evaluation and delay in CT head scan leading to failure in providing timely interventions causing Patient 7 to undergo emergency right craniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) on 7/18/2024. Patient 7 was found with no brain function during the operation. Patient 7 subsequently died on 7/20/2024. (Refer to A-0395) 2. The facility failed to ensure that a post-fall huddle (a meeting held promptly after a patient fall to discuss the circumstances, contributing factors, and strategies to prevent future falls) was completed for one of 34 sampled patients (Patient 17), after Patient 17 reported an unwitnessed near-fall incident (an event where a patient almost falls but catches themselves without any witnesses present), in accordance with the facility’s policy regarding fall prevention. This deficient practice had the potential to result in repeated falls and injuries for Patient 17 and other patients due to non-compliance with policies, increasing the risk of falls, compromising safety, and causing delays or inadequate treatment. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46333 Based on interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that a record of discussion of a patient’s post-fall (after a fall [an unintentional descent to the floor or a lower surface [like a bed or chair], with or without injury, often due to a combination of patient risks [like confusion, weakness, age] and environmental hazards [like poor lighting or slippery floors], leading to potential serious harm]) X-ray (radiograph, a medical imaging technique used to view the internal structure of the body, which helps in diagnosing fractures or other conditions) results and recommendations for treatment were written, completed, filed, and readily accessible in the electronic medical record (EMR, digital version of paper chart) for one of 34 sampled patients (Patient 17), in accordance with the facility’s medical rules and regulations pertaining to medical record completion. This deficient practice has the potential to disrupt the continuity of care and potentially delay treatment due to the absence of accurate information necessary for formulating a patient’s treatment plan. (Refer to A-0438) 2. The facility failed to ensure Radiologist documented critical test result (a laboratory or imaging result that falls significantly outside the normal range, indicating a, life-threatening condition requiring immediate, rapid clinical intervention) communication on the radiology report, in accordance with the facility’s policy and procedure regarding critical results reporting and documentation, for two of 34 sampled patients’ (Patient 7 and Patient 15) medical records when: 2.a. Radiologist did not document the name of licensed practitioner receiving Patient 7’s critical MRI (magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to create detailed images of organs, and bones) report on 7/15/1024; 2.b. Radiologist did not document the critical results of Patient 15’s CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head and whether CT head results were communicated to any licensed practitioners on 12/15/2025. This deficient practice could result in a lack of proof of critical results communication to the responsible licensed practitioner, potentially causing delays in patient care. (Refer to A-0449) 3. The facility failed to ensure its nursing staff documented a complete neurological assessment (a comprehensive evaluation of the brain, spinal cord, and nerves, checking functions like mental status, motor skills, sensation, balance, coordination, and reflexes, to diagnose disorders, monitor conditions, or identify issues affecting cognitive, physical, or sensory abilities) for one of 34 sampled patients (Patient 7), when Patient 7’s pupil(black, circular opening in the center of the eye) assessment was missing from the record on 7/17/2024 at 8 p.m. This deficient practice had the potential to result in an inaccurate assessment of Patient 7’s neurological status which could potentially delay Patient 7’s treatment and care. (Refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Discharge Planning was met, as evidenced by: 1. The facility failed to ensure that one of 34 patients (Patient 17) was discharged from the hospital to the Skilled Nursing Facility (SNF) with applicable medical information (discharge instructions) pertaining to Patient 17’s course of rehabilitation (process of helping an individual achieve the highest level of function) and treatment, post-discharge goals of care, and treatment preferences at the time of discharge to the appropriate post-acute care service facility (a healthcare setting providing 24/7 medical care, rehabilitation [like physical/occupational therapy], and supportive services for patients needing a higher level of care after a hospital stay). This deficient practice compromised Patient 17’s well-being, safety, and had the potential for post-discharge needs to be unmet which could result in mismanagement of Patient 17’s condition, potential readmission, and deteriorating health outcomes. (Refer to A-0810) 2. The facility failed to ensure that one of 34 sampled patient’s (Patient 17) goals of care and treatment preference regarding discharge planning (the process of organizing a patient’s safe and smooth transition from a hospital to home or another care setting, ensuring they have the necessary care, support, and instructions for continued recovery), was taken into consideration, in accordance with the facility’s policy regarding hospital discharge planning, when Patient 17 was discharged on 6/25/2025 from the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) to the Emergency Department (ED, the department of a hospital responsible for providing emergency care) without Patient 17’s knowledge despite the insurance company’s approval to extend Patient 17’s stay in the ARU until 7/1/2025 while awaiting SNF (Skilled Nursing Facility, a residential facility providing a high level of medical care) placement. This deficient practice had the potential to result in psychological distress, rendering Patient 17 anxious and powerless, which can negatively impact Patient 17’s recovery and trust in the healthcare process. (Refer to A-0816) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Surgical Services was met, as evidenced by: 1. The facility failed to implement and enforce the facility’s surgical services policies and procedures and the equipment manufacturer’s safety instructions during a head and neck procedure for one (1) of four (4) patients sampled (Patient 1) to prevent an operating room fire (an uncontrolled ignition during surgery) when: 1.a. The facility did not ensure preoperative education (instructions given to patients before surgery) was provided to Patient 1 to avoid alcohol-based hair/skin products prior to the procedure, which increases the fire risk when heat-producing devices (such as electrosurgical instruments) are used. 1.b. The facility did not ensure the supply and use of non0flammable, water-soluble surgical jelly (a fire-resistant gel applied to hair/skin around the surgical site to reduce the chance of ignition) for high fire-risk head/neck procedures. 1.c. The facility did not ensure all operating room (OR) staff received training on OR fire-risk protocols (procedures to prevent, detect, and respond to fires in the operating room) after the fire incident on 11/4/2025. 1.d. The facility did not ensure adherence to manufacturer instructions for alcohol-based skin antisepsis (a disinfectant applied to the skin before surgery), including using the correct applicator size and allowing adequate drying time (time for the alcohol to fully evaporate before draping or using electrical equipment). 1.e. The facility did not ensure preventive maintenance (PM) checks (scheduled safety and functional inspections) on the electrosurgical generator (the “Bovie,” a machine that uses electrical energy to cut tissue or stop bleeding), were maintained, in accordance with manufacturer specifications. The Bovie was used during Patient 1’s procedure when the surgical fire was ignited. These deficient practices resulted in a surgical fire during Patient 1’s scalp cyst excision (surgical removal of a cyst, an abnormal sac of tissue on the scalp) on 11/4/2025, causing Patient 1 to sustain: Second-degree burns (which damage the epidermis [outer skin layer] and part of the dermis [deeper skin layer], resulting in pain, redness, swelling, and blistering) and Third-degree burns (which destroy the entire thickness of the skin and may extend to fat, muscle, or underlying structures, appearing white, brown, or charred, and may be painless initially due to nerve damage. These injuries often require specialized wound care and may need skin grafts). (Refer to A-0951) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the Governing Body (the group of individuals who have ultimate legal authority and responsibility for the organization’s operations and compliance with regulatory requirements) failed to ensure contracted biomedical services were provided in a safe and effective manner for one (1) of one (1) equipment-related incidents reviewed. The Governing Body failed to ensure the contracted biomedical company completed diagnostic testing (a process used to check that medical equipment works properly and safely) on equipment involved in a surgical fire (a fire that occurs during surgery, often caused by heat or sparks from surgical devices) associated with patient harm and failed to ensure the contractor provided a written report of the testing to assist in determining whether equipment malfunction (failure of a device to operate as intended) may have contributed to the incident. This deficient practice resulted in an incomplete evaluation of equipment involved in a surgical fire and had the potential to result in continued use of equipment with unidentified defects, increasing the likelihood of similar incidents, compromising patient safety during future surgical procedures, and limiting the hospital’s ability to implement preventive measures through its Quality Assessment and Performance Improvement (QAPI) program (a hospital-wide program that monitors and improves quality and safety). Findings: During a review of Patient 1’s Operative Report (a formal surgical record documenting the procedure), dated 11/4/2025, the report indicated that Patient 1 had noticed a lump (a localized swelling or mass) on the scalp (the skin covering the skull) that was increasing in size and requested removal. The report further indicated: “As soon as the mass was excised (surgically removed) from the scalp, smoke (visible vapor from combustion) was noted coming from the drape (a sterile cloth used to cover the patient during surgery), and the drape was quickly removed. A fire (uncontrolled combustion producing heat and flames) was noted under the drape, and the patient sustained a burn (injury caused by heat) over the right and left face (front part of the head), chin (area below the lower lip), and anterior neck area (front portion of the neck).” During an interview on 12/16/2025 at 11:05 a.m. with the Director of Perioperative Services (DPS), the DPS stated that on 11/4/2025, Patient 1 experienced a surgical fire (an uncontrolled ignition during surgery) injury during an elective procedure (a planned, non-emergency surgery) while under MAC anesthesia (Monitored Anesthesia Care, a type of sedation where the patient remains responsive) with an open oxygen source (oxygen delivered without a sealed airway device). The combination of oxygen delivery via mask (supplemental oxygen provided through a face mask), use of electrocautery (a surgical instrument that uses electrical current to cut tissue or stop bleeding), and alcohol-based prep solution (ChloraPrep, a skin disinfectant containing alcohol) created a high-risk environment for ignition (conditions that increase the likelihood of fire). During an interview on 12/19/2025 at 3:10 p.m. with Vice President of Quality and Risk Management (VPQRM), VPQRM stated that after the surgical fire incident on 11/04/2025, the electrocautery equipment was sequestered, and the former biomedical contractor verbally reported that testing was completed, and the machine had no issues. However, the facility did not receive a hard copy of the testing report. The VPQRM stated that if the report had been provided, it would have been collected by the Risk Manager (a staff member responsible for managing patient safety and risk events) and included in the Root Cause Analysis (RCA, a structured process to identify the underlying causes of an adverse event) submitted to the QAPI committee (a hospital committee that reviews quality and safety issues). The VPQRM confirmed that the RCA lacked evidence of equipment testing and that new diagnostic testing was now required before the equipment could be returned to service. During a concurrent observation and interview on 12/18/2025 at 11:02 a.m. with the Biomedical Technician (BT) 2 in the biomedical storage area, the machine involved in the fire was observed with a red tag indicating: “Out of order, do not touch, under investigation, (name of former Biomedical contracted company) verified unit, no fault found by this company, follow up with [Chief Operating Officer].” A sticker on the machine indicated a previous testing when the machine was first installed indicated, “Electrosurgical output test results dated 4/2025.” BT 2 confirmed the sticker values did not match the electronic report. BT 2 stated they were unsure how the discrepancy occurred. During an interview on 12/22/2025 at 10:16 a.m. with VPQRM, VPQRM stated the facility’s process when equipment was involved in an unusual occurrence (an unexpected event that could cause harm) was to sequester the equipment, tag it “Do Not Use,” and call Biomedical for evaluation (request inspection and testing by biomedical engineering staff). The VPQRM confirmed the facility did not have a written policy describing this process and instead adopted the policy of the former biomedical contractor. The VPQRM further stated that after the equipment involved in the OR fire was sequestered, the facility did not obtain the testing results from the former biomedical contracted company. During the same concurrent interview and record review on 12/22/2025 at 10:16 a.m. with VPQRM, a review of an email sent by the former biomedical contractor to VPQRM on 12/22/2025 indicated that no report of testing completed on the equipment involved in the fire incident, was provided. VPQRM confirmed that the facility had not received any documentation of diagnostic testing from the contractor. During an interview on 12/22/2025 at 4:35 p.m. with the Chief Executive Officer (CEO), the CEO stated the Governing Body was responsible for oversight of contract services, including annual review of clinical contracts and reporting to QAPI and medical staff for reevaluation if services were not performed as required. The CEO confirmed this process was not followed with the former biomedical company. The facility was unaware that maintenance testing was not completed per manufacturer specifications and that testing of the machine involved in the fire was not documented. During a review of the facility’s “Governing Board By-Laws (a foundational governance document that outlines the structure, authority, and responsibilities of the hospital’s governing body), dated 1/12/2023, the By-laws indicated, “the Governing Board has ultimate accountability for safety and quality of patient care and must periodically review hospital activities to ensure compliance.” During a review of the facility’s adopted policy titled, “Medical Equipment Management Plan,” dated July 2025, the policy indicated that equipment involved in an incident causing or potentially causing serious injury must be removed from service and impounded, and investigations should include performance and safety testing (verification that equipment functions safely and effectively) per manufacturer specifications (instructions provided by the equipment maker). During a review of the contracted agreement between the contracted biomedical company and the facility titled, “Asset Management Agreement,” dated 8/15/2025. The agreement indicated, “(Name of the contracted company) will ensure performance of scheduled maintenance in accordance with, and at no less frequency than the up-to-date, original manufacturers’ specifications ...All scheduled maintenance and repair documentation will be documented and recorded within (name of electronic system), our computerized information management system, and will be accessible by CLIENT.” During a review of the facility’s policy and procedure (P&P) titled, “Contracting Vendor Services: Processing Management and Quality Assurance,” dated 8/28/2024, the P&P indicated, the Governing Board will ensure contracts meet quality standards and overall mission. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment / Performance Improvement Plan (QAPI) 2025,” dated 6/25/2025, the P&P indicated, “The (name of the facility) Governing Board: Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. Acts strategically to ensure the delivery of high-quality care and services.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 34 sampled patients (Patient 16), was notified of their rights as a hospital patient (the fundamental entitlements and protections patients have in healthcare, ensuring they are treated with dignity, involved in decisions [informed consent/refusal], receive quality care, have privacy, and can voice complaints, encompassing rights to be informed, respected, non-discriminated, and have autonomy over their treatment choices), when the facility failed to obtain Patient 16’s signature on the conditions of admission (COA, the contractual terms a person agrees to when entering a facility like a hospital or university, outlining responsibilities like payment, consent for treatment/information release) to indicate Patient 16’s knowledge of and understanding of their rights as a patient, in accordance with the facility’s policy regarding hospital registration/admission process. This deficient practice had the potential to result in Patient 16 not aware of their protections within the healthcare setting, allowing them to make informed decisions about their care, maintain autonomy, and exercise their rights to privacy and respect. Findings: During a review of Patient 16’s History of Present Illness (HPI, a detailed account of the symptoms and progression of a patient’s current health issue), dated 11/14/2025, the HPI indicated that Patient 16 arrived at the facility’s emergency department (ED, a specialized area within the hospital equipped to handle urgent and life-threatening medical conditions) due to chest pain and was diagnosed with a heart attack, requiring immediate life-saving intervention. During a review of Patient 16’s triage (initial assessment of the severity of the patient’s condition to determine the priority of treatment) note, dated 11/14/2025, the note indicated that Patient 16 arrived at 8:50 a.m., was not in distress (not experiencing pain or discomfort), and was described as alert and oriented x 4 (aware of person, place, time, and situation). During a review Patient 16’s Conditions of Admission (COA, the contractual terms a person agrees to when entering a facility like a hospital or university, outlining responsibilities like payment, consent for treatment/information release) form, dated 1/14/2025, the form indicated that the form was not signed by Patient 16. Instead, on 1/14/2025 at 9:14 a.m., the admitting clerk wrote “Medically unable” without providing a documented reason why Patient 16 was not able to sign. During a review of Patient 16’s informed consent (process by which a patient voluntarily confirms their willingness to undergo a particular medical intervention after being informed of all the risks, benefits, alternatives, and potential outcomes) for left and/or right catheterization and angiography with possible percutaneous transluminal coronary angioplasty and stent placement with possible intra-aortic balloon pump (procedure involving the insertion of a thin tube into the heart’s arteries to diagnose and treat blockages, potentially including the placement of a balloon-tipped catheter and stent to open narrowed arteries, and the use of a balloon pump to support the heart), the informed consent was dated 11/14/2025 at 9:20 a.m. and signed by Patient 16. During an interview on 12/18/2025 at 10:59 a.m. with the admitting director (Dir 5), Dir 5 explained the process for admitting clerks when obtaining registration forms from patients during registration. Dir 5 said that once a patient was screened by a medical doctor, they can be registered. Dir 5 said, “Registration in the Emergency Department (ED) involves collecting demographic information, insurance details, and copies of relevant documents. The process includes obtaining consent to treat, explaining the patient’s rights and responsibilities, and informing them that medical doctors are independent contractors who bill separately from the hospital.” During the same interview on 12/18/2025 at 11:03 a.m. with the admitting director (DIR 5), DIR 5 said that if admitting clerks were unable to obtain the patient’s consent at that time, they document the reason why. Dir 5 said, “The admitting staff make three (3) attempts to follow up, including contacting the family or going to the patient’s bedside. It’s important to ensure that patients are aware of what they are consenting to, which includes a general consent for all treatments and procedures performed in the hospital unless a specific consent is required.” During a concurrent interview and record review on review on 2/18/2025 at 11:03 a.m. with the admitting director (DIR 5), Patient 16’s COA form, which was filled out by the admitting clerks, was reviewed. DIR 5 said that only one attempt was made to obtain the conditions of admission form signed by the patient (Patient 16), and it was documented that Patient 16 was medically unable. DIR 5 stated that documentation should specify why the patient couldn’t sign and that follow-up attempts should be made upon hospital admission. During an interview on 12/8/2025 at 11:45 a.m. with the admitting clerk (AC), the AC said that the process for obtaining registration forms had been the same for at least 3 years and said that when a patient was medically unable to sign, it required a note explaining why the patient was not able to sign. The AC also stated that at least 3 follow-up attempts with the patient were required as per the facility’s practices. During a review of the facility’s policy and procedure (P&P) titled, “Registration Process, Patient,” dated 6/2022, the P&P indicated: 1. A completed account will have met the following criteria: All required forms are signed, scanned, and maintained in accordance with policy. Every effort will be made to obtain all required information from the patient or physician’s office at the time of registration. At the time of registration and/or admission, the patient or the patient’s legal representative shall acknowledge receipt by signing the following consent forms: a. Conditions of Service (defines the terms and conditions under which services are provided to the patient) b. Advanced Directive Acknowledgement Form (if applicable) (documents the patient’s wishes regarding medical treatment if they are unable to communicate) c. An Important Message from Medicare (if applicable) (informs Medicare beneficiaries of their rights) d. Notice of Privacy Practice Acknowledgment Form (patients are provided the Notice of Privacy Practice Booklet if they have not previously received the booklet) (outlines how the patient’s medical information may be used and disclosed) e. Directory Opt-Out Acknowledgment Form (allows patients to opt-out of being listed in the hospital directory) f. Patient Rights (a document that informs patients of their rights within the healthcare facility) 2. If the patient or patient’s legal representative is unable to sign any forms, consents, etc., at the time of admission, a reasonable attempt will be made to contact the patient’s emergency contact to notify them of the need for signed consents. Two additional attempts will be made to obtain the patient’s or legal representative’s signature; the first follow-up attempt will be within 48 hours of admission. If signatures were not obtained during the first attempt, the second one will be within the next 24 hours. 3. All attempts to obtain signatures shall be documented in the ADT registration system by the Admitting Representative. 4. Patients also receive a copy of all the forms upon completion of the registration. 5. Upon admission to the hospital, patients receive a Patient Folder and Visitors Guide to help orient them to the hospital.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to: 1. Ensure that timely and safe care was provided for one of 34 sampled patients (Patient 15), when diagnostic (identifying the nature of an illness) procedure (a medical treatment or operation), neurological consultation (meeting with a specialist in the nervous system), code stroke activation (initiating an emergency response for a brain attack), and physician notification (informing the doctor), were not promptly completed, when Patient 15’s condition changed, in accordance with the hospital’s policies in ensuring timely stroke diagnosis (blockage of blood flow to the brain) and avoiding delay with stroke interventions. This deficient practice resulted in a delay of care for Patient 15 potentially worsening Patient 15’s medical condition and health outcomes and possibly leading to increased risk of complications such as permanent neurological deficit (such as paralysis and speech impairment), prolonged recovery time and even death, and violating Patient 15’s right to receive timely care (the legal and ethical obligation of healthcare facilities to provide prompt and appropriate treatment without unnecessary delay). 2. Ensure one of 34 sampled patients (Patient 19), was treated with courtesy and respect, in accordance with the facility’s policies on Patient Rights and “Standards of Behavior,” when Registered Nurse (RN) 9 placed her (RN 9’s) hand in front of Patient 19’s face and violated Patient 19’s personal space in an attempt to de-escalate (communication and action strategies used to calm intense, agitated, or potentially violent situations by reducing emotional intensity and preventing harm, focusing on empathy, calm self-regulation, and clear, non-confrontational interaction to guide the situation to a safer resolution) Patient 19 on 11/3/2025. This deficient practice resulted in violating Patient 19’s right to be treated with courtesy and receive safe care in the hospital. Findings: 1. During an interview on 12/15/2025 at 11:37 a.m. with ICU (Intensive Care Unit - a hospital unit for critically ill patients who need close monitoring and advanced care) nurse (RN 20), RN 20 said: “Patient (Patient 15) was admitted on 12/12/2025. The patient came from ED (Emergency Department - the hospital area for emergency care) and was admitted to DOU (Definitive Observation Unit - a step-down unit for patients who need close observation but not full ICU care). The patient (Patient 15) then had an RRT (Rapid Response Team - a group of clinicians called when a patient’s condition suddenly worsens) due to hypertensive crisis (a severe and dangerous rise in blood pressure). I found out the patient had a stroke (cerebrovascular accident - when blood flow to part of the brain is blocked or reduced) yesterday. During my assessment in the morning, I noted the patient was lethargic (very sleepy and hard to wake) and snoring while on minimal sedation with Precedex (dexmedetomidine - a sedative used in ICU to calm patients without major breathing problems). I stopped the sedation and checked again, then noted the patient (Patient 15) was unresponsive (not reacting to touch or voice). I did another neuro check (neurological assessment - checking brain and nerve function) and had another colleague and the charge nurse check. We all confirmed it (Patient 15 being unresponsive) and called Code Stroke (hospital emergency protocol for suspected stroke), then followed the protocol. The patient was sent for a STAT CT head (urgent computed tomography scan of the brain). The STAT CT head scan showed a left thrombus (blood clot) on the MCA (Middle Cerebral Artery - a major artery that supplies blood to the brain).” During a review of Patient 15’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/12/2025, the H&P indicated that Patient 15 was admitted as a John Doe (an unidentified patient whose real name is unknown at the time of admission), after a witnessed seizure (a sudden, uncontrolled electrical disturbance in the brain) at a restaurant and was admitted to DOU (Definitive Observation Unit, a specialized hospital unit for close monitoring of patients who are critically ill or unstable) with required neuro checks every 4 hours (neurological assessments to monitor brain function and detect changes) and a neurologist consultation (a nervous system specialist). During a concurrent interview and record review on 12/19/2025 at 10:47 a.m. with the clinical supervisor (Sup 1), Patient 15’s physician orders (written instructions from a doctor for medications, treatments, or consultations), dated 12/12/2025, was reviewed. The record indicated that an order for neuro consult was placed on 12/12/2025 at 7:43 p.m. Sup 1 said that the physician should place an order for the consult and contact the consulting physician. Sup 1 also stated that occasionally, a physician may forget to contact the consultant, and if the consult did not come, nursing staff would call them (consultants). Sup 1 stated, “If there is still no response, they (nursing staff) can escalate (take the issue to a higher authority, such as the house supervisor, to ensure action is taken).” During a review of Patient 15’s Nursing MD Notification record, dated 12/13/2025, the record indicated that the neurologist (Neuro 1/MD 6) was contacted on 12/13/2025 at 11:20 a.m. regarding a pending neuro consult (a formal request for a specialist in the nervous system to evaluate the patient) ordered by the hospitalist on 12/12/2025 at 7:43 p.m. This information was confirmed on 12/19/2025 during record review with the clinical supervisor (Sup 1). During further review of Patient 15’s EMH (Electronic Medical Record - a digital version of a patient’s medical chart) for the admission on 12/12/2025, the record indicated that the neurologist’s first documented note was on 12/14/2025 at 6:05 p.m. and indicated that the reason for the consult was to evaluate for stroke (a condition caused by blockage or bleeding in the brain, leading to brain damage and neurological deficits). The note indicated the following: “On the night of 12/13/2025, RRT (Rapid Response Team - a team that responds to clinical emergencies) was called last night for uncontrolled hypertension (very high blood pressure) and unresponsiveness. LKW (Last Known Well - the last time the patient was observed without stroke symptoms) is unclear; however, he (Patient 15) was noted to be ‘sleeping’ at 8 p.m. last night. Code Stroke (an emergency protocol to rapidly evaluate and treat suspected stroke) was activated, and Patient 15’s CTA (Computed Tomography Angiography - an imaging test using CT technology and contrast dye to visualize blood vessels) demonstrated a left M1 occlusion (a blockage in the M1 segment of the left middle cerebral artery, which supplies blood to a large portion of the brain and can cause severe stroke symptoms).” During a review of Patient 15’s admission time record, dated 12/12/2025, the record indicated that Patient 15 was admitted on 12/12/2025 at 6:31 p.m. and physically arrived in the DOU (Definitive Observation Unit - a specialized hospital unit for close monitoring of patients who are critically ill or unstable) on 12/13/2025 at 12:16 a.m. During a concurrent interview and record review on 12/19/2025 at 11:27 a.m. with the clinical supervisor (Sup 1), Patient 15’s physician orders, dated 12/13/2025, were reviewed. The record indicated that a STAT (an urgent order meaning the test should be done immediately, typically within 20-30 minutes and no longer than an hour) MRI (Magnetic Resonance Imaging - an imaging test that uses magnetic fields and radio waves to create detailed pictures of the brain and other organs) order was placed on 12/13/2025 at 10:25 a.m. and indicated the following: reason for exam: seizure and syncope (temporary loss of consciousness, often called fainting). Study comments: to evaluate for stroke (a condition caused by blockage or bleeding in the brain, which can lead to brain damage and disability). During the same concurrent interview and record review on 12/19/2025 at 11:27 a.m. with the clinical supervisor (Sup 1), Sup 1 said that the MRI was not performed. Sup 1 also reviewed Patient 15’s record and stated that the record had no documentation indicating why the MRI was not done and no documentation showing that the physician was contacted or informed about why the MRI was not performed. Sup 1 said that if the reason the MRI was not performed was the inability to complete the checklist (a safety screening form required before MRI to ensure no metal implants or devices that could cause harm during the scan), then the CTA (Computed Tomography Angiography - an imaging test using CT technology and contrast dye to visualize blood vessels) could be typically ordered instead. During a concurrent interview and record review on 12/19/2025 at 1:55 p.m. with the clinical supervisor (Sup 1), Patient 15’s vital signs (VS - measurements of essential body functions including blood pressure [BP], heart rate [HR], respiratory rate [RR], and temperature), dated 12/13/2025, were reviewed. The record indicated the following documented VS for Patient 15: -12/13/2025 at 6:14 p.m.: BP 145/98 (blood pressure - systolic 145 mmHg and diastolic 98 mmHg, which is elevated), no other vital signs documented. -12/13/2025 at 9:00 p.m.: BP 193/146 (severely high blood pressure), HR 112 (heart rate - beats per minute), Respirations 20 (breaths per minute), no other VS documented. Nursing note indicated MD was notified of the blood pressure, and hydralazine (a medication that lowers blood pressure by relaxing blood vessels) 10 mg (milligrams - a unit of measurement for medication dose) times 2 doses and labetalol (a medication that lowers blood pressure) 10 mg once were given. -12/13/2025 at 11:49 p.m.: BP 213/133, no other VS documented. Nursing note: MD paged, unable to reach, awaiting call back. -12/14/2025 at 12:11 a.m.: BP 226/155, no other VS documented. Nursing note: attempted to page MD again, worsening BP, unable to reach MD. (Patient 15) given PRN (as needed) hydralazine IV (intravenous - administered directly into a vein). 12/14/2025 at 1:17 a.m.: BP 220/143, no other VS documented. MD saw patient at bedside and decided to move patient to the ICU (Intensive Care Unit - a specialized unit for critically ill patients) to start on a Cardene drip (nicardipine - an intravenous medication used to quickly lower blood pressure). No follow-up VS documented. -Sup 1 said, “A follow-up blood pressure should have been documented, but it was not.” Sup 1 then said that Patient 15 was physically moved to the ICU on 12/14/2025 at 3:03 a.m. to be started on a Cardene drip. During a concurrent interview and record review on 12/19/2025 at 1:41 p.m. with the clinical supervisor (Sup 1), Patient 15’s neuro-check assessment record (a documented neurological evaluation to monitor brain function and detect changes), dated 12/13/2025 and 12/14/2025, was reviewed. The record indicated that Patient 15’s neuro-check on 12/14/2025 at 12:00 a.m. was not performed. On 12/14/2025 at 3:30 a.m., the nurse documented that Patient 15 was lethargic (drowsy and difficult to arouse), opened eyes but did not track or follow commands. Patient 15 was observed with some right arm and left leg weakness (loss of strength in specific limbs). During the same concurrent interview and record review on 12/19/2025 at 1:41 p.m. with the clinical supervisor (Sup 1), Sup 1 said “Based on previously documented neurological assessments (dated 12/13/2025, with last neuro assessment documented at 7:52 p.m. on 12/13/2025), Patient 15 was non-verbal (unable to speak), either confused or lethargic (drowsy and difficult to arouse), but had no documented persistent weakness on the right side. This was the first time the nurse documented weakness on the right side [at 3:30 a.m., on 12/14/2025], which is a change of condition (a significant alteration in the patient’s status requiring immediate attention). The nurse should have notified the physician about these changes, and this should have been documented in the MD notification section. However, there is no documentation that the nurse informed the intensivist (a physician specializing in critical care) of the weakness on the right side.” During an interview on 12/19/2025 at 2:36 p.m. with the neurologist (Neuro 1) Neuro 1 stated: “The patient (Patient 15) was admitted altered, homeless, found down, and initially as a John Doe with polysubstance abuse (combined use of multiple psychoactive substances, often to enhance effects, counteract side effects, or increase pleasure, involving both legal and illegal drugs like alcohol, cannabis, opioids, or stimulants), possibly intoxicated. I received the consult call the day after admission, not on the day of admission. Typically, the physician places an order and nurses notify me, but in this case, the request came late. When I first saw the patient, they (Patient 15) had already deteriorated overnight and were in the ICU. The night before, the patient (Patient 15) was confused but moving all four extremities and talking. By the next day, nurses reported they could not wake him up and he (Patient 15) became globally aphasic (unable to speak or understand language due to severe brain injury affecting both expressive and receptive communication) and could not move the right side (right-sided hemiplegia, paralysis of the muscles on the right side of the body, often caused by damage to the left side of the brain).” During the same interview on 12/19/2025 at 2:36 p.m. with the neurologist (Neuro 1), Neuro 1 stated, “Neuro-checks (regular neurological assessments to monitor brain function) are important to see if the patient is progressing or not progressing and possibly getting worse. Neurological signs of worsening include dysphagia (difficulty swallowing), muteness (inability to speak), and other parameters such as alertness and neurological symptoms that can indicate deterioration. Change in LOC (level of consciousness, the patient’s state of awareness and responsiveness) would be a sign of worsening and we would call a code stroke (an emergency protocol to rapidly evaluate and treat suspected stroke) if the patient is becoming more lethargic or sleepy, which may indicate bleeding in the brain or an evolving stroke that is getting worse.” During the same interview on 12/19/2025 at 2:36 p.m. with the neurologist (Neuro 1), Neuro 1 also said, “Calling code stroke helps initiate treatment and set BP (blood pressure) parameters. Sometimes the patient may be a candidate for an intervention to diagnose and initiate prompt treatment, such as CTA (Computed Tomography Angiography, an imaging test to visualize blood vessels) and CT (Computed Tomography, an imaging test to detect brain abnormalities).” During an interview on 12/22/2025 at 2:36 p.m. with the neurologist (Neuro 1), Neuro 1 stated: “STAT (an urgent order meaning the test or procedure should be done immediately, typically within 20-30 minutes, and certainly within an hour). If I order something STAT, I expect the nurse to call me and explain why it was not done promptly. Maybe the patient is compensating or being intubated, but they need to notify me about the reason for the delay. It is not acceptable if they don’t do the test. If I order something, I expect the nurses to communicate the reason why it was not completed.” During an interview on 12/19/2025 at 3:33 p.m. with intensivist (MD 4), MD 4 said the following: “I admitted the patient (Patient 15) to the ICU (Intensive Care Unit) ... the increased BP (blood pressure) ... I don’t remember why exactly I admitted the patient (Patient 15) ...I remember checking the patient, but the patient was out (unresponsive), and I think we asked for the CT (computed tomography scan) ... but I don’t remember ...I started him on a drip (Cardene drip - nicardipine infusion for blood pressure control), and I cannot recall why I started him on Precedex (dexmedetomidine - sedative) too ... It was probably because of agitation (restlessness) and why Precedex? ... because the medication is without the side effect of suppressing respiratory function (breathing). I don’t remember if a stroke (cerebrovascular accident) was suspected at any point, but Precedex would still be the sedative I’d go with ... unless the patient had bradycardia (slow heart rate), then I would not order Precedex. CT head would be ordered anyway ... Having weakness (neurological deficit) would not contraindicate (prevent) ordering Precedex. I also don’t remember if I was notified of right-sided weakness prior to starting the patient on Cardene and Precedex ... It would not be contraindicating, and the CT head would be ordered anyway ...” During an interview on 12/19/2025 at 3:41 p.m. with the attending physician (MD 5), MD 5 stated that based on Patient 15’s presentation to the ED (Emergency Department) and initial lab results, MD 5 was concerned about Patient 15’s heart and spoke with the cardiologist, who recommended obtaining an echocardiogram (an ultrasound test that uses sound waves to create images of the heart to assess its structure and function). During the same interview on 12/19/2025 at 3:41 p.m. with the attending physician (MD 5), MD 5 stated “I admitted the patient (Patient 15) to DOU (Definitive Observation Unit) and the patient (Patient 15) had no focal deficit (no localized neurological impairment such as weakness or numbness on one side) on admission. He (Patient 15) was positive for multiple drugs in his urine toxicology report (a laboratory test that detects the presence of drugs or substances in urine). I also called the neurologist (MD 6) from the time of admission and consulted with her (MD 6); she (the neurologist, MD 6) usually comes within 24 hours to see patients. I ordered a STAT (immediately) brain MRI (Magnetic Resonance Imaging, an imaging test that uses magnetic fields and radio waves to create detailed pictures of the brain), but it could not be done because the checklist (a safety screening form prior to undergoing MRI to ensure there are no metals in the patient’s body that may interfere with the test)) was impossible to complete since the patient (Patient 15) was unresponsive. If MRI cannot be done, CTA (Computed Tomography Angiography, an imaging test that uses CT technology and contrast dye to visualize blood vessels) should be considered. The reason I ordered MRI and neuro checks was because the patient (Patient 15) was found to be seizing.” During the same interview on 12/19/2025 at 3:41 p.m. with the attending physician (MD 5), MD 5 stated the following: “Patient 15 was post-ictal (a state of altered consciousness following a seizure, often involving confusion, drowsiness, or inability to respond) and had no family, and we did not know the history. Patient was not able to provide any information. In the DOU (Definitive Observation Unit), the patient became very hypertensive (having abnormally high blood pressure), maybe because he (Patient 15) was withdrawing (experiencing symptoms after stopping or reducing use of drugs or alcohol). MD 5 said that CTA (Computed Tomography Angiography) was considered instead of MRI, and said, “ We (the intensivist and the attending MD 5) did order the CTA for this patient (Patient 15) together with the intensivist in the ICU (after code stroke was activated). The patient went to ICU overnight (on 12/14/2025) because of very high blood pressure. MD 5 then also stated: “Stroke was not considered until after the CTA of the brain results on [12/14/2025], which changed the scenario.” During a review of Patient 15’s EHR (Electronic Health Record - a digital system that stores patient health information), dated 12/14/2025, the record indicated that CT head without contrast (Computed Tomography scan of the head performed without intravenous contrast - used to detect bleeding, infarcts, or structural abnormalities) resulted on 12/14/2025 at 10:28 a.m., indicating that the imaging diagnostic test was ordered for altered mental status and headache. The impression indicated that Patient 15 sustained a large region of acute to subacute (“acute to subacute infarct,,” it suggests the stroke occurred recently but not immediately) infarct in the left MCA (Middle Cerebral Artery) territory with a dense left MCA sign demonstrated. There is a local mass effect with effacement of the sulci (Explanation: The impression means there is significant brain tissue damage due to a stroke in the left MCA region. A dense MCA sign suggests a clot in the artery. Local mass effect refers to swelling that compresses nearby brain structures, and effacement of the sulci means the normal grooves on the brain surface are being flattened due to swelling). During a review of Patient 15’s EMR (a digital system that stores patient health information), for the presence of documentation of the time when code stroke was called, the EHR indicated that Code stroke was called at 9:47 a.m. This information was confirmed during record review on 12/19/2025 with clinical supervisor (Sup 1). During a review of Patient 15’s physician orders record, dated 12/14/2025, the record indicated that Precedex drip (dexmedetomidine - a sedative medication used for ICU patients to reduce agitation without significant respiratory depression) was ordered by MD 4 on 12/14/2025 at 4:10 a.m. with a goal to achieve a RASS score of -1 (RASS [Richmond Agitation-Sedation Scale] is a clinical tool used to assess a patient’s level of sedation or agitation. It ranges from +4 [combative] to -5 [unarousable]; A score of -1 means the patient is drowsy but easily arousable to voice, which is often the target for light sedation in ICU settings). During an interview on 12/22/2025 at 10:14 a.m. with Registered Nurse (RN 20), RN 20 stated that she (RN 20) would not start Precedex (a sedative medication used to reduce anxiety and agitation) until stroke (blockage or bleeding in the brain causing loss of function) was ruled out because Precedex could mask the symptoms of stroke (Precedex causes sedation (sleepiness and reduced alertness) and can lower blood pressure and heart rate effects may hide or make it harder to detect stroke symptoms such as: Sudden confusion or changes in mental status, Slurred speech, Weakness or numbness on one side of the body, Difficulty following commands.” During an interview on 12/22/2025 at 10:14 a.m. with ICU Charge Nurse relief (CN 7), CN 7 said that a new onset of one-sided weakness (loss of strength on one side of the body) should be considered as possible stroke symptoms according to BEFAST (Balance, Eyes, Face, Arms, Speech, Time - a stroke recognition tool) and would require further assessment. During the same interview on 12/22/2025 at 10:14 a.m. with ICU Charge Nurse relief (CN 7), CN 7 further stated that, nurse should call RRT (Rapid Response Team - a team that responds to clinical emergencies) or Code Stroke (an emergency protocol to rapidly evaluate and treat suspected stroke) if patient were exhibiting stroke symptoms such as one-sided weakness. CN 7 then said, “If the patient was in ICU (Intensive Care Unit - a specialized unit for critically ill patients), nurse should let the intensivist (a physician specializing in critical care) know.” During an interview on 12/22/2025 at 2:24pm with President Elect (MD 3), MD 3 said that consultants (consulting physicians) were an admitting physician’s choice. MD 3 also said that the admitting physician had to make the call and to make sure the consulting doctor agreed to see the patient. MD 3 then said the following, “The consult should communicate with the admitting physician or tell the admitting physician if they cannot see the patient within the required timeframe, the consultant should inform the admitting physician so the admitting can call someone else to see the patient. It’s important for them to communicate so there’s no delay in patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Code Stroke,” dated 10/2023, the P&P indicated that “The emergent process for recognition and treatment of acute stroke patients. Stroke symptoms include Sudden confusion, trouble speaking, or understanding, loss of vision in one eye or both eyes, severe headache with no known cause, and sudden numbness or weakness of the face, arm, or leg, especially on one side of the body ... When an inpatient meets the acute stroke criteria, onset of symptoms within three (3) hours or last known well time is three (3) hours or less, x9999 will be called by any staff that identifies the changes in the patient condition to page overhead, and alert the appropriate team members ...Inpatient team member roles: a. Recognize the symptoms of stroke b. Establish time of onset of symptoms... d. Charge Nurses in the ICU will activate Code Stroke (not Rapid Response) by calling the hospital emergency number at x9999 and state you are activating a Code Stroke e. Obtain the Code Stroke packet for documentation purposes.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment-Nursing,” dated 6/2025, the P&P indicated that “Nursing reassessment of a patient will reflect at a minimum a review of patient-specific data, pertinent changes, and response to interventions. More frequent reassessment will be completed as appropriate for the patient population and/or individual patient needs. Nursing reassessment will be documented in electronic health record (EHR) under daily nursing assessment.” During a review of the facility’s Medical Rules and Regulations (R&R), [undated], the R&R indicated that “3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient. And/or relatives of the patient....” During a review of the facility’s policy and procedure (P&P) titled, “Consultation Response Time,” dated 12/2025, the P&P indicated that “Consultation Request: Order initiated by the attending physician, who directly contact the consulting physician as required by General Rules and Regulations §6. 1-4.Timely Consultation: The consulting physician must both evaluate the patient and directly communicate with the requesting physician within the required timeframe. The comprehensive consultation note (H&P or equivalent) must be completed within 24 hours of the initial request. Inpatient consultations: Within 12 hours of request unless otherwise specified as required under General Rules §7.2-1. During a review of the facility’s policy and procedure (P&P) titled, “Chart Checks-12 and 24 Hour,” dated 5/2025, the P&P indicated that “All patients’ health records will be reviewed for accuracy and completion of physician orders for the past 24 hours by the 7 pm-7 am licensed personnel assigned to the patient at midnight ...A 12 hours check of physician’s orders will be completed and documented at the end of each shift at hand off report. Any orders needing further actions will be communicated to the ongoing nurse... Procedure: Review each chart for accuracy of transcription of licensed independent practitioners’ orders including, but not limited to, all medications, diagnostic tests, diet orders, consultations and others...” During a review of the facility’s policy and procedure (P&P) titled, “Diagnostic Imaging Scope of Service,” dated 5/2025, the P&P indicated, “Goals and Objectives ... to provide quality and timely customer service to all patients/customers visiting the Diagnostic Imaging Department ... MRI (Magnetic Resonance Imaging) is staffed 7:00 am to 7:00 pm; after hours and weekends, with an ‘on-call’ technologist available by pager for emergencies and STATs (immediate actions) with a 30-minute response time... MRI TAT (Turnaround Time) average is four (4) hours unless STAT orders within sixty (60) minutes.” 2. During a review of Patient 19’s “Emergency Department note (ED note, Emergency Department physician’s note documents a patient’s emergency department visit),” dated 9/27/2025, the ED note indicated, Patient 19 was admitted to the facility with diagnoses including but not limited to failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and need for assistance with personal care. During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/28/2025, the H&P indicated, Patient 19 was quadriplegic (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) due to motor vehicle accident. During an interview on 12/16/2025 at 10:35 a.m. with the Director (DIR) 1 of Medical Surgical (specialty unit that focuses on the care of patients with general health conditions or who had a recent surgery) Unit, DIR 1 stated DIR 1 received an allegation of abuse ( the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish) report, reported by the night shift supervisor on 11/4/2025, involving RN 9 and Patient 19, which allegedly occurred on 11/3/2025. During the same interview on 12/16/2025 at 10:35 a.m. with DIR 1, DIR 1 stated after investigation, it was concluded RN 9 had violated Patient 19’s personal space when RN 9 placed hand gesture stop on Patient 19’s face. DIR 1 stated RN 9’s action was not acceptable. DIR 1 stated RN 9 received disciplinary action (measures taken by an employer to correct employee misconduct). During an interview on 12/16/2025 at 4:26 p.m. with RN 9, RN 9 stated the following: on 11/3/2025, Certified Nurse Assistant (CNA) 1 called her (RN 9) for assistance in cleaning Patient 19. As they were turning Patient 19 to do the cleaning, Patient 19 screamed and cursed at them (RN 9 and CNA 1). RN 9 stated to Patient 19, “Please stop it and be quiet.” RN 9 stated she (RN 9) placed her (RN 9’s) right hand, almost close to Patient 19’s face, as a gesture to stop. RN 9 stated Patient 19 did not stop cursing and was more upset, so RN 9 left the patient’s room. During the same interview on 12/16/2025 at 4:26 p.m. with RN 9, RN 9 stated on 11/5/2025, DIR 1 provided education about the situation regarding what to do and instruction to escalate to charge nurse, supervisor and manager. During an interview on 12/18/2025 at 12:25 p.m. with the Nurse Manager (NM 5) of the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), NM 5 stated all patients had the right to receive safe, respectful and high-quality care. During a concurrent interview and record review on 12/19/2025 at 4:15 p.m. with the Human Resources Manager (HRM), RN 9’s record of discipline (disciplinary record) titled, “Verbal Conversation,” dated 11/26/2025, was reviewed. The disciplinary record indicated a written warning was issued to RN 9 due to violation of the facility’s policy of standard behavior and improper de-escalation technique (communication and action strategies used to calm intense, agitated, or potentially violent situations by reducing emotional intensity and preventing harm, focusing on empathy, calm self-regulation, and clear, non-confrontational interaction to guide the situation to a safer resolution). The disciplinary record also indicated (on 11/3/2025) RN 9 was moving hand towards Patient 19’s mouth with the intent to stop Patient 19 from verbal slurs and such action further escalated Patient 19’s agitation. HRM stated RN 9 violated standard 3 about safety and standard 4 about courtesy within the standards of behavior policy and procedure. During a review of the facility’s policy and procedure (P&P) titled, “Standards of Behavior,” approved 11/26/2024, the P&P indicated, “Scope: This policy pertains to all ...employees ... Quality Care with Compassion and Respect. The Standard or Behavior delineate the expectations of behavior of all who are referenced in the Scope of this policy. Those who are referenced are also committed and expected to uphold behaviors that do not undermine a culture of safety, as defined by the Joint Commission (TJC) ...Standard 3 Safety: Doing all that we can to keep our patients and each other safe ...Standard 4 Courtesy: A culture of respect and compassion for patients and colleagues: ...Listen with care and empathy, avoid interrupting and confirm what you have heard ...Listen to customers’ concerns, and do not rationalize or place blame. Let the customer know we will work to make things right ...” During a review of the facility’s policy and procedure (P&P) titled, “Code of Conduct,” dated 11/26/2024, the P&P indicated, “The Code of Conduct applies to the healthcare of professionals who work with or are affiliated with [facility name] or its facilities. In addition to the guidelines set forth in the Code of Conduct, healthcare professionals are expected to carry all required licenses and follow the ethical and professional standards dictated by their respective professional organizations and licensing boards.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 11/27/2025, the P&P indicated, “The patient has the right to: 1. Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, belief, and preferences.””

“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: 46238 Based on interview and record review, the facility failed to ensure that one of 34 sampled patients (Patient 17), was made aware of the discharge order from the acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) to the Emergency Department (ED) and included in the preparation of her (Patient 17) discharge plan on the day (6/25/2025) Patient 17 was discharged from the facility’s ARU to the Emergency Department after Patient 17 returned to the facility from an outpatient procedure, in accordance with the facility’s policy on Patient Rights. Patient 17 was discharged from the ARU while she (Patient 17) was away from the facility for a procedure, without her (Patient 17) knowledge of the discharge, without receiving necessary discharge instructions, and without subsequent placement in a skilled nursing facility (SNF, a medical center providing 24/7 care, including skilled nursing (like injections, wound care) and rehabilitation (physical, occupational, speech therapy) by licensed professionals, bridging hospital stays for recovery from surgery, illness, or injury). This deficient practice violated Patient 17’s right (fundamental principles ensuring individuals receive respectful, dignified, and informed care, empowering them to participate in decisions about their health, refuse treatment, maintain privacy, and access care without discrimination, covering everything from consent and understanding diagnoses to appealing insurance denials) to participate in the development and implementation of her (Patient 17) discharge plan, which can negatively impact Patient 17’s care coordination and recovery. Findings: During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence), after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones) was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture (a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s Daily Focus Assessment Report (a daily snapshot of patient status and care)-Case management (CM) notes, on 12/17/2025 at 11:02 a.m. with the System Analyst (IT 1), IT 1 verified that on 6/24/2025 case management entered the following note: “ ...Met with Patient 17 notifying the patient of insurance extending hospital stay day by day until the facility could find placement ... Patient 17 expressed preferences for placement and was in agreement with discharge plan...” During a review of Patient 17’s Daily Focus Assessment Report on 12/17/2025 at 11:28 a.m. with the System Analyst (IT 1), IT 1 verified that on 6/25/2025 at 10:03 a.m., the case manager (CM) documented the following in Patient 17’s medical report: “Patient 17 needs placement to go... met with medical doctor (MD 1) who said that Patient 17 needed to be discharged into a Skilled Nursing Facility (SNF), but not able to accept the patient back (back to the ARU) due to she ( Patient 17) does not meet the criteria for rehab anymore... Informed physician that SNF placement is still pending, and insurance will provide daily authorization until have accepting SNFs... received paper authorization from insurance with authorized ARU (Acute Rehab Unit) stay until 7/1/2025... placed in the patient’s chart...” During a review of Patient 17’s digital medical record (an Electronic Medical Record [EMR] or Electronic Health Record [EHR]-is the computerized version of a patient’s paper chart) on 12/17/2025 at 11:55 a.m. with the System Analyst (IT 1), IT 1 verified that Patient 17’s discharge order, which indicated to discharge Patient 17 to a Skilled Nursing Facility (SNF)- was placed 6/25/2025 at 7:04 p.m. when Patient 17 was out for an outpatient surgical procedure. During the same record review on 12/17/2025 at 11:55 a.m. with the System Analyst (IT 1),, IT 1 also verified that Patient 17’s digital record contained no uploaded nursing discharge instructions (detailed guidelines given to patients upon their discharge from a hospital or healthcare facility to provide information on post-discharge care, including medications, follow-up appointments, dietary restrictions, activity limitations, and signs of potential complications with the purpose to ensure that patients have the necessary information to manage their health effectively at home and to prevent readmission due to misunderstandings or lack of information). During an interview on 12/18/2025 at 10:06 a.m. with the Manager of Acute Rehab (MN 4), MN 4 explained that the discharge process required ensuring patients were stable, with vital signs (VS, objective measurements of the body’s most basic functions-temperature, pulse [heart rate], respiration [breathing] rate, and blood pressure-that provide crucial information about a person’s general physical health, indicating how well vital organs are working and helping to detect underlying medical issues or recovery progress ) obtained 1-2 hours before discharge. MN 4 also said the following, “The case manager (CM) works with the family to arrange medication and transportation, confirming and notifying the nurse and physician about the discharge destination. If there is no placement, the CM communicates this to the physician, escalating as needed to the supervisor or manager. A patient should have a safe discharge location and should receive discharge instructions detailing follow-up care, medication management, and any necessary education. The transfer to another facility involves communicating all patient care details to the receiving facility to ensure continuity of care.” During the same interview on 12/18/2025 at 10:06 a.m., with the Manager of Acute Rehab (MN 4), MN 4 said the following, “When a patient is discharged, they should have a place to go to. The case manager should work on placement and will confirm and notify the nurse and physician about the discharge order specifying where the patient will be discharged to... The clarification with the case manager (CM) will be done when there is no placement, so we have to get back to the physician and say the patient has no placement. We have to escalate if the physician is pushing discharge. Escalate to the house supervisor and manager, but if I am not on site, the house supervisor has to be informed. I was not aware of Patient 17’s discharge without discharge arrangements being done. The patient (Patient 17) was brought back to the unit [on 6/25/2025 at 8:45 p.m.], but there was a discharge order placed by the physician [when Patient 17 returned to ARU after the outpatient surgical procedure], and when Patient 17 presented to the unit ARU), the transport team was directed to discharge the patient (Patient 17) to the Emergency Department (ED, a specialized unit in a hospital designed to address various urgent and critical medical conditions ) (Patient 17 was not aware that she will be discharged to the ED on 6/25/2025 after returning from an outpatient procedure). That’s where the CM could follow up with Skilled Nursing Facility (SNF) placement from there. Yes, the patient (Patient 17) required Skilled Nursing Facility (SNF) placement as per MD discharge order, but we sent the patient (Patient 17) to the Emergency Department (ED), so the case management could follow up with the patient in the ED.” During an interview on 12/18/2025 at 10:20 a.m. with the Manager of Acute Rehab (MN 4), MN 4 also stated the following: “Was it a safe discharge for patient (Patient 17)? I don’t know. It was an isolated case. The patient should have had a place to go. The patient did not receive discharge instructions; they should be able to follow up on care for themselves and continue care and treatment. Patients need to know what follow-up was needed and receive education regarding medication. But the patient (Patient 17) was aware of the discharge plan (Patient 17 was aware about the discharge plan to a SNF but not about being discharged to the ED on 6/25/2025 while waiting for SNF placement) and declined everything that was offered. The order with authorization [to extend ARU stay day by day until placement is found] came late. The physician (MD 1) said to discharge the patient (Patient 17) on 6/25/2025. I’m not sure what the regulation says about this situation; I am not familiar. All I know is that the patient went to the Emergency Department (ED) and remained there while the case manager continued to work to get her (Patient 17) placement. Patient (Patient 17) was safe in the ED.” During an interview on 12/18/2025 at 11:07 a.m. with medical doctor (MD 1), MD 1, who discharged Patient 17, said the following: “Sometimes we have an order and placement, but the patient refuses ... and then they will change their mind, and from the insurance standpoint ... the insurance will say the patient needs to go, so the patient has to go... Patient 17 met the criteria for discharge and no longer met the criteria for Acute Rehab Unit admission... and there was no authorization from the insurance guaranteeing that the patient (Patient 17) could stay until placement was found (this was contrary to the case management notes indicating insurance approval to extend Patient 17’s stay in the ARU until 7/1/2025 while awaiting SNF placement)... It was a safe discharge... I discharged to the emergency department (ED)...” During an interview on 12/18/2025 at 12:40 p.m. with Case Managers (CM 1 and CM 2), CM 1 and CM 2 said that on 6/25/2025 Patient 17 had an outpatient procedure scheduled and CM 1 arranged for the transportation to take the patient (Patient 17) to and bring the patient (Patient 17) back to ARU (Acute Rehab Unit) after the procedure. “Patient (Patient 17) was not aware of the discharge order (to the ED) on 6/25/2025. Patient (Patient 17) had no (SNF) placement ready on 6/25/2025. In fact, patient (Patient 17) was also homeless, as they (Patient 17) were evicted from their apartment that day. Patient (Patient 17) was supposed to come back to the rehab unit and thought they were coming back to ARU. But once patient (Patient 17) left for the outpatient procedure on 6/25/2025, MD 1 said patient (Patient 17) was discharged because she (Patient 17) no longer met the criteria for admission in the ARU, as per MD 1 order...and the MD 1 said we wouldn’t take patient (Patient 17) back. So, patient (Patient 17) went to the procedure but could no longer come back to the unit (ARU). MD 1 said to send patient (Patient 17) to the ED after the procedure, but this patient (Patient 17) had an order to go to SNF, and no SNF was ready... Patient safety was on the line. We had a discharge order but no placement, and patient (Patient 17) was practically homeless. Patient (Patient 17) needed to go to a nursing home. The physician sent the patient (Patient 17) to the ED so they would not be on the streets. So, we did our best to hold patient (Patient 17) in the ED, providing them with a safe place until placement was found...” During a review of the complaint received by the Department of Public Health (DPH, a state agency responsible for public health, including the oversight and regulation of healthcare facilities), received on 12/09/2025, the complainant (Patient 17) stated the following: “I was illegally discharged from acute rehabilitation and dumped in the Emergency Department (ED) on June 25, 2025, I was illegally discharged from acute rehabilitation while undergoing surgery at [Organization]. After a 7-hour standoff, the supervisor falsely promised I would be admitted to an inpatient bed if I went to the ED. I was transported to the ED around 6:00 AM on June 26, 2025. I was held in the ER for approximately two days without proper admission. Because I was dumped from upstairs and not admitted with an emergency, I was listed as the lowest priority. The first morning shift on June 26 told me I was getting re-admitted to an inpatient bed. I did not realize I would not be re-admitted. I could not sleep without a bed and lost track of time. I was not fed properly. I am vegetarian and could not eat what was provided.” During a review of Patient 17’s Daily Focus Assessment Report, dated 6/25/2025, at 5:15 p.m., the report indicated that case management, the manager of the Acute Rehab Unit (MN 4), the Chief Nursing Officer (CNO), and the Medical Director of ARU (MD 1) made a decision not to accept Patient 17 back to the acute rehab unit after Patient 17’s outpatient procedure (was completed on 6/25/2025) and to discharge Patient 17. During a review of Patient 17’s Electronic Medical Record (EMR), dated 6/26/2025 through 6/27/2025, the record indicated that Patient 17 arrived at the emergency department (ED) on 6/26/2025 at 5:12 a.m. (following discharge from the ARU) and was seen by the physician at 7:06 a.m. During a review of Patient 17’s Emergency Department (ED) note, dated 6/26/2025, the Emergency Department note indicated that the patient (Patient 17) reported to the ED physician that they (Patient 17) were pending transfer to a skilled nursing facility after being admitted to the rehab unit in June (2025) for physical and occupational therapy (help people of all ages participate in meaningful daily activities, or “occupations,” by improving skills, adapting environments, and providing adaptive equipment to increase independence, health, and quality of life, covering self-care [dressing, eating]) after suffering a wrist and leg fractures. The ED note also indicated that Patient 17 mentioned undergoing a procedure at [organization] on 6/25/2025; upon returning, Patient 17 found she had been discharged from the rehab floor with no bed available, hence Patient 17 being taken to the ED (to await SNF placement). The ED note indicated that the rehab physician informed the ED physician that Patient 17 could be discharged home (Patient 17 was homeless) or transferred to a nursing facility (the SNF placement was pending), as home physical therapy and equipment had been arranged. However, Patient 17 refused to go home. During a concurrent interview and record review on 12/19/2025 at 3:20 p.m. with registered nurse (RN 17), Patient 17’s medical records from the Emergency Department (ED) visit, dated 6/26/2025 through 6/27/2025, was reviewed. RN 17 confirmed that Patient 17 had no diet order placed throughout her stay in the emergency department from 6/26/2025 through 6/27/2025 and no documentation indicating that Patient 17 was provided nutrition. RN 17 said that providing nutrition, such as a diet order and documenting intake was not required for a patient in the emergency department. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 8/2025, the P&P indicated that, “...Patient care shall be provided in a safe environment... to ensure that all employees and contractors fully support and ensure the rights of its patients... and shall not discriminate against any individual because of the patient’s ability or inability to pay....The patient has the right to considerate and respectful care, and to be made comfortable.... Patients have the right to effective communication and to participate in the development and implementation of their plan of care.... Patients have the right to be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from the hospital. They have the right to be involved in the development and implementation of their discharge plan...” During a review of the facility’s policy and procedure (P&P), titled “Hospital discharge planning,” the following was noted: “Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to their discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs... The case manager, social worker, or hospital staff shall engage the patient, and/or the patient’s representative, actively in the development of the discharge plan by incorporating the patient’s goals and preferences into the plan.” During a review of the facility’s policy and procedure (P&P), titled “Discharge Plan for Homeless Patients,” the P&P indicated the following: “Documentation of discharge planning will include completed discharge instructions with patient name and signature, documentation of the patient’s cognitive intactness, and documentation that the patient understands and agrees with the discharge plan, including medications and follow-up care.” The facility did not provide the requested “Admission, Transfer, and Discharge Policy” during the survey. During an interview on 12/18/2025, at 9:25 a.m. with the Vice President of Quality Risk Management (VPQRM), the VPQRM stated that the facility did not have a policy for “Nursing Discharge Instructions” and lacked any other policies that described the discharge process for patients.”

“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: 46238 Based on interview and record review, the facility failed to inform one of 34 sampled patients (Patient 17) about the results of diagnostic imaging (non-invasive technologies-such as X-rays and ultrasounds-that create detailed pictures of the body’s internal structures to detect, diagnose, and monitor medical conditions) done, in accordance with the facility’s policy on Patient Rights regarding the right to receive information pertaining to their own care, after Patient 17 reported sustaining a near fall (an unintentional descent to the floor or a lower surface [like a bed or chair], with or without injury, often due to a combination of patient risks [like confusion, weakness, age] and environmental hazards [like poor lighting or slippery floors], leading to potential serious harm) on 6/24/2025. This deficient practice violated Patient 17’s right to stay informed about her (Patient 17) health condition and to make decisions about her (Patient 17) care, including the ability to request or refuse treatment. Findings: During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones) was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture (a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s Daily Focus Assessment Report (a report that documents the patient’s daily condition and any significant events), dated 12/24/2025, the report indicated that Patient 17 reported a near-fall (an event where a patient almost falls but catches themselves) in the bathroom while sitting on a toilet bowl, mentioning that her (Patient 17) right hand and arm touched the floor to prevent further falling down. The report also indicated that the registered nurse assigned to take care of Patient 17 on 6/24/2025 called the physician’s assistant to report this incident and obtained an order for an X-ray (a way for providers to get pictures of the inside of your body) of the right arm/hand. During an interview on 12/10/2025 at 4:50 p.m. with Patient 17, Patient 17 stated that the fall she (Patient 17) sustained on 6/24/2025 was never reported, investigated or treated. As a result, Patient 17 said she (Patient 17) was still dealing with repercussions to the right wrist and hand, including a hairline fracture (a tiny crack in a bone) that she (Patient 17) believed was sustained during the fall. Patient 17 said, “I have been experiencing issues and pain, which necessitated another surgical intervention at [Organization] to correct the injury. I never received any treatment for the fall at the facility.” During a review of Patient 17’s electronic medical record (EMR) on 12/17/2025 with the System Analyst (IT 1), IT 1 confirmed that Patient 17’s EMR had no notes regarding a physician’s follow-up on the near-fall, imaging results, treatment recommendations, and documentation of discussion indicating the physician informed Patient 17 of X-ray results [dated 6/24/2025] and discussed treatment options and provided recommendations prior Patient 17’s discharge on 12/25/2025. During an interview on 12/17/2025 at 3:16 p.m. with the President Elect/Interim Chief of Staff (MD 3), MD 3 said that the expectation from all physicians was to document all patients’ pertinent medical information in the progress notes. During an interview on 12/17/2025 at 12:09 p.m. with the Physician’s Assistant (PA), the PA stated the following, “I work in conjunction with multiple doctors in the Acute Rehabilitation Unit (ARU), but primarily with Medical Doctor (MD 1). I do my rounds in the morning, and if I receive a call later during the day, I document any incidents that occurred after my physical rounds the following day. I remember Patient 17 and recall ordering an X-ray. The impression of the report did not indicate an “acute fracture,” so the fracture must have been old. I did not have another X-ray for comparison but informed MD 1 about the results. The following day, I did not round on this patient. I am unaware if the fracture was sustained in the facility during the reported unwitnessed near-fall by Patient 17. I did not follow up on the results with the patient; I only communicated this with my supervising physician (MD 1).” During the same interview on 12/17/2025 at 12:08 p.m. with the physician’s assistant (PA), the PA said the following regarding the required documentation following up the fall: “It should definitely be documented in the progress notes that the patient fell. The patient should be monitored, continue with the pain management, review imaging results, document in progress notes, and make sure it does not happen again.” During an interview on 12/18/2025 at 11:08 a.m. with MD 1, MD 1 stated that Patient 17’s near-fall on 6/24/2025 was discussed with Patient 17. MD 1 said the facility did not have comparison X-rays and assumed the fracture was old. MD 1 said that Patient 17 should have been notified of the findings, informing the patient that there was no newly acquired/sustained fracture during Patient 17’s near-fall on 6/24/2025. MD 1 also confirmed there was no documentation in progress notes regarding the evaluation of the fall, the fall itself, and the recommendations for the patient. MD 1 stated that Patient 17 was not in significant pain during the evaluation. MD 1 recommended that the patient follow up with her orthopedist (a doctor specialized in diagnosing and treating bone, joint, muscle, and ligament conditions). Once MD 1 obtained copies from [name of another organization] of previously completed X-rays of Patient 17’s arm and was able to compare, MD 1 confirmed the injury was old. This confirmation came a week after Patient 17’s discharge (Patient 17 was discharged 6/25/2025). During a review of the facility’s policy and Procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated 7/2025, the P&P indicated that: “The patient has the right to receive information about their health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms they can understand. They have the right to effective communication and to participate in the development and implementation of their plan of care ... Reasonable responses to any reasonable requests made for service.” During a review of the facility’s Medical Rules and Regulations,” [undated], the Rules and Regulations (R&R) indicated, “3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician...””

“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: 50516 Based on observation, interview and record review, the facility failed to ensure two of 34 sampled patients (Patient 19 and Patient 28) had their call light (a remote control at the bedside used by a patient to signal his or her need for assistance from professional staff) within their reach, in accordance with the facility’s policy regarding call light system. This deficient practice had the potential to result in a delay of care and accommodation of Patient 19’s and Patient 28’s care needs which may cause physical and emotional distress for Patient 19 and Patient 28. Findings: 1. During a review of Patient 19’s “History and Physical (H&P),” dated 9/28/2025, the H&P indicated Patient 19 was admitted to the facility for an “Unsafe discharge due to lack of support at home” and was brought back to the facility. Patient 19 had a medical history of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), autonomic dysfunction (body has difficulty monitoring heart rate, blood pressure and temperature), urinary tract infections (UTI, an infection in the bladder or urinary tract) and deep vein thrombosis (DVT, blood clot in the vein). During a concurrent observation and interview on 12/15/2025 at 2:52 p.m. with Patient 19, Patient 19 stated he (Patient 19) called for help by using a blue call light (a remote control at the bedside used by a patient to signal his or her need for assistance from professional staff) that looks like a ramp. The call light was observed behind Patient 19 and away from Patient 19’s head. During a concurrent observation and interview on 12/15/2025 at 3:03 p.m. with Charge Nurse (CN) 2 and Registered Nurse (RN) 2, in Patient 19’s room, a call light in the form of two, blue square panels was observed behind Patient 19’s head. CN 2 stated Patient 19 could not use his hand and used his head. CN 2 pulled the call light from behind Patient 19’s head. RN 2 positioned the call light next to Patient 19’s head. Patient 19 turned his head to activate the call light. Patient 19 stated the call light had not been on for a week. During an interview on 12/15/2025 at 3:10 p.m. with Registered Nurse (RN) 8, RN 8 stated call lights were placed next to the patient for easy access. RN 8 stated she (RN 8) expected the call light to be next to him (Patient 19) because she knew he (Patient 19) can’t use and move his arms and legs. RN 8 stated the call light was important for Patient 19’s safety, assistance needs, and overall care. RN 8 also said that if the call light was not available, a patient might feel frustrated, particularly if they required pain medication, needed something else, or were hungry. During a review of the facility’s policy and procedure (P&P) titled, “Call Light System,” dated 11/26/2024, the P&P indicated, “To ensure prompt and effective response to patient/resident call lights in the acute and subacute care setting, enhancing patient safety, satisfaction, and the overall quality of care ...Ensure that the call light is always within easy reach of the patient/resident. For paraplegic patients/residents who may have limited upper body mobility, adaptive call light devices should be provided to ensure they can easily signal for assistance.” 2. During a review of Patient 28’s “Rehabilitation Post - Admission Assessment,” dated 12/8/2025, the record indicated Patient 28 was admitted to the facility for comprehensive care that included physical and occupational therapy services (evidence-based, holistic interventions that enable people of all ages to regain or develop skills for daily living, working, and playing after injury, illness, or disability. Therapists customize environments, provide adaptive equipment, and train patients in self-care tasks (ADLs) to maximize independence) and 24-hour rehabilitation nursing care after a cerebrovascular accident (CVA, stroke-loss of blood flow to a part of the brain). Patient 28’s medical history included hypertension (HTN, high blood pressure), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). The record further indicated Patient 19 needed maximum assistance with self-care and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 12/15/2025 at 12:12 p.m. with Nurse Manager (NM) 4 in Patient 28’s room, Patient 28’s call light was not next to the patient. NM 4 was asked where Patient 28’s call light was located and stated, “Oh, it’s on the floor.” NM 4 removed the call light from the floor, cleaned it, and placed it within reach of Patient 28. During an interview on 12/18/2025 at 3:23 p.m. with NM 4, NM 4 emphasized the importance of the call light as a communication toll for patients to reach nurses. NM 4 said that if the call light was not within reach, patients could not communicate their care needs. NM 4 stated that during hourly rounding, staff must ensure the call light was accessible to the patient. During a review of the facility’s policy and procedure (P&P) titled, “Call Light System,” dated 11/26/2024, the P&P indicated, “To ensure prompt and effective response to patient/resident call lights in the acute and subacute care setting, enhancing patient safety, satisfaction, and the overall quality of care ...Ensure that the call light is always within easy reach of the patient/resident.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 50594 Based on interview and record review, the facility failed to protect four (4) of 34 sampled patients (Patient 31, Patient 32, Patient 33, and Patient 34) from potential physical abuse (as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish) when an alleged nursing staff (Registered Nurse [RN] 9) was allowed to continue to work before the investigation of an alleged physical abuse, was completed. RN 9 was placed on investigatory suspension on 11/4/2025 following an allegation of abuse by a patient (Patient 19) and was released from suspension and worked on 11/7/2025 morning shift while the facility’s Human Resources (HR) Department was still performing investigation the same day (11/7/2025). RN 9 was assigned to take care of four of 34 sampled patients (Patient 31, Patient 32, Patient 33 and Patient 34) before the investigation was completed by HR department. This deficient practice had the potential to put Patient 31, Patient 32, Patient 33 and Patient 34 at risk for emotional and/or physical distress, and place other patients at risk for potential abuse. Findings: During a review of Patient 19’s “Emergency Department note (ED notes, Emergency Department physician’s note documents a patient’s emergency department visit,” dated 9/27/2025, the ED notes indicated, Patient 19 was admitted to the facility with diagnoses including but not limited to failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and need for assistance with personal care. During a review of Patient 19’s, “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/28/2025, the H&P indicated Patient 19 was quadriplegic (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) due to motor vehicle accident. During an interview on 12/16/2025 at 10:35 a.m. with Director (DIR) 1 of Medical Surgical (specialty unit that focuses on the care of patients with general health conditions or who had a recent surgery) , DIR 1 stated DIR 1 received an allegation of abuse (as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish) report which allegedly occurred on 11/3/2025 reported by the night shift supervisor on 11/4/2025 involving RN 9 and Patient 19. DIR 1 stated Patient 19 reported RN 9 shoved a big roll of tape into Patient 19’s mouth. DIR 1 stated Certified Nursing Assistant (CNA, someone who help patients with daily activities, monitor vital signs, and help with patient comfort and hygiene) 1, was in the room. DIR 1 said that per the report, CNA1 indicated that Patient 19 was about to spit again, so RN 9 placed her hand in front Patient 19’s face, a hand gesture to make patient 19 stop, to block Patient 19’s mouth in case patient (Patient 19) spits. During the same interview on 12/16/2025 at 10:35 a.m. with DIR 1, DIR 1 stated that RN 9’s hand gesture near Patient 19’s face violated personal space and was unacceptable. During a concurrent interview and record review on 12/16/2025 at 2:52 p.m. with Senior Human Resources Business Partner (SHRBP) 1, the “Re-Instate Access -Employee Suspension,” was reviewed. The record indicated RN 9 was placed on suspension (not allowing to work) on 11/4/2025 and was off suspension effective on 11/6/2025. SHRBP 1 stated RN 9 was reinstated (release the employee back to work) on 11/5/2025 based on witnesses’ statement and on the investigatory meeting held with the alleged employee (RN 9) on 11/5/2025. SHRBP 1 stated on 11/7/2025 she (SHRBP 1) interviewed three staff members: CNA 1, RN 18, and RN 19. During an interview on 12/16/2025 at 5:07 p.m. with Human Resources Manager (HRM), HRM stated HR conducts their (HR) own investigation. HRM also stated HR would determine whether to reinstate the employee or not after completion of investigation. During a review of RN 19’s “Timecard (a tool used to track and record the hours worked by an employee),” dated 11/7/2025, the timecard record indicated, RN 9 clocked in at 6:48 a.m. and clocked out at 7:25 p.m. on 11/7/2025. During a review of the unit assignment titled, “Shift Summary by Skill,” dated 11/7/2025, the unit assignment indicated RN 9 was assigned to take care of Patient 31, Patient 32, Patient 33, and Patient 34 on 11/7/2025. During an interview on 12/17/2025 at 9:20 a.m. with Director of Human Resources (DIR 2), DIR 2 stated SHRBP1 was still investigating Patient 19’s alleged abuse case on 11/7/2025 (the date RN 9 returned to work). DIR 2 stated RN 9 should not have been released back to work until all of the investigation was completed to prevent further incidents to the patients and putting other patients’ safety at risk. During a review of Patient 31’s “Preoperative History and Physical (preoperative H&P, review of patient medical, surgical, family history include a physical exam and helps surgical team to determine if a patient is healthy enough to undergo a surgery), dated 11/5/2025, the preoperative H&P indicated, Patient 31 was admitted to the facility for worsening of condition and worsening of anemia (a condition where the body does not have enough healthy red blood cells). During a review of Patient 32’s “History and Physical (H&P),” dated 11/6/2025, the H&P indicated Patient 32 was admitted to the facility for complaint of persistent diarrhea. During a review of Patient 33’s “History and Physical (H&P),” dated 11/6/2025, the H&P indicated, Patient 33 was admitted to the facility for obstructive uropathy (occurs when urine cannot drain though the urinary tract). During a review of Patient 34’s “History and Physical (H&P),” dated 10/31/2025, the H&P indicated, Patient 34 was admitted to the facility for complaint of headache. During a review of the facility’s policy and procedure (P&P) titled, “Investigations,” dated 11/30/2022, the P&P indicated, “To provide guidelines and procedures related to investigations involving caregivers ...Upon completion of the interview, the caregiver(s) directly involved normally will be placed on investigative suspension (according to the Collective Bargaining Agreement for covered caregivers) and/or other actions may be taken ...All interviews will be conducted after HR receives notification of the incident ...Once all interviews and document reviews are completed, an evaluation of each individual caregiver’s participation in the incident will be identified and validation of such will be cross-referenced in the investigative statement or other documents ...Based on information gathered, the Human Resources department will suggest action to be taken with regard to the individual caregivers.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 11/27/2025, the P&P indicated, “The patient has the right to: 1. Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychosocial, spiritual and personal values, belief, and preferences.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse or Neglect, Elder or Dependent Adult,” date approved 3/22/2023, the P&P indicated, “[facility name] is committed to assuring that the facility is doing all that is within its control to prevent occurrences of abuse ...All hospital staff will receive education and training regarding the identification, reporting and treatment of abuse or neglect of an elder or dependent adult.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a hospital?wide program that uses data to identify problems, test solutions, and improve patient safety and quality) program collected and analyzed sufficient data during the root cause analysis (RCA, a structured process to identify underlying causes of an adverse event) of an operating room (OR, the hospital surgical suite where operations are performed) fire for one (1) of four (4) sampled patients (Patient 1), in accordance with the facility’s QAPI plan. The QAPI program did not identify contributing factors or implement corrective actions, including preoperative patient education (instructions given to a patient before surgery to reduce risk and prepare for the procedure), use of non-flammable, water-soluble surgical jelly (a fire?resistant gel applied to hair/skin near the surgical site to reduce ignition risk), staff training (education on policies and procedures), adherence to manufacturer instructions (device or product use directions provided by the maker), and preventive maintenance (PM, scheduled safety and performance inspections per manufacturer specifications). This deficient practice left the facility unable to prevent recurrence of similar events because QAPI did not collect, analyze, or act on critical data. Findings: During a review of Patient 1’s Operative Report (the formal surgical record documenting the procedure), dated 11/4/2025, the report indicated smoke (visible vapor from combustion) was noted coming from the drape (a sterile cloth used to cover the patient during surgery) and a fire (uncontrolled combustion producing heat and flames) occurred under the drape during the procedure, resulting in burns (injury caused by heat) to the right and left face (front part of the head), chin (area below the lower lip), and anterior neck (front portion of the neck). During an interview on 12/16/2025 at 11:05 a.m. with the Director of Perioperative Services (DPS), DPS stated, “Patient 1 experienced a surgical fire during an elective (a surgery that isn’t an emergency and can be scheduled in advance) scalp procedure while under Monitored Anesthesia Care (MAC, sedation where the patient remains responsive) with an open oxygen source. Oxygen delivery by mask, use of electrocautery (a surgical instrument that uses electrical current to cut tissue or stop bleeding), and an alcohol-based prep solution [ChloraPrep] created a high-risk environment for ignition.” During an interview on 12/19/2025 at 2:45 p.m. with DPS, DPS stated, “It is very important to get training done, have to do investigation while it is fresh, and review with staff. All staff should have been re-educated on OR fire safety as soon as possible. After completing education, it should have been reported to QAPI. This did not occur.” During a concurrent interview and record review on 12/17/2025 at 2:47 p.m. with the Manager of Perioperative Services (MP), the facility’s policy titled, “OR Fire Prevention and Response,” dated 11/2025, was reviewed. The policy indicated staff must receive training on OR fire-risk protocols and included changes that ChloraPrep would not be used for surgical sites above the xiphoid (lowest part of the breast bone). MP stated, “Not all OR staff received the training after the fire incident.” During a concurrent observation and interview on 12/16/2025 at 3:37 p.m. in the OR supply room with CN 10, surgical jelly was not available. CN 10 stated, “We never stock surgical jelly.” During a concurrent interview and record review on 12/16/2025 at 11:45 a.m. with DPS, the facility’s policy titled, ‘Skin Antisepsis and Prepping of Patient,’ dated 7/25/2025, was reviewed. DPS confirmed the policy required coating hair near the surgical site with non-flammable surgical jelly when oxygen was used during head and neck surgery. DPS confirmed surgical jelly was not used for Patient 1. During an interview on 12/17/2025 at 11:24 a.m. with RN 1, RN 1 stated (the OR staff) they waited three minutes for the antiseptic solution to dry before draping Patient 1. During a concurrent interview and record review on 12/17/2025 at 2:47 p.m. with DPS, the manufacturer’s instructions for the 26 mL ChloraPrep applicator, were reviewed. The instructions indicated: Do not use 26 mL applicator for head and neck surgery. Hair may take up to 1 hour to dry. Do not drape or use an ignition source until solution is completely dry. This information was confirmed by DPS. During a concurrent interview and record review on 12/17/2025 at 12:24 p.m. with Registered Nurse (RN) 10 from the Patient Admission Testing Unit, Patient 1’s “Preoperative Instruction” (written or verbal directions given to a patient before surgery), was reviewed. RN 10 stated that Patient 1 was scheduled to have surgery on the scalp (operation on the skin covering the skull) on 11/4/2025. RN 10 confirmed that on 10/30/2025, a call was made to Patient 1, but Patient 1 could not be reached. RN 10 further confirmed that Patient 1 did not receive preoperative instructions (guidance provided before surgery to reduce risks and prepare the patient) prior to surgery. During a concurrent interview and record review on 12/17/2025 at 10:12 a.m. with Biomedical Technician (MB), the maintenance record for the electrosurgical generator (Bovie), was reviewed. MB stated six-month preventive maintenance was not performed between October 2024 and October 2025, resulting in an 11-month gap, and bipolar testing was not completed. During a concurrent interview and record review on 12/17/2025 at 10:30 a.m. with Biomedical Technician (MB), the manufacturer’s service manual was reviewed, confirming these requirements regarding completion of bipolar testing. During an interview on 12/19/2025 at 3:48 p.m. with the Manager of Biomedical (BM), BM stated, “The result of the test on the electrocautery involved in the OR fire was never obtained by QAPI. It must be collected and be part of the RCA record and handed over to Risk Management.” During an interview on 12/19/2025 at 3:10 p.m. with the Vice President of Quality and Risk Management (VPQRM, the executive responsible for patient safety, incident investigation, and quality oversight), VPQRM stated that after the fire, the electrocautery equipment was sequestered (removed from service and isolated), the former biomedical contractor verbally reported that testing was completed and the machine had no issues, the VPQRM also stated the facility did not receive a written testing report. VPQRM said that if a report had been provided, it would have been collected by the Risk Manager (staff overseeing incident documentation and follow-up) and included in the RCA (root cause analysis) submitted to the QAPI committee (hospital committee that reviews quality and safety issues), confirming the RCA lacked evidence of equipment testing. The VPQRM stated it was important that the QAPI program collected all data pertinent to the OR fire, because the facility may develop a performance improvement project in 2026 to address issues found. During an interview on 12/22/2025 at 10:16 a.m. with VPQRM, the VPQRM stated the facility’s process when equipment was involved in an unusual occurrence (an unexpected event that could cause harm) was to sequester the equipment (remove from use and isolate), tag it “Do Not Use,” and call Biomedical (biomedical engineering staff) for evaluation (inspection/testing). VPQRM stated the facility did not have a written policy describing this process and stated the policy of the former biomedical contractor had been adopted (accepted and used by the facility). VPQRM stated the facility did not obtain testing results from the former biomedical contracted company. During a review on 12/22/2025 of an email (written electronic communication) sent by the former biomedical contractor to VPQRM, the email indicated no report of testing completed on the equipment involved in the fire, was provided. VPQRM stated the facility had not received any documentation of diagnostic testing from the contractor. During an interview on 12/22/2025 at 10:30 a.m. with the Chief Operating Officer (COO), COO confirmed they were not aware that there was no testing of the electrocautery machine used during the OR fire. COO also confirmed they were not aware that maintenance was not performed in accordance with manufacturer specifications. During an interview on 12/22/2025 at 4:35 p.m. with the Chief Executive Officer (CEO), the CEO stated the Governing Body was responsible for oversight of contract services and reporting to QAPI. The CEO confirmed this oversight process was not followed with the former biomedical company. During a review of the Medical Executive Committee Minutes, dated 11/19/2025, the minutes indicated: “Sentinel Event - Operating Room Fire: A patient experienced a rare OR fire, sustaining second-degree facial burns; the case was referred to a burn center. An RCA was completed. Findings indicated: -A Bovie was used above the xiphoid process. -Chlorhexidine (alcohol-based antiseptic) was used for skin prep; presumed drips into hair increased flammability. -Patient was on mask oxygen at the time. -Immediate corrective action: Future cases involving Bovie use above the xiphoid process will use Betadine only to prevent recurrence.” During a review of the facility’s “Quality Assessment/Performance Improvement Plan (QAPI) 2025,” dated 6/2025, the QAPI Plan indicated: -The hospital will identify customer needs and evaluate performance. -Determine opportunities for improvement by analyzing quality, patient safety, and performance. -Conduct thorough root cause analyses for sentinel events and critical incidents, focusing on process and system factors. -Immediate actions for adverse events include removing hazards, assessing the patient, removing involved caregivers, notifying authorities if needed, and reporting/escalation. -After immediate actions, perform RCA and establish corrective actions such as policy revisions, education, and training. -Continuously improve patient outcomes, safety, and effectiveness. -Monitor all aspects of patient care and service to identify and resolve breakdowns. -Collect and analyze data to identify patterns, compare performance, and act on undesirable variations.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team performed a thorough review and analysis regarding a patient’s death for one of 34 sampled patients (Patient 7) to identify its root cause and plan for corrective actions, when there was a delay of escalating care for Patient 7’s evolving (progressive, getting worse) stroke (happens when blood flow to part of the brain is blocked or a blood vessel bursts, depriving brain cells of oxygen and nutrients, causing them to die within minutes) on 7/17/2024, in accordance with the facility’s QAPI plan. This deficient practice had the potential to result in increasing the likelihood of similar events from recurring and put stroke (damage to the brain from interruption of its blood supply) patients’ safety at risk. Findings: During a review of Patient 7’s consultation notes (formal report written by a specialist after examining a patient, detailing their assessment, diagnosis and specific recommendations for treatment and management) by neurosurgeon (medical doctor specializing in the surgical and non-surgical treatment of the brain, spinal cord and peripheral nerve, [NSG 1]), dated 7/18/2024, the consultation notes indicated, Patient 7 was admitted on 7/14/2024 with right MCA (middle cerebral artery) infarct (type of stroke resulting from failure of blood supply), doing relatively well until the morning of 7/17/2024 when Patient 7’s neuro status (neurological status, the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological [neuro] exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) deteriorated (getting worse) with worsening left sided weakness and becoming obtunded (reduced level of consciousness). The consultation notes also indicated Patient 7 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During a review of Patient 7’s nursing admission assessment titled, “Admission Assessment Inquiry,” dated 7/14/2024, the admission assessment indicated, on 7/14/2024 at 10:54 a.m., Patient 7 was alert with Glasgow Coma Scale (GCS, assesses consciousness after brain injury, ranging from 3 to 15, by summing points for eye [4], verbal [5], and motor [6] responses) score of 15 out of 15 (a score of 8 or less generally indicates severe injury/coma, 9 to12 moderate, and 13 to15 mild) and NIH Stroke Scale (NIHSS, a tool used to quickly assess stroke severity, track changes, and guide treatment, with scores from 0 [no symptoms] to 42 [severe stroke]) score of 17 out of 42 (a score of 1 to 4 is minor, 5 to 15 is moderate, 16 to 20 is moderate-to-severe, and above 20 is severe). During a concurrent interview and record review on 12/16/2025 at 10:29 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s “Daily Assessment Inquiry (nursing daily assessment),” dated 7/17/2024, was reviewed. The nursing daily assessment indicated Patient 7’s GCS and NIHSS scores as follows: -at 7:10 a.m.: Patient 7’s GCS score was 14 out of 15 (3 - opens eye to speech/ sound, 5 - oriented [knows name, place, time], alert and appropriate, 6 - obeys commands); -at 10:46 a.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 1 - no verbal response, 5 - localizes to pain stimulus) and NIHSS score was 17 out of 42; -at 8 p.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 2 - unintelligible moans, 4 - withdraws [pulls away] from painful stimulus) and NIHSS score was 34 out of 42; NM 1 stated the following: at 10:46 a.m., there was a change in Patient 7’s GCS score from 14 to 8 which could suggest a neuro status change. Nurse should have activated RRT for rapid assessment. At 8 p.m. Patient 7’s NIHSS score was double (score of 34) from previous assessment (score of 17 at 10:47am). The higher the NIHSS score suggested more neuro deficits that Patient 7 was experiencing. The nurse should have activated a code stroke. NM 1 stated that delay in calling Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) and code stroke (a facility-specific emergency response for neurological changes and suspected strokes) could compromise Patient 7’s health. Patient 7 could become brain dead. During a review of Patient 7’s physician progress notes, dated 7/17/2024, documented by NEURO 1, the physician progress notes indicated, “date of service: 7/17/2024 at 5:51 p.m. ... patient (Patient 7) has been sleeping the entire day ... (Patient 7) projectile vomiting (forceful expulsion of stomach contents) during my (NEURO 1) encounter and vomiting bile (yellowish-green stomach contents) ... mental status - somnolent (sleepy, drowsy), difficult to arouse (to stay awake) ... not talking ... sensory - does not withdraw from nailbed pressure ... plan ... check CT (Computerized Tomography, a medical imaging test using X-rays and a computer to create detailed, cross-sectional “slices” or 3D views of the inside of your body, showing bones, organs, soft tissues, and blood vessels with much greater detail than a standard X-ray) head wo (without) contrast.” During a review of Patient 7’s physician orders, dated 7/17/2024, the physician order indicated there was a STAT (a medical abbreviation for immediately or without delay) CT head without contrast ordered by Patient 7’s neurologist (NEURO 1) on 7/17/2024 at 9:47 p.m. (almost four [4] hours after NEURO 1’s visit on 7/17/2024 at 5:51 p.m.) with reason for cerebrovascular accident (CVA - stroke; damage to the brain from interruption of its blood supply). During a concurrent interview and record review on 12/16/2025 at 11:16 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s physician orders dated 7/17/2024 and 7/18/2024, were reviewed. The physician orders indicated there was a STAT CT head without contrast ordered by Patient 7’s neurologist (NEURO 1) on 7/17/2024 at 9:47 p.m. with reason for cerebrovascular accident (CVA), and a STAT CT head without contrast ordered by Patient 7’s intensivist (ICU 1) on 7/18/2024 at 12:27 a.m. with reason for cerebrovascular accident. NM 1 stated the CT scan order placed on 7/17/2024 at 9:47 a.m. was not done. NM 1 stated there was no documentation indicating any reason for not performing the CT scan. NM 1 stated Patient 7’s CT head scan was completed on 7/18/2024 at 12:51a.m. after the second STAT CT scan order was placed. During an interview on 12/18/2025 at 8:32 a.m. with the Director (DIR 3) of Telemetry, DIR 3 stated the following: for nursing, STAT order meant to be done within 30 minutes. Nurses should call the CT technician to follow up if the STAT CT scan ordered was not done within the time frame. Nurses should also notify the physician for any CT delay and document the reason. During an interview on 12/19/2025 at 2:32 p.m. with NEURO 1, NEURO 1 stated the following: when a STAT CT head was ordered. She (NEURO 1) expected it to be done within 30 minutes to an hour. Nurses should call the physician and tell the physician why it was not done promptly so the physician could decide what to do. If the patient was not stable (means that a patient’s condition is not changing rapidly, their vital signs [like heart rate, blood pressure] are steady, and they aren’t in immediate danger) for the CT scan, then the physician could escalate the care and stabilize the patient first then take patient to the CT scan. During a review of Patient 7’s CT Head without contrast report, dated 7/18/2024 at 12:51 a.m., the CT report indicated, “evolving (progressing, getting worse) right MCA (middle cerebral artery) territory infarct (type of stroke resulting from failure of blood supply) with significantly larger area involved compared to prior ... there is right to left midline shift (the displacement of brain structures from the center line, a serious sign of increased pressure inside the skull caused by things like stroke, tumors or head injury) of 12 mm (millimeters, a unit of measure) ... there appeared to be right uncal herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings).” During a review of Patient 7’s physician progress notes, dated 7/18/2024, documented by NEURO 1, the physician progress notes indicated, “CT was delayed but was completed showing cerebral (brain) edema (swelling) with worse midline shift. I (NEURO 1) recommended consulting NSGY (neurosurgery) for emergent craniotomy (a neurosurgical procedure to temporarily remove a piece of skull to access and operate the brain) at 1 a.m.” During an interview on 12/17/2025 at 10:20 a.m. with NSG 1, NSG 1 stated the following: NSG 1 received a text message from ICU 1 on 7/18/2024 at 12:50 a.m. requesting consultation for Patient 7 for worsening of CT head scan and midline shift. NSG 1 did not see the text message until 3 a.m. (2 hours later) because NSG 1 was sleeping. NSG 1 stated he (NSG 1) was the on-call neurosurgeon that day (7/18/2024). Normally consultation requests were done by phone call not by text messaging. If the on-call physician did not reply within 30 minutes, the requesting physician should have contacted the backup physician. NSG 1’s back up physician did not receive any phone call either. NSG 1 stated he (NSG 1) coordinated care with ICU 1 and facility’s operation team for surgery then rushed to the hospital to see Patient 7. During a review of Patient 7’s operation notes (surgical procedure report), dated 7/18/2024, the operation notes indicated, Patient 7 underwent right hemicraniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) for massive malignant (dangerous) brain swelling following a large MCA stroke. The operation notes also indicated, “patient (Patient 7) had no brain function ... recommend brain death exam protocol (examination by doctor to confirm all brain function has permanently stopped, making the person legally dead), followed by withdrawal of care if brain death confirmed.” During a review of Patient 7’s “Death Pronouncement” note, dated 7/20/2024, the “Death Pronoucement” note indicated, Patient 7’s time of death was on 7/20/2024 at 1:01 a.m. During an interview on 12/17/2025 at 10:24 a.m. with Neurosurgeon (NSG 1), NSG 1 stated the following: physicians (MD 8 and NEURO 1) were made aware of Patient 7’s increased sleepiness but there was no escalation in care to address Patient 7’s neuro status decline. Patient 7 was not sent to ICU for closer observation and there was no follow up CT head scan done until later the night. Patient 7’s neuro status was deteriorating and there was no necessary step taken to intervene. For stroke patients, the earlier the interventions, the better to increase chance of survival and preserve brain function. NSG 1 stated, “this (Patient 7’s death) was a preventable death.” During an interview on 12/17/2025 at 10:37 a.m. with NSG 1, NSG 1 stated the following: he (NSG 1) alerted and requested the chair of Medicine Department (a medical staff unit focused on internal medicine [diagnosing and treating adult illnesses]) to review Patient 7’s case shortly after Patient 7’s death (7/20/2024). He (NSG 1) also notified the facility’s Chief Executive Officer (CEO) and Chief Medical Officer (CMO) July this year (2025) urging for Patient 7’s case review. Patient 7’s death was preventable. There should be peer review (medical peer review is a performance assessment to evaluate other physician’s clinical performances) and root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) to identify the problems and find a solution so the same mistake would not happen to other patients. NSG 1 also stated, “it had been over a year and a half since Patient 7’s death (7/20/2024) and he (NSG 1) had not received any feedback.” During an interview on 12/17/2025 at 10:41 a.m. with the Vice President of Quality (VPQ), VPQ stated quality coordinators at Quality Department (hospital department examines the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) reviewed mortality (death) cases at the facility. During an interview on 12/17/2025 at 10:45 a.m. with VPQ, VPQ stated Patient 7’s case was reviewed at Medicine Department in October 2025 and reviewed by Multi-disciplinary Peer Review Committee (MDPR committee, a medical staff committee review and discuss referred cases focusing on process improvement and practice issues; to advise and make recommendations to the appropriate medical staff department and the MEC [Medical Executive Committee, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital]) in November 2025. During an interview on 12/17/2025 at 11:38 a.m. with the Chief Medical Officer (CMO), CMO stated CMO received request from NSG 1 to review Patient 7’s case. CMO referred Patient 7’s case to Quality Department for peer review. During an interview on 12/17/2025 at 12:44 p.m. with the Intensivist (ICU 1), ICU 1 stated the following: Patient 7’s death was preventable. There was change of neuro status in the morning (7/17/2024). If the imaging (CT head scan) was done earlier, intervention could have been provided earlier and might potentially change the outcome. During an interview on 12/19/2025 at 10:47 a.m. with the Clinical Quality Coordinator (QC 3), QC 3 stated the following: Patient 7’s mortality case was reviewed. QC 3 identified there was delay in performing the CT head scan and referred to the Chair of Medicine Department at that time for review. The Chair of Medicine Department would review and then determine if there were other disciplines involved and notify them. QC 3 would refer all quality-of-care concerns identified during mortality review to the Chair of Medicine Department only. QC 3 stated, “this was how I have been doing.” QC 3 further stated the following: QC 3 did not identify any delay in nursing care because there was communication between the physicians and nurses. QC 3 also confirmed QC 3 did not refer the CT delay issue to another Quality Coordinator (QC) who handled CT service line for review. During an interview on 12/19/2025 at 10:50 a.m. with VPQ, VPQ stated the following: each facility’s quality coordinator oversaw different service lines. When the Quality Coordinator identified any concerns involving other disciplines, the quality coordinator should have notified the other quality coordinators who oversaw the corresponding service line to escalate for review. During an interview on 12/19/2025 at 10:54 a.m. with VPQ, VPQ stated the following: preventable death meant a death could have been prevented, it would be categorized as an adverse event (unfavorable medical occurrence) depending on circumstances and would trigger a root cause analysis (RCA). The purpose of RCA was to identify the root cause and develop or improve the process to prevent same or similar events from happening again. VPQ stated there was no RCA performed on Patient 7’s death. During a review of the facility’s “Quality Assessment/ Performance Improvement Plan (QAPI) 2025 (QAPI Plan),” dated 6/2025, the QAPI Plan indicated, “Goals. The primary goals of [the facility’s] QAPI Plan are based on annual performance and are to: 1. Continually and systemically plan, design, measures, assess, and improve performance of priority focus areas and patient safety, 2. To improve healthcare outcomes, and 3. To reduce and prevent medical/health care errors ... Actions. To achieve these goals the plan strives to ... Plan and incorporate processes for conducting thorough and credible comprehensive systemic assessments (root cause analyses), focusing on process and system factors in response to sentinel events and other critical incidents as defined by the hospital ... Conduct root cause analysis to identify apparent and/or root causes of the event and establish corrective actions accordingly. These actions may include, but may not be limited to, process and policy revisions, education and training.” During a review of the facility’s policy and procedure (P&P) titled, “Adverse Events and Unusual Occurrences: Governmental Reporting,” dated 8/2025, the P&P indicated, “Purpose: The purpose of this policy is to establish a process through which all incidents, adverse and sentinel events, can be identified, understood and diminished or eliminated, when possible; to reduce likelihood of similar events from recurring ... Definition(s): Adverse Event: A patient safety event that resulted in harm to the patient. Sentinel Event: (a sub category of adverse events) A patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm ... Root Cause Analysis: is an assessment conducted to prevent recurrence of an event by identifying the reason(s) underlying an undesirable condition or problem in the system. The analysis focuses on systems and processes, not individual performance ... It is the policy of [the facility] to respond to all adverse and sentinel events with an immediate investigation and response which would include a thorough and credible root cause analysis (RCA) to identify the underlying causes and the opportunities for improvements to the systems and processes that will reduce the probability of such event recurring.””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its medical staff provided quality care to respond and manage an evolving (progressing, getting worse) stroke (a sudden disruption of blood flow to the brain) for one of 34 sampled patients (Patient 7) when medical staff: 1. Failed to direct nursing staff to perform neurological (neuro) assessment (assessment performed by nurse to check for patient’s mental status and alertness) every four (4) hours for Patient 7 who was admitted for acute (new onset) stroke on 7/14/2024. This deficient practice resulted in inadequate neurological monitoring for Patient 7, preventing staff from identifying, in a timely manner, Patient 7’s declining (getting worse) neuro status (the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) on 7/17/2024. 2. Failed to consult neurosurgeon (medical doctor specializing in the surgical and non-surgical treatment of the brain, spinal cord and peripheral nerve) in an urgent manner on 7/18/2024 when the Intensivist (critical care physician, medical doctor specialized in managing critically ill patients [ICU 1]) contacted neurosurgeon (NSG 1) via text messaging and with no follow up on 7/18/2024 at 1 a.m. This deficient practice resulted in NSG 1 did not respond to consultation request until 7/18/2024 at 3 a.m. for consultation of emergency craniotomy (a neurosurgical procedure to temporarily remove a piece of skull to access and operate the brain) for Patient 7. 3. Failed to perform peer review (medical peer review is a performance assessment to evaluate other physician’s clinical performances) in a timely manner after Patient 7’s death (7/20/2024). As of 12/22/2025, peer review results were still pending the facility’s Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) review to make the final decision. This deficient practice had the potential to allow medical staff to continue the same deficient practice and lead to future reoccurrence putting stroke patients’ lives at risk. These cumulative deficient practices resulted in delay in treating Patient 7’s evolving stroke on 7/17/2024 which subsequently contributed to Patient 7’s death on 7/20/2024. These deficient practices also had the potential to put other stroke patients at risk for getting substandard quality of care. Findings: 1. During a review of Patient 7’s consultation notes (formal report written by a specialist after examining a patient, detailing their assessment, diagnosis and specific recommendations for treatment and management), dated 7/18/2024, documented by neurosurgeon (medical doctor specializing in the surgical and non-surgical treatment of the brain, spinal cord and peripheral nerve, [NSG 1]), the consultation notes indicated, Patient 7 was admitted on 7/14/2024 with right MCA (middle cerebral artery) infarct (type of stroke resulting from failure of blood supply), doing relatively well until the morning of 7/17/2024 when Patient 7’s neuro status (neurological status, the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological [neuro] exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) deteriorated (getting worse) with worsening left sided weakness and becoming obtunded (reduced level of consciousness). The consultation notes also indicated Patient 7 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During a review of Patient 7’s nursing admission assessment titled, “Admission Assessment Inquiry,” dated 7/14/2024, the admission assessment indicated, on 7/14/2024 at 10:54 a.m., Patient 7 was alert with Glasgow Coma Scale (GCS, assesses consciousness after brain injury, ranging from 3 to 15, by summing points for eye [4], verbal [5], and motor [6] responses) score of 15 out of 15 (a score of 8 or less generally indicates severe injury/coma, 9 to12 moderate, and 13 to15 mild) and NIH Stroke Scale (NIHSS, a tool used to quickly assess stroke severity, track changes, and guide treatment, with scores from 0 [no symptoms] to 42 [severe stroke]) score of 17 out of 42 (a score of 1 to 4 is minor, 5 to 15 is moderate, 16 to 20 is moderate-to-severe, and above 20 is severe). During a review of Patient 7’s MRI (magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to create detailed images of organs, and bones) Brain without contrast (dye) report (MRI report), dated 7/15/2024, the MRI report indicated Patient 7 had a “moderate-to-large size area of restricted diffusion (MRI term describing limited movement of water molecules within tissues most famously seen in acute stroke due to cell swelling) involving right frontoparietal lobe (refer to the interconnected regions of the front lobe [behind the forehead and the parietal lobe [at the top/back of the head]) ... compatible with acute (new onset) to subacute (transition phase between acute and chronic [long-term]) infarct (type of stroke resulting from failure of blood supply).” During a review of Patient 7’s consultation notes, dated 7/15/2024, documented by neurologist (medical doctor specialized in diagnosing, treating and managing disorder of the brain, spinal cord, peripheral nerves and muscles [NEURO 1]), the consultation notes indicated, Patient 7 was “awake, alert and oriented, speech/language was fluent, followed commands ... PERRL (pupils equal, round, reactive to light) ... left hemiparesis (weakness on one side of the body).” The consultation notes also indicated care plan for Patient 7 to include neuro check (neuro assessment, assessment performed by nurse to check for patient’s mental status and alertness) every four (4) hours and NIHSS per protocol. During a review of Patient 7’s “Daily Assessment Inquiry (nursing daily assessment),” dated 7/17/2024, the nursing daily assessment indicated neuro assessment was performed on 7/17/2024 as follows: -at 7:10 a.m.: Patient 7 was alert, both pupils were brisk (pupils quickly shrinking when a light is shone to them, indicating a healthy brain function) at 2 millimeters (mm, a unit of measure, in this case refer to pupil size), clear speech, bilateral (both) hand grip was light, left arm and left leg strength was weak, GCS score was 14 out of 15 (3 - opens eye to speech/ sound, 5 - oriented [knows name, place, time], alert and appropriate, 6 - obeys commands); -at 10:46 a.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 1 - no verbal response, 5 - localizes to pain stimulus) without any other neurological assessment documented; -at 8 p.m.: Patient 7 was lethargic (a state of unusual drowsiness and reduced mental alertness), no pupils assessment documented, unable to perform hand grips, GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 2 - unintelligible moans, 4 - withdraws [pulls away] from painful stimulus); -at 12:40 a.m. (7/18/2024): Patient 7 was unresponsive, bilateral pupils were fixed at 4 mm, GCS score was 6 out of 15 (1 - no eye opening, 1 - no verbal response, 4 - withdraws from painful stimulus). During an interview on 12/16/2025 at 10:23 a.m. with the Nurse Manager (NM 1) of Telemetry, NM 1 stated there was no physician order placed for neuro check every four (4) hours for Patient 7 since admission (7/14/2024). Patient 7’s neurological assessment including GCS score and NIHS Stroke Scale was done once a shift (every 12-hour shift) per unit (telemetry floor) protocol. During an interview on 12/16/2025 at 2:37 p.m. with Registered Nurse (RN) 23, RN 23 stated the following: patients with acute stroke should be placed on neuro check at least every four (4) hours. It was important to monitor stroke patients frequently to identify any new or worsening of neurological deficits. “Time is brain (a medical phase emphasizing that during a stroke, brain tissue dies rapidly),” nurse should call physician or call Code Stroke (a facility-specific emergency response for neurological changes and suspected strokes) right away because worsening of neurological status could be fatal. During an interview on 12/17/2025 at 10:03 a.m. with Neurosurgeon (NSG 1), NSG 1 stated the following: acute stroke patients were at high risk for brain swelling after initial stroke. It was important to have frequent neuro monitoring to catch any signs of worsening of symptoms such as increasing drowsiness, worsening of weakness, worsening of slurred speech, no longer able to open eyes, so physician could be alerted and order a STAT (a medical abbreviation for immediately or without delay) computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) to determine if there was any worsening of cerebral (brain) swelling and to transfer the patient to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) for closer observation and monitoring. During an interview on 12/17/2025 at 12:12 p.m. with Intensivist (critical care physician, medical doctor specialized in managing critically ill patients [ICU 1]), ICU 1 stated the following: there should be frequent neuro checks at a minimum of every four (4) hours for stroke patients because they were at higher risk for brain swelling. Any signs of altered mental status, vomiting, change in pupils either fixed or dilated could be signs of brain herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings). Any acute changes in neuro status would need an evaluation of the current stroke and a STAT CT head scan. ICU 1 also stated, “time is brain, the more you delay in care, the patient will have permanent neuro deficit and can die.” During an interview on 12/17/2025 at 12:23 p.m. with ICU 1, ICU 1 stated the following: the physician would decide the frequency of neuro check based on patient’s stroke size and need and put in a physician order. Physician order was used to communicate with nursing staff to direct patient care and treatment. Physician progress note could not replace a physician order. During a review of Patient 7’s “Rapid Response Team Documentation Form (RRT form),” dated 7/18/2024, the RRT form indicated, RRT was called on 7/18/2024 at 12:05 a.m. due to Patient 7 experiencing respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and change in level of consciousness. The RRT form also indicated Patient 7 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to ICU for higher level of care. During a review of the facility’s “Medical Staff Bylaws,” dated 10/2020, the Med Staff Bylaws indicated, “Responsibilities of the Medical Staff Members ... Each member of the Medical Staff shall: 1. Provide his patients with care at the generally recognized professional level of quality and efficiency established by the Medical Staff 2. Abide by the Medical Staff Bylaws, Rules and Regulations and by all other lawful Standards, Policies, and Rules of the medical center approved by the Medical Staff ... 10. Work cooperatively with members, nurses, hospital administrations and others so as not to adversely affect patient care.” During a review of the facility’s “Medical Staff General Rules and Regulations (Med Staff Rules and Regs),” dated 10/2020, the Med Staff Rules ad Regs indicated, “General Rules and Regulations shall be established to control the conduct of work of the Medical Staff as a whole ... Article III: Admission and Discharge of Patients 3.1General Guidelines ... 3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient ... Article VI: Consultations 6.1 General Guidelines 6.1-1 The good conduct of medical practice includes the proper and timely use of consultations. Judgement as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment, rests with the practitioner responsible for the care of the patient. On the other hand, it is the duty of the organized Medical Staff through its Department Chairs and Medical Executive Committee to see that those with clinical privileges do not fail in the matter of calling consultants as needed.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.” 2. During a review of Patient 7’s consultation notes by neurosurgeon (NSG 1), dated 7/18/2024, the consultation notes indicated, “Patient 7 was admitted on 7/14/2024 with right MCA infarct, doing relatively well until the morning of 7/17/2024 when Patient 7’s neuro status deteriorated with worsening left sided weakness and becoming obtunded. The consultation notes also indicated Patient 7 was intubated and transferred to Intensive Care Unit. During a review of Patient 7’s “History and Physical (H&P),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry floor due to acute cerebrovascular accident (CVA, also known as stroke) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During a review of Patient 7’s CT Head without contrast report, dated 7/18/2024 at 12:51 a.m., the CT report indicated, “evolving right MCA territory infarct with significantly larger area involved compared to prior ... there is right to left midline shift of 12 mm ... there appeared to be right uncal herniation.” During a review of Patient 7’s physician progress notes, dated 7/18/2024, documented by neurologist (NEURO 1), the physician progress notes indicated, “CT was delayed but was completed showing cerebral edema with worse midline shift. I (NEURO 1) recommended consulting NSGY (neurosurgery) for emergent craniotomy at 1 a.m.” During a review of Patient 7’s physician progress note, dated 7/18/2024, documented by the Intensivist (ICU 1), the physician progress notes indicated, “addendum on 7/18/2024 at 1:01 a.m.: discussed with neurology (NEURO 1) ... recommends given patient’s (Patient 7’s) young age, only diabetes as (Patient 7’s) comorbidity, and previous normal functional status that (Patient 7) would benefit from craniotomy. Will reach out to NSG (neurosurgeon) ...” During an interview on 12/17/2025 at 10:03 a.m. with Neurosurgeon (NSG 1), NSG 1 stated neurosurgeons usually would get involved when there was a need to perform decompressive craniotomy for life saving measure for stroke patients experiencing massive brain swelling. During an interview on 12/17/2025 at 10:20 a.m. with NSG 1, NSG 1 stated the following: NSG 1 received a text message from ICU 1 on 7/18/2024 at 12:50 a.m. requesting consultation for Patient 7 for worsening of CT head scan and midline shift. NSG 1 did not see the text message until 3 a.m. (2 hours later) because NSG 1 was sleeping. NSG 1 stated he (NSG 1) was the on-call neurosurgeon that day (7/18/2024). Normally consultation requests were done by phone call not by text messaging. If the on-call physician did not reply within 30 minutes, the requesting physician should have contacted the backup physician. NSG 1’s back up physician did not receive any phone call either. NSG 1 stated he (NSG 1) coordinated care with ICU 1 and facility’s operation team for surgery then rushed to the hospital to see Patient 7. During an interview on 12/17/2025 at 10:24 a.m. with NSG 1, NSG 1 stated the following: Patient 7’s neuro status was deteriorating and there was no necessary step taken to intervene. For stroke patients, the earlier the interventions, the better to increase chance of survival and preserve brain function. NSG 1 stated, “this (Patient 7’s death) was a preventable death.” During an interview on 12/17/2025 at 12:39 p.m. with ICU 1, ICU 1 stated the following: ICU 1 remembered contacting NSG 1 after speaking with NEURO 1 but did not remember what time and how the communication was made. ICU 1 did not remember asking nursing staff to contact NSG 1. ICU 1 stated, “there was a lot going on at that time. I was trying to stabilize the patient (Patient 7) medically.” During an interview on 12/17/2025 at 3:20 p.m. with the President-Elect (PE/MD 3) of Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital), PE/MD 3 stated if physicians communicated through text messaging, the receiving physician might not see it right away. During an interview on 12/17/2025 at 3:25 p.m. with the Secretary (SEC) of MEC, SEC stated NSG 1 reached out to SEC with concern of ICU 1 texting NSG 1 for Patient 7’s urgent consult (on 7/18/2024). SEC stated, “situation like this, phone call would be more appropriate.” During a review of Patient 7’s operation notes (procedure report), dated 7/18/2024, the operation notes indicated, Patient 7 underwent right hemicraniectomy for massive malignant brain swelling following a large MCA stroke. The operation notes also indicated, “patient (Patient 7) had no brain function ... recommend brain death exam protocol, followed by withdrawal of care if brain death confirmed.” During a review of Patient 7’s “Death Pronouncement” note, dated 7/20/2024, the “Death Pronoucement” note indicated, Patient 7’s time of death was on 7/20/2024 at 1:01 a.m. During a review of the facility’s “Medical Staff Bylaws,” dated 10/2020, the Med Staff Bylaws indicated, “Responsibilities of the Medical Staff Members ... Each member of the Medical Staff shall: 1. Provide his patients with care at the generally recognized professional level of quality and efficiency established by the Medical Staff 2. Abide by the Medical Staff Bylaws, Rules and Regulations and by all other lawful Standards, Policies, and Rules of the medical center approved by the Medical Staff ... 10. Work cooperatively with members, nurses, hospital administrations and others so as not to adversely affect patient care.” During a review of the facility’s “Medical Staff General Rules and Regulations (Med Staff Rules and Regs),” dated 10/2020, the Med Staff Rules ad Regs indicated, “General Rules and Regulations shall be established to control the conduct of work of the Medical Staff as a whole ... Article III: Admission and Discharge of Patients 3.1General Guidelines ... 3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient ... Article VI: Consultations 6.1 General Guidelines 6.1-1 The good conduct of medical practice includes the proper and timely use of consultations. Judgement as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment, rests with the practitioner responsible for the care of the patient. On the other hand, it is the duty of the organized Medical Staff through its Department Chairs and Medical Executive Committee to see that those with clinical privileges do not fail in the matter of calling consultants as needed.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.” 3. During an interview on 12/17/2025 at 10:24 a.m. with Neurosurgeon (NSG 1), NSG 1 stated the following: Patient 7’s neuro status was deteriorating and there was no necessary step taken to intervene (on 7/17/2024). For stroke patients, the earlier the interventions, the better to increase chance of survival and preserve brain function. NSG 1 stated, “this (Patient 7’s death) was a preventable death.” During an interview on 12/17/2025 at 10:37 a.m. with NSG 1, NSG 1 stated the following: he (NSG 1) alerted and requested the chair of Medicine Department (a medical staff unit focused on internal medicine [diagnosing and treating adult illnesses]) to review Patient 7’s case shortly after Patient 7’s death (on 7/20/2024). He (NSG 1) also notified the facility’s Chief Executive Officer (CEO) and Chief Medical Officer (CMO) July this year (2025) urging for Patient 7’s case review. Patient 7’s death was preventable. There should be peer review (medical peer review is a performance assessment to evaluate other physician’s clinical performances) and root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) to identify the problems and find a solution so the same mistake would not happen to other patients. NSG 1 also stated, it had been over a year and a half since Patient 7’s death (7/20/2024) and he (NSG 1) had not received any feedback. During an interview on 12/17/2025 at 10:45 a.m. with Vice President of Quality (VPQ), VPQ stated Patient 7’s case was reviewed at Medicine Department in October 2025 and reviewed by Multi-disciplinary Peer Review Committee (MDPR committee, a medical staff committee review and discuss referred cases focusing on process improvement and practice issues; to advise and make recommendations to the appropriate medical staff department and the MEC [Medical Executive Committee, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital]) in November 2025. During an interview on 12/17/2025 at 11:38 a.m. with the Chief Medical Officer (CMO), CMO stated CMO received request from NSG 1 to review Patient 7’s case. CMO referred Patient 7’s case to Quality Department (hospital department examines the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) for peer review. During an interview on 12/17/2025 at 3:31 p.m. with the Secretary (SEC) of Medical Executive Committee (MEC), SEC stated the following: he (SEC) was the Chair of Medicine Department in 2024. NEURO 1 reached out to him (SEC) about Patient 7’s case and requested peer review. Peer review process started at department level first then depending on the result, it would be referred to Multi-disciplinary Peer Review Committee (MDPR) for next level of peer review, then MDPR would make recommendation to MEC for final decision. SEC, as the chair of Medicine Department, did an initial screening of case and agreed there was deviation from standard of practice and needed to escalate to peer review. Patient 7’s case was scheduled in September 2024 for departmental peer review. However, NEURO 1 did not show up in the department peer review meeting. Patient 7’s case peer review was rescheduled. Then, there were internal conflicts which arose within the MEC. Patient 7’s case peer review was postponed. SEC further stated the following: there was a delay in peer review for Patient 7’s case. Delay of peer review could impact patient’s safety if the physician practice did not improve. During a review of the facility’s “Medical Staff Meeting - Medicine Section Meeting - Peer Review” meeting minutes (Medicine PR minutes), dated 10/8/2025, the Medicine PR minutes indicated, Patient 7’s case was deferred during 9/18/2024 and 11/18/2024 department peer review meeting due to the absence of the reviewee. Peer review was rescheduled and reviewed during the department peer review meeting on 10/8/2025 and decision was made to refer to MDPR for next level review. During an interview on 12/18/2025 at 4:29 p.m. with VPQ, VPQ stated Patient 7’s case was reviewed during MDPR meeting on 11/18/2025 but meeting minutes were not available for review at this time. During a review of the facility’s “Medical Executive Committee” meeting minutes (MEC meeting minutes), dated 11/19/2025, the MEC meeting minutes indicated, 11/18/2025 Multi-disciplinary Peer Review Committee (MDPR) meeting minutes were not available for review at this time. During an interview on 12/22/2025 at 2:40 p.m. with the President-Elect (PE/MD 3) of Medical Executive Committee (MEC), PE/MD 3 stated the following: MEC would review MDPR meeting minutes including peer review recommendations for final review and decision making. MEC was the only committee with enforcement (to take action) power over the medical staff. The MEC would review 11/18/2025 MDPR meeting minutes during the next meeting in January 2026 (December was dark meaning no MEC meeting). During a review of the facility’s “Medical Staff Bylaws,” dated 10/2020, the Med Staff Bylaws indicated, “Article IX Peer Review & Corrective Action ... 9.1 Criteria for Initiation ... Any person may provide information to the Medical Staff about the conduct, performance, or competence of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (1) detrimental to patient safety or to the delivery of quality patient care within the medical center; (2) unethical; (3) contrary to the Medical Staff Bylaws, and Rules and Regulations ... a request for an investigation or action against such member may be initiated by the President of the Medical Staff, a Department Chairman, Chief Executive Officer, Medical Executive Committee or the Governing Board ... the goals of the peer review processes are to prevent, detect and resolve problems and potential problems through routine collegial monitoring, education and counseling. However, when necessary, remedial measures, including formal investigation and discipline, must be implemented and monitored for effectiveness ... peers in the departments and committees are responsible for carrying out delegated review and quality improvement functions as described in the Medical Staff Peer Review Policy in a manner that is consistent, timely, defensible, balanced, useful and ongoing ...” During a review of the facility’s “Medical Staff General Rules and Regulations (Med Staff Rules and Regs),” dated 10/2020, the Med Staff Rules ad Regs indicated, “General Rules and Regulations shall be established to control the conduct of work of the Medical Staff as a whole ... Article III: Admission and Discharge of Patients 3.1General Guidelines ... 3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient ... Article VI: Consultations 6.1 General Guidelines 6.1-1 The good conduct of medical practice includes the proper and timely use of consultations. Judgement as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment, rests with the practitioner responsible for the care of the patient. On the other hand, it is the duty of the organized Medical Staff through its Department Chairs and Medical Executive Committee to see that those with clinical privileges do not fail in the matter of calling consultants as needed.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its Registered Nurses (RNs) provided adequate monitoring and took action to manage one of 34 sampled patients (Patient 7) who had an acute (new onset) stroke (a sudden disruption of blood flow to the brain), when Patient 7 presented progressive deterioration (getting worse) in neurological status (the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) on 7/17/2024 as evidenced by: 1. Inadequate and incomplete neurological (neuro) assessment (assessment performed by nurse to check for patient’s mental status and alertness) on 7/17/2024. 2. Failure to activate Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) when Patient 7 experienced a change in neuro status on 7/17/2024 at 10:47 a.m. and progressively deteriorated throughout the day. RRT was not called until 7/18/2024 at 12:05 a.m. 3. Failure to follow up and carry out STAT (a medical abbreviation for immediately or without delay) computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) ordered on 7/17/2024 at 9:37 p.m. CT head scan was done on 7/18/2024 at 12:51 a.m. These deficient practices resulted in a delay in Rapid Response Team (RRT) evaluation and delay in CT head scan leading to failure in providing timely interventions causing Patient 7 to undergo t emergency right craniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) on 7/18/2024. Patient 7 was found with no brain function during the operation. Patient 7 subsequently died on 7/20/2024. On 12/18/2025 at 2:33 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Manager of Accreditation, Regulatory & Licensing (MARL), Chief Nursing Officer (CNO) and Assistant Chief Nursing Officer (ACNO). The facility failed to ensure its Registered Nurses (RNs) provided adequate monitoring and took action to manage an acute (new onset) stroke (a sudden disruption of blood flow to the brain) patient (Patient 7) when Patient 7 presented progressive deterioration (getting worse) in neurological status (the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) on 7/17/2024, resulting in delay in Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) activation and delay in computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury). Patient 7 subsequently died on 7/20/2024. Patient 7 was admitted to the facility on 7/14/2024 for acute stroke. Patient 7 was awake, alert and oriented with a Glasgow Coma Scale Score (GCS, assesses consciousness after brain injury, ranging from 3 to 15, by summing points for eye [4], verbal [5], and motor [6] responses) of 15 out of 15 (a score of 8 or less generally indicates severe injury/coma, 9 to12 moderate, and 13 to15 mild) and NIH Stroke Scale (NIHSS, a tool used to quickly assess stroke severity, track changes, and guide treatment, with scores from 0 [no symptoms] to 42 [severe stroke]) score of 17 out of 42 (a score of 1 to 4 is minor, 5 to 15 is moderate, 16 to 20 is moderate-to-severe, and above 20 is severe) as baseline. On 7/17/2024, Patient 7 was noted to have a decrease of GCS score at 8 out of 15 and became more lethargic (a state of unusual drowsiness and reduced mental alertness) since the morning of 7/17/2024. Nursing staff did not call RRT or activate Code Stroke (a facility-specific emergency response for neurological changes and suspected strokes) in response to Patient 7’s acute change in neuro condition. Patient 7’s condition continued to deteriorate. Patient 7’s NIHSS score was doubled to 34 out of 42 during the night shift nurse assessment on 7/17/2024 at 8 p.m. and yet no RRT was called. There was a STAT (a medical abbreviation for immediately or without delay) CT head scan order placed on 7/17/2024 at 9:47 p.m. but it was not carried out. RRT was finally called on 7/18/2024 at 12:06 a.m. when Patient 7 was experiencing respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway) and altered mental status (AMS - disruption in how the brain works that causes a change in behavior). Patient 7 was emergently intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and sent for STAT CT head scan. The STAT CT head scan completed on 7/18/2024 at 12:58 a.m. indicated Patient 7 had a right to left midline shift (the displacement of brain structures from the center line, a serious sign of increased pressure inside the skull caused by things like stroke, tumors or head injury) with herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings). Patient 7 then underwent emergency right craniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) on 7/18/2024. Patient 7 was pronounced dead on 7/20/2024. The delay in escalation of care including calling RRT and STAT CT head resulted in a failure in providing timely interventions and contributed to Patient 7’s death on 7/20/2024. On 12/22/2025 at 5:31 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), and Manager of Accreditation, Regulatory & Licensing (MARL) with the Chief Nursing Officer (CNO) in attendance over the phone, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the facility had implemented a series of targeted interventions: the stroke order set was revised to mandate neuro check (neurological assessment performed by nursing staff) frequency options (every hour, every two [2] hours, every four [4] hours) based on NIHSS guidelines, and a nurse-driven order set was created to ensure adequate neuro checks when the stroke order set was not initiated. Nursing staff were being re-educated through in-person huddles and in-services on comprehensive neurological assessments (neuro check), the BEFAST stroke recognition mnemonic (a tool to recognize stroke signs and symptoms), and the importance of activating Rapid Response Teams (RRT) when patient conditions change (decline) from baseline or when STAT imaging orders were delayed beyond 60 minutes. Monthly audits of neurological assessments would be conducted and reported to both the Stroke and Quality Management Committees. Policies including “Code Stroke” and “Consultation Response Time” were updated to include NIHSS evidence-based options for neuro checks, allowing any staff to initiate Code Stroke, and require direct verbal communication (in person or by telephone) between physicians for consultations with documentation in physician progress notes while electronic messaging alone was not sufficient accordingly. Memos with read receipts were sent to Internal Medicine and Family Practice Committee members to ensure awareness of these changes. Additionally, radiology technicians (staff creates diagnostic images to help physicians diagnose disease and injuries) received directives to document any delays or cancellations in imaging procedures and escalate issues to the Radiologist (medical doctor specializing in diagnosing and treating disease using medical imaging). These comprehensive measures aimed to enhance patient safety, improve response times, and ensure adherence to best practices in stroke care. Findings: 1. During a review of Patient 7’s consultation notes (formal report written by a specialist after examining a patient, detailing their assessment, diagnosis and specific recommendations for treatment and management), dated 7/18/2024, documented by neurosurgeon (medical doctor specializing in the surgical and non-surgical treatment of the brain, spinal cord and peripheral nerve, [NSG 1]), the consultation notes indicated, “Patient 7 was admitted on 7/14/2024 with right MCA (middle cerebral artery) infarct (type of stroke resulting from failure of blood supply), doing relatively well until the morning of 7/17/2024 when Patient 7’s neuro status (neurological status, the overall condition and function of your brain, spinal cord, and nerve, assessed through a neurological exam checking mental status [alertness, cognition], checking sizes and reaction of pupils, motor skills [strength, balance, coordination], reflexes and sensation) deteriorated (getting worse) with worsening left sided weakness and becoming obtunded (reduced level of consciousness). The consultation notes also indicated Patient 7 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill). During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left-sided weakness. During a review of Patient 7’s nursing admission assessment titled, “Admission Assessment Inquiry,” dated 7/14/2024, the admission assessment indicated, on 7/14/2024 at 10:54 a.m., Patient 7 was alert with Glasgow Coma Scale (GCS, assesses consciousness after brain injury, ranging from 3 to 15, by summing points for eye [4], verbal [5], and motor [6] responses) score of 15 out of 15 (a score of 8 or less generally indicates severe injury/coma, 9 to12 moderate, and 13 to15 mild) and NIH Stroke Scale (NIHSS, a tool used to quickly assess stroke severity, track changes, and guide treatment, with scores from 0 [no symptoms] to 42 [severe stroke]) score of 17 out of 42 (a score of 1 to 4 is minor, 5 to 15 is moderate, 16 to 20 is moderate-to-severe, and above 20 is severe). During a review of Patient 7’s MRI (magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to create detailed images of organs, and bones) Brain without contrast (dye) report (MRI report), dated 7/15/2024, the MRI report indicated Patient 7 had a “moderate-to-large size area of restricted diffusion (MRI term describing limited movement of water molecules within tissues most famously seen in acute stroke due to cell swelling) involving right frontoparietal lobe (refer to the interconnected regions of the front lobe [behind the forehead and the parietal lobe [at the top/back of the head]) ... compatible with acute (new onset) to subacute (transition phase between acute and chronic [long-term]) infarct (type of stroke resulting from failure of blood supply).” During a review of Patient 7’s consultation notes, dated 7/15/2024, documented by neurologist (medical doctor specialized in diagnosing, treating and managing disorder of the brain, spinal cord, peripheral nerves and muscles [NEURO 1]), the consultation notes indicated, Patient 7 was “awake, alert and oriented, speech/language was fluent, followed commands ... PERRL (pupils equal, round, reactive to light) ... left hemiparesis (weakness on one side of the body).” The consultation notes also indicated care plan for Patient 7 to include neuro check (assessment performed by nurse to check for patient’s mental status and alertness) every four (4) hours and NIHSS per protocol. During an interview on 12/15/2025 at 10:38 a.m. with a Telemetry Registered Nurse (RN) 21, RN 21 stated the following: nurses should perform neuro assessment (neuro check) every four (4) hours for stroke patients. The neuro assessment would include checking a patient’s level of consciousness (measures a person’s awareness and responsiveness to stimuli), pupils’ sizes and reaction, ability to move all extremities and strength, and Glasgow Coma Scale (GCS) while NIH Stroke Scale (NIHSS) would be done once a shift (every 12-hour shift). If there were any changes noted in neuro assessment, nurses should call Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) and notify the physician. During a concurrent interview and record review on 12/16/2025 at 10:06 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s “Daily Assessment Inquiry (nursing daily assessment),” dated 7/17/2024, was reviewed. The nursing daily assessment indicated neuro assessment was performed on 7/17/2024 as follows: -at 7:10 a.m.: Patient 7 was alert, both pupils were brisk (pupils quickly shrinking when a light is shone to them, indicating a healthy brain function) at 2 millimeters (mm, a unit of measure, in this case refer to pupil size), clear speech, bilateral (both) hand grip was light, left arm and left leg strength was weak, GCS score was 14 out of 15 (3 - opens eye to speech/ sound, 5 - oriented [knows name, place, time], alert and appropriate, 6 - obeys commands); -at 10:46 a.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 1 - no verbal response, 5 - localizes to pain stimulus) without any other neurological assessment documented; -at 8 p.m.: Patient 7 was lethargic (a state of unusual drowsiness and reduced mental alertness), no pupils assessment documented, unable to perform hand grips, GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 2 - unintelligible moans, 4 - withdraws [pulls away] from painful stimulus); -at 12:40 a.m. (7/18/2024): Patient 7 was unresponsive, bilateral pupils were fixed at 4 mm, GCS score was 6 out of 15 (1 - no eye opening, 1 - no verbal response, 4 - withdraws from painful stimulus). -NM 1 stated the following: the neuro assessment (neuro check) performed at 8 p.m. was incomplete because the pupil’s assessment was missing. There was no pupil check for about 17 hours (from 7:10 a.m. to 12:40 a.m. next day). The incomplete neuro check could lead to missing identification of Patient 7’s changing neuro condition. Fixed pupils would suggest significant neuro issues which were usually a late sign of severe neurological damage. During an interview on 12/16/2025 at 10:23 a.m. with the Nurse Manager (NM 1) of Telemetry, NM 1 stated there was no physician order placed for neuro check every four (4) hours for Patient 7. Patient 7’s neurological assessment and NIHS Stroke Scale was done once a shift (every 12-hour shift) per unit protocol. During an interview on 12/16/2025 at 2:37 p.m. with Registered Nurse (RN) 23, RN 23 stated the following: patients with acute stroke should be placed on neuro check at least every four (4) hours. It was important to monitor stroke patients frequently to identify any new or worsening of neurological deficits. “Time is brain (a medical phase emphasizing that during a stroke, brain tissue dies rapidly),” nurse should call physician or call Code Stroke right away because worsening of neurological status could be fatal. During an interview on 12/17/2025 at 10:03 a.m. with Neurosurgeon (NSG 1), NSG 1 stated the following: acute stroke patients were at high risk for brain swelling after initial stroke. It was important to have frequent neuro monitoring to catch any signs of worsening of symptoms such as increasing drowsiness, worsening of weakness, worsening of slurred speech, no longer able to open eyes, so physician could be alerted and order a STAT (a medical abbreviation for immediately or without delay) computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) to determine if there was any worsening of cerebral (brain) swelling and to transfer the patient to Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) for closer observation and monitoring. During an interview on 12/17/2025 at 12:12 p.m. with Intensivist (critical care physician, medical doctor specialized in managing critically ill patients [ICU 1]), ICU 1 stated the following: there should be frequent neuro checks at a minimum of every 4 hours for stroke patients because they were at higher risk for brain swelling. Any signs of altered mental status, vomiting, change in pupils either fixed or dilated could be signs of brain herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings). Any acute changes in neuro status would need an evaluation of the current stroke and a STAT CT head scan. ICU 1 also stated, “time is brain (a medical phase emphasizing that during a stroke, brain tissue dies rapidly), the more you delay in care, the patient will have permanent neuro deficit and can die.” During an interview on 12/18/2025 at 8:32 a.m. with the Director (DIR 3) of Telemetry, DIR 3 stated the following: it was the nurse’s responsibility to perform neuro assessment on patients. Nurses were required to perform a complete neuro assessment including checking the level of consciousness, orientation, pupils’ sizes and reaction, extremities movement and strength, and speech. Nurses were also required to perform a complete neuro assessment when there was a decrease in GCS score. Nurses should call RRT immediately to get quick intervention upon identifying any acute change in a patient’s neuro status. During a review of Patient 7’s “Rapid Response Team Documentation Form (RRT form),” dated 7/18/2024, the RRT form indicated, RRT was called on 7/18/2024 at 12:05 a.m. due to Patient 7 experiencing respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and change in level of consciousness. The RRT form also indicated Patient 7 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to ICU for higher level of care. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment - Nursing,” dated 6/2025, the P&P indicated, “The Registered Nurse must conduct a comprehensive assessment of the patient ... The scope and intensity of assessment are based on the patient’s diagnosis, the care setting, the patient’s desire of care, and the patient’s response to any previous care. Reassessments are completed at regular intervals determined by a patient’s response to care and significant changes in condition or diagnosis.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.” 2. During a review of Patient 7’s “History and Physical (H&P),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry floor due to acute cerebrovascular accident (CVA, also known as stroke) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During a review of Patient 7’s nursing admission assessment titled, “Admission Assessment Inquiry,” dated 7/14/2024, the admission assessment indicated, on 7/14/2024 at 10:54 a.m., Patient 7 was alert with Glasgow Coma Scale (GCS) score of 15 out of 15 and NIH Stroke Scale (NIHSS) score of 17 out of 42. During a review of Patient 7’s MRI Brain without contrast report, dated 7/15/2024, the MRI report indicated Patient 7 had a “moderate-to-large size area of restricted diffusion involving right frontoparietal lobe ... compatible with acute to subacute infarct.” During a concurrent interview and record review on 12/16/2025 at 10:29 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s “Daily Assessment Inquiry (nursing daily assessment),” dated 7/17/2024, was reviewed. The nursing daily assessment indicated Patient 7’s GCS and NIHSS scores as follows: -at 7:10 a.m.: Patient 7’s GCS score was 14 out of 15 (3 - opens eye to speech/ sound, 5 - oriented [knows name, place, time], alert and appropriate, 6 - obeys commands); -at 10:46 a.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 1 - no verbal response, 5 - localizes to pain stimulus) and NIHSS score was 17 out of 42; -at 8 p.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 2 - unintelligible moans, 4 - withdraws [pulls away] from painful stimulus) and NIHSS score was 34 out of 42; -NM 1 stated the following: at 10:46 a.m., there was a change in Patient 7’s GCS score from 14 to 8 which could suggest a neuro status change. Nurse should have activated RRT for rapid assessment. At 8 p.m. Patient 7’s NIHSS score was double (score of 34) from previous assessment (score of 17 at 10:47am). The higher the NIHSS score suggested more neuro deficits that Patient 7 was experiencing. The nurse should have activated a code stroke. NM 1 stated that delay in calling RRT and code stroke (a facility-specific emergency response for neurological changes and suspected strokes) could compromise Patient 7’s health. Patient 7 could become brain dead. During a concurrent interview and record review on 12/16/2025 at 10:32 a.m. with NM 1, Patient 7’s “MD communication” notes, dated 7/17/2024, was reviewed. The “MD communication” notes indicated, on 7/17/2024, RN 11 left message for NEURO 1 for consult and at 3:19 p.m., RN 11 informed NEURO 1 about Patient 7’s change of condition that “patient (Patient 7) is more lethargic today (7/17/2024). Doctor (NEURO 1) said [NEURO 1] will come see the patient (Patient 7) today (7/17/2024).” NM 1 stated Patient 7 was showing neuro status change and RN 11 should have called RRT and/or Code Stroke despite calling the physician. During an interview on 12/16/2025 at 2:37 p.m. with Registered Nurse (RN) 23, RN 23 stated the following: patients with acute stroke should be placed on neuro check at least every four (4) hours. It was important to monitor stroke patients frequently to identify any new or worsening of neurological deficits. “Time is brain,” nurse should call physician or call Code Stroke right away because worsening of neurological status could be fatal. Another NIHSS assessment should be performed to evaluate the patient. The higher the NIHSS score the more severe the stroke symptoms patients experienced. Patients should be sent for STAT CT head scan right away. During a concurrent interview and record review on 12/18/2025 at 10:01 a.m. with the Director (DIR 3) of Telemetry, Patient 7’s “MD communication” notes, dated 7/17/2024 at 11:52 p.m. and Patient 7’s “Rapid Response Team Documentation Form,” dated 7/18/2024, were reviewed. The “MD communication” notes, indicated on 7/14/2024 at 11:52 p.m., Patient 7’s attending physician (MD 8) was called due to Patient 7 who had episodes of a few seconds of apnea (temporary pauses in breathing) and heart rate was sustained at 120’s. The “MD communication” note also indicated, “waiting for [MD 8] to call back. The “Rapid Response Team Documentation Form,” indicated, RRT was called on 7/18/2025 at 12:05 a.m. due to Patient 7 experiencing respiratory failure and change in level of consciousness. DIR 3 stated nursing staff should have activated RRT right away when MD 8 did not answer the phone. DIR 3 confirmed the RRT was called thirteen (13) minutes after call was made to MD 8 on 7/14/2024 at 11:52 p.m. During a review of Patient 7’s Rapid Response Team Documentation Form, dated 7/18/2024, the RRT form indicated, RRT was called on 7/18/2024 at 12:05 a.m. due to Patient 7 experiencing respiratory failure and change in level of consciousness. The RRT form also indicated Patient 7 was intubated and transferred to ICU for higher level of care. During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team (RRT),” dated 9/2025, the P&P indicated, “establish a procedure for a rapid assessment of a patient with acute status changes. The goal is to improve patient outcomes by providing a means for rapid and timely interventions ... initiation of RRT includes, but is not limited to ... acute change in mental status, lethargy, agitation, confusion ... stroke ...” During a review of the facility’s policy and procedure (P&P) titled, “Code Stroke,” dated 11/2023, the P&P indicated, “Definition(s): Code Stroke: the emergent process for recognition and treatment of acute stroke patients. Stroke symptoms include: sudden numbness or weakness of the face, arm, or leg, especially on one side of the body, sudden confusion, trouble speaking, or understanding ... Inpatient: When an inpatient meets the acute stroke criteria, onset of symptoms within three (3) hours or last known well time is three (3) hours or less, X 9999 will be called by any staff that identifies the changes in patient condition and notify PBX to page RRT overhead, and alert the appropriate team members ... Rapid Response Nurse a. assess the patient to determine the onset of symptoms, the symptoms the patient is demonstrating and perform a modified NIHSS stroke screen. If positive, the Rapid Response Nurse will contact the hospital operator by dialing X 9999 and state the need to page a Code STROKE.” 3. During a review of Patient 7’s “History and Physical (H&P),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry floor due to acute (new onset) cerebrovascular accident (CVA - stroke; a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left-sided weakness. During a review of Patient 7’s MRI Brain without contrast report, dated 7/15/2024, the MRI report indicated Patient 7 had a “moderate-to-large size area of restricted diffusion involving right frontoparietal lobe ... compatible with acute to subacute infarct.” During a review of Patient 7’s consultation notes, dated 7/15/2024, documented by neurologist (NEURO 1), the consultation notes indicated, Patient 7 was “awake, alert and oriented, speech/language was fluent, followed commands ... PERRL ... left hemiparesis.” The consultation notes also indicated care plan for Patient 7 included neuro check every four (4) hours and NIHSS per protocol. During a review of Patient 7’s physician progress notes, dated 7/17/2024, documented by NEURO 1, the physician progress notes indicated, “date of service: 7/17/2024 at 5:51 p.m. ... patient (Patient 7) has been sleeping the entire day ... (Patient 7) projectile vomiting (forceful expulsion of stomach contents) during my (NEURO 1) encounter and vomiting bile (yellowish-green stomach contents) ... mental status - somnolent (sleepy, drowsy), difficult to arouse (to stay awake) ... not talking ... sensory - does not withdraw from nailbed pressure ... plan ... check CT head wo (without) contrast (dye).” During an interview on 12/15/2025 at 2:39 p.m. with the Director (DIR 7) of Imaging Services, DIR 7 stated the facility’s CT scan service was available 24-hour 7 days a week and STAT CT scan should be completed within 60 minutes from scan (scanning performed by radiology technician) to be read (result interpreted by a radiologist) per national standard. During a concurrent interview and record review on 12/16/2025 at 11:16 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s physician orders, dated 7/17/2024 and 7/18/2024, were reviewed. The physician orders indicated there was a STAT CT head without contrast ordered by Patient 7’s neurologist (NEURO 1) on 7/17/2024 at 9:47 p.m. with indicated reason for cerebrovascular accident (CVA), and a STAT CT head without contrast ordered by Patient 7’s intensivist (ICU 1) on 7/18/2024 at 12:27 a.m. with indicated reason for cerebrovascular accident. NM 1 stated the CT scan order placed on 7/17/2024 at 9:47 a.m. was not done. NM 1 stated there was no documentation indicating any reason for not performing the CT scan. NM 1 stated Patient 7’s CT head scan was completed on 7/18/2024 at 12:51a.m. after the second STAT CT scan order was placed. During an interview on 12/18/2025 at 8:32 a.m. with the Director (DIR 3) of Telemetry, DIR 3 stated the following: for nursing, STAT order meant to be done within 30 minutes. Nurses should call the CT technician to follow up if the STAT CT scan ordered was not done within the time frame. Nurses should also notify the physician for any CT delay and document the reason. During an interview on 12/19/2025 at 2:32 p.m. with NEURO 1, NEURO 1 stated the following: when a STAT CT head was ordered. She (NEURO 1) expected it to be done within 30 minutes to an hour. Nurses should call the physician and tell the physician why it was not done promptly so the physician could decide what to do. If the patient was not stable for the CT scan, then the physician could escalate the care and stabilize the patient first then take patient to the CT scan. During a review of Patient 7’s CT Head without contrast report, dated 7/18/2024 at 12:51 a.m., the CT report indicated, “evolving (progressing, getting worse) right MCA (middle cerebral artery) territory infarct (type of stroke resulting from failure of blood supply) with significantly larger area involved compared to prior ... there is right to left midline shift (the displacement of brain structures from the center line, a serious sign of increased pressure inside the skull caused by things like stroke, tumors or head injury) of 12 mm (millimeters, a unit of measure) ... there appeared to be right uncal herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings).” During a review of Patient 7’s physician progress notes, dated 7/18/2024, documented by NEURO 1, the physician progress notes indicated, “CT was delayed but was completed showing cerebral (brain) edema (swelling) with worse midline shift. I (NEURO 1) recommended consulting NSGY (neurosurgery) for emergent craniotomy (a neurosurgical procedure to temporarily remove a piece of skull to access and operate the brain) at 1 a.m.” During a review of Patient 7’s operation notes (procedure report), dated 7/18/2024, the operation notes indicated, Patient 7 underwent right hemicraniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) for massive malignant (dangerous) brain swelling following a large MCA stroke. The operation notes also indicated, “patient (Patient 7) had no brain function ... recommend brain death exam protocol (examination by doctor to confirm all brain function has permanently stopped, making the person legally dead), followed by withdrawal of care if brain death confirmed.” During a review of Patient 7’s “Death Pronouncement” note, dated 7/20/2024, the “Death Pronoucement” note indicated, Patient 7’s time of death was on 7/20/2024 at 1:01 a.m. During a review of the facility’s policy and procedure (P&P) titled, “Daily Workflow,” dated 9/2020, the P&P indicated, “STAT Examinations: 1. Request for STAT exams may be made at any time. a) the call should be made to the CT technologist ... c) the STAT exam should be done as soon as possible after the information is received by Imaging ... Priority of Examinations (Orders in which examinations are performed): 1. Code Stroke CT Brain 2. Trauma Cases - rule out bleeding 3. STAT Exams 4. ASAP or High Priority 5. ICU/CCU cases 6. Regular nursing floors ...” During a review of the facility’s policy and procedure (P&P) titled, “Diagnostic Imaging Scope of Service,” dated 5/2025, the P&P indicated, “Goals and Objectives ... to provide quality and timely customer service to all patients/customers visiting the Diagnostic Imaging Department ... turn around times ... computerized tomography (CT) ... STAT orders within sixty (60) minutes ... Relationship with other departments ... the department works with all hospital clinical, administrative and support departments and services to provide appropriate and safe patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.””

“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: 46238 Based on interview and record review, the facility failed to ensure that a post-fall huddle (a meeting held promptly after a patient fall to discuss the circumstances, contributing factors, and strategies to prevent future falls) was completed for one of 34 sampled patients (Patient 17), after Patient 17 reported an unwitnessed near-fall incident (an event where a patient almost falls but catches themselves without any witnesses present), in accordance with the facility’s policy regarding fall prevention. This deficient practice had the potential to result in repeated falls and injuries for Patient 17 and other patients due to non-compliance with policies, increasing the risk of falls, compromising safety, and causing delays or inadequate treatment. Findings: During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence), after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones), was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture ( a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s Daily Focus Assessment Report (a report that documents the patient’s daily condition and any significant events), dated 12/24/2025, the report indicated that Patient 17 reported a near-fall (an event where a patient almost falls but catches themselves) in the bathroom while sitting on a toilet bowl, mentioning that her (Patient 17) right hand and arm touched the floor to prevent further falling down. The report also indicated that the registered nurse assigned to take care of Patient 17 on 6/24/2025 called the physician’s assistant to report this incident and obtained an order for an X-ray (a way for providers to get pictures of the inside of your body) of the right arm/hand. During a concurrent interview and record review on 12/17/2025 at 10:20 a.m. with the System Analyst (IT 1), a post-fall huddle record (a meeting held promptly after a patient fall to discuss the circumstances, contributing factors, and strategies to prevent future falls), dated 6/24/2025, was requested, but not provided by the facility. During an interview on 12/17/2025 at 12:30 p.m. with the Manager of Accreditation and Regulatory Licensing (MQRM), MQRM confirmed that no post-fall huddle record was completed by nursing staff after Patient 17 reported a near-fall on 6/24/2025. During a concurrent interview and record review on 12/18/2025 at 9:52 a.m. with the Manager of the Acute Rehabilitation Unit (NM 4), Patient 17’s nurse’s note (Daily Focus Assessment Report, dated 6/24/2025) regarding the fall on 6/24/2025, was reviewed. NM 4 said, “After the fact, I investigated the fall. I interviewed the nurse. The patient stated that they fell and caught themselves on the floor. The physician’s assistant was notified about the fall and ordered X-rays. Per our policy and procedure, the nurse should have completed an incident report-an unusual event that happened to the patient, which can be something the patient is claiming or stating, and we want to submit it so it can be assigned to someone for an investigation. Patients can benefit from it because we should follow up on the outcomes and prevent the same incident from occurring again, ensuring the safety of the patient. We have a fall prevention and management policy. The nurse escalated it to the charge nurse, and the charge nurse said there was no need for an incident report, so it was not done because the patient only sustained a near-fall, not an actual fall. A post-fall huddle is usually done after a fall event. It involves stopping work and providing feedback on what they (nurses and the patient) were doing at that time, and we want to get feedback from the nurse who leads the huddle. The huddle should have been done for Patient 17...” NM 4 did not provide a comment on possible implications for Patient 17 for not conducting a post-fall huddle with nursing staff and for not following the policy and procedure regarding fall prevention that was established in the facility. During an interview on 12/18/2025 at 9:45 a.m. with the Vice President of Quality Risk Management (VPQRM), VPQRM stated that Patient 17’s accidental fall (a fall that occur due to extrinsic environmental risk factors or hazards: spills on the floor (such as water or urine), tripping on clutter, tubing/cords on the floor or errors in judgement ( such as not paying attention or leaning against a curtain or unlocked furniture) on 6/24/2025 was not escalated by nursing to the quality department, and risk management was unaware of the incident until a complaint was received. VPQRM confirmed that no event report was completed for Patient 17’s fall on 6/24/2025. During a review of the facility’s policy and procedure (P&P) titled, Fall Prevention Management, Mobility and Ambulation,” dated 2/2025, the P&P indicated that, “After a fall, f. Conduct Post Fall Debrief and complete Post Fall Debrief Form. Ask the patient what happened, if patient able to self-report. Information may be used to prevent repeat falls... 3. Documentation: Complete an online event report. e. Complete Post Fall Debriefing Form for all falls and send original to Unit Manager/Director. f. Manager/Director will review and send to Risk Management/Patient Safety Officer or designee...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that a record of discussion of a patient’s post-fall (after a fall [an unintentional descent to the floor or a lower surface [like a bed or chair], with or without injury, often due to a combination of patient risks [like confusion, weakness, age] and environmental hazards [like poor lighting or slippery floors], leading to potential serious harm]) X-ray (radiograph, a medical imaging technique used to view the internal structure of the body, which helps in diagnosing fractures or other conditions) results and recommendations for treatment were written, completed, filed, and readily accessible in the electronic medical record (EMR, digital version of paper chart) for one of 34 sampled patients (Patient 17), in accordance with the facility’s medical rules and regulations pertaining to medical record completion. This deficient practice has the potential to disrupt the continuity of care and potentially delay treatment due to the absence of accurate information necessary for formulating a patient’s treatment plan. Findings: During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones) was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture (a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s Daily Focus Assessment Report (a report that documents the patient’s daily condition and any significant events), dated 12/24/2025, the report indicated that Patient 17 reported a near-fall (an event where a patient almost falls but catches themselves) in the bathroom while sitting on a toilet bowl, mentioning that her (Patient 17) right hand and arm touched the floor to prevent further falling down. The report also indicated that the registered nurse assigned to take care of Patient 17 on 6/24/2025 called the physician’s assistant to report this incident and obtained an order for an X-ray (a way for providers to get pictures of the inside of your body) of the right arm/hand. During a review of Patient 17’s Physician Progress note, dated 6/25/2025, the note indicated that the diagnostic report (X-ray), dated 6/24/2025 of Patient 17’s right forearm (the part of the arm between the elbow and the wrist, containing two long bones, the radius and the ulna), indicated the following: “s/p (status post, it means ‘after’) ORIF (Open Reduction Internal Fixation, a procedure for placement of surgical hardware such as plates or screws used to support the bone) of the distal radius ( ... hardware intact... there is a mildly displaced ulnar styloid process (a bony projection at the distal end of the ulna)... no osseous lesions identified (no abnormal bone tissue detected). There is an overlying splint seen... impression: mildly displaced fracture of the ulnar styloid process (a fracture that is not in perfect alignment but only slightly out of place).” During an interview on 12/10/2025 at 4:50 p.m. with Patient 17, Patient 17 said the following regarding the fall sustained on 6/24/2025 and stated that the fall was never reported or investigated, and she (Patient 17) was never treated for it. As a result, Patient 17 said she was still dealing with repercussions to the right wrist and hand, including a hairline fracture (a tiny crack in a bone) that she (Patient 17) was believed was sustained during the fall. Patient 17 said, “I have been experiencing issues and pain, which necessitated another surgical intervention at [Organization] to correct the injury. I never received any treatment for the fall at the facility.” During a concurrent interview and record review on 12/17/2025 at 2:28 p.m. with radiologist (MD 2, Medical Doctor specializing in diagnosing and treating diseases and injuries using medical imaging techniques such as X-rays, CT scans, MRI scans, nuclear medicine, and ultrasounds), Patient 17’s X-ray results, dated 6/24/2025, was reviewed. MD 2 stated that the report should specify if the fracture was acute (a condition that arises suddenly and is usually severe, but short in duration) or chronic (a condition that develops slowly and is long-lasting). MD 2 reviewed the images and said that the fracture was most likely old but could not confirm 100% due to the lack of comparison images. During an interview on 12/17/2025 at 3:16 p.m. with the President Elect/Interim Chief of Staff (MD 3), MD 3 said that the expectation from all physicians was to document all patients’ pertinent medical information in the progress notes. During an interview on 12/17/2025 at 12:09 p.m. with the Physician’s Assistant (PA), the PA stated the following, “I work in conjunction with multiple doctors in the Acute Rehabilitation Unit (ARU), but primarily with Medical Doctor (MD 1). I do my rounds in the morning, and if I receive a call later during the day, I document any incidents that occurred after my physical rounds the following day. I remember Patient 17 and recall ordering an X-ray. The impression of the report did not indicate an “acute fracture,” so the fracture must have been old. I did not have another X-ray for comparison but informed MD 1 about the results. The following day, I did not round on this patient. I am unaware if the fracture was sustained in the facility during the reported unwitnessed near-fall by Patient 17. I did not follow up on the results with the patient; I only communicated this with my supervising physician, MD 1.” During the same interview on 12/17/2025 at 12:08 p.m. with the physician’s assistant (PA), the PA said the following regarding the required documentation following up the fall: “It should definitely be documented that the patient fell in the progress notes. The patient should be monitored, continue with the pain management, review imaging results, document in progress notes, and make sure it does not happen again.” During an interview on 12/18/2025 at 11:08 a.m. with MD 1, MD 1 stated that Patient 17’s near-fall on 6/24/2025, was discussed with Patient 17. MD 1 admitted they (medical staff) did not have comparison X-rays and assumed the fracture was old. MD 1 said that Patient 17 should have been notified of the findings, informing the patient that there was no newly acquired/sustained fracture during Patient 17’s near-fall on 6/24/2025. MD 1 also confirmed there was no documentation in progress notes regarding the evaluation of the fall, the fall itself, and the recommendations for the patient. MD 1 stated that Patient 17 was not in significant pain during the evaluation. MD 1 recommended that the patient follow up with their orthopedist (a doctor specialized in diagnosing and treating bone, joint, muscle, and ligament conditions). Once MD 1 obtained copies from [organization] of previously completed X-rays of Patient 17’s arm and was able to compare, MD 1 confirmed the injury was old. This confirmation came a week after Patient 17’s discharge. During a review of the facility’s Medical Rules and Regulations,” the Rules and Regulations (R&R) indicated that, “3.1-8 Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician...””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure Radiologist documented critical test result (a laboratory or imaging result that falls significantly outside the normal range, indicating a, life-threatening condition requiring immediate, rapid clinical intervention) communication on the radiology report, in accordance with the facility’s policy and procedure regarding critical results reporting and documentation, for two of 34 sampled patients’ (Patient 7 and Patient 15) medical records when: 1. Radiologist did not document the name of licensed practitioner receiving Patient 7’s critical MRI (magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to create detailed images of organs, and bones) report on 7/15/1024; 2. Radiologist did not document the critical results of Patient 15’s CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head and whether CT head results were communicated to any licensed practitioners on 12/15/2025. This deficient practice could result in a lack of proof of critical results communication to the responsible licensed practitioner, potentially causing delays in patient care. Findings: 1. During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left-sided weakness. During an interview on 12/16/2025 at 4:50 p.m. with the Director (DIR 7) of Imaging Services, DIR 7 stated radiologists were required to document who they spoke to with date and time on the imaging report when reporting a critical result. During a concurrent interview and record review on 12/17/2025 at 2:28 p.m. with Radiologist (Medical Doctor specializing in diagnosing and treating diseases and injuries using medical imaging techniques such as X-rays, CT scans, MRI scans, nuclear medicine, and ultrasounds, [MD 2]), Patient 7’s MRI (magnetic resonance imaging, uses powerful magnets, radio waves, and a computer to create detailed images of organs, and bones) Brain without contrast (dye) report (MRI report), dated 7/15/2024, was reviewed. The MRI report indicated Patient 7 had a “moderate-to-large size area of restricted diffusion (MRI term describing limited movement of water molecules within tissues most famously seen in acute stroke due to cell swelling) involving right frontoparietal lobe (refer to the interconnected regions of the front lobe [behind the forehead and the parietal lobe [at the top/back of the head]) ... compatible with acute (new onset) to subacute (transition phase between acute and chronic [long-term]) infarct (type of stroke resulting from failure of blood supply).” The MRI reported also indicated, “Addendum Report: The above findings were relayed by the radiology assistant at 9:15 a.m. on 7/15/2024.” MD 2 stated acute infarct was considered as a critical result (a laboratory or imaging result that falls significantly outside the normal range, indicating a life-threatening condition requiring immediate, rapid clinical intervention). MD 2 confirmed that Patient 7’s MRI report did not indicate who received the critical result. MD 2 stated that documenting the recipient’s name was for proof of communication, including who received it and the date and time the critical result was communicated. During an interview on 12/22/2025 at 2:30 p.m. with the President-Elect (PE/MD 3) of MEC (Medical Executive Committee, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital), PE/MD 3 stated that critical results were findings that required immediate attention from the physician. Radiologists helped to maintain and facilitate the communication of critical results. Radiologists must document in the imaging report who the radiologist spoke with and what date and time. PE/MD 3 stated it was important to document so the team would know exactly what date and time, and the person the critical result was reported to so the physician could take further action in a timely manner. It was for better communication. During a review of the facility’s policy and procedure (P&P) titled, “Critical Results,” dated 11/2024, the P&P indicated, “Purpose: to establish guidelines and ensure timely reporting of critical results to the physician ... Critical results are diagnostic findings so extreme that they indicate a potentially dangerous situation requiring immediate notification and action by a licensed medical practitioner. Critical results include but not limited to, diagnostic tests, imaging studies ... such findings require rapid communication of the result to a physician ... At [the facility] it is expected that no more than sixty (60) minutes shall elapse between the identification of and the reporting of a critical result ... Radiology critical results are immediately called to a licensed care provider by the radiologist. Documentation of this communication is recorded by the radiologist in the dictated report via the use of the words: CRITICAL RESULTS, followed by the phrase “Call to (Name of licensed responsible nurse)”. 2. During a review of Patient 15’s “History and Physical (H&P),” dated 12/12/2025, the H&P indicated that Patient 15 was admitted after a witnessed seizure (a sudden, uncontrolled electrical disturbance in the brain) at a restaurant and was admitted to DOU (Definitive Observation Unit, a specialized hospital unit for close monitoring of patients who are critically ill or unstable). During an interview on 12/16/2025 at 4:50 p.m. with the Director (DIR 7) of Imaging Services, DIR 7 stated radiologists were required to document who they spoke to with date and time on the imaging report when reporting a critical result. During an interview on 12/22/2025 at 2:30 p.m. with the President-Elect (PE/MD 3) of MEC, PE/MD 3 stated critical results were findings that required immediate attention from the physician. Radiologists helped to maintain and facilitate the communication of critical results. Radiologists must document in the imaging report who the radiologist spoke with and what date and time. PE/MD 3 stated it was important to document so the team would know exactly what date and time, and the person the critical result was reported to so the physician could take further action in a timely manner. It was for better communication. During a concurrent interview and record review on 12/22/2025 at 3:31 p.m. with Radiologist (MD 11), Patient 15’s computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) without contrast (dye) report (CT report 1), dated 12/14/2025, was reviewed. The CT report 1 indicated, “Impression: large region of acute to subacute infarct in the left MCA territory with a dense left MCA sign demonstrated. There is local mass effect with effacement of the sulci.” The CT report 1 indicated the report was electronically signed by Radiologist (MD 12) on 12/14/2025 at 10:28 a.m. MD 11 stated CT report 1 indicated a critical result because there was an infarct. It would require communication between the radiologist and the licensed practitioner. MD 11 confirmed that there was no documentation of critical result communication on CT report 1. During a concurrent interview and record review on 12/22/2025 at 3:36 p.m. with MD 11, Patient 15’s CT report of CT Angiogram Brain and Neck with contrast (CT report 2), dated 12/14/2025, was reviewed. The CT report 2 indicated, “Impression: Abrupt cutoff of the distal M1 segment of the left MCA compatible with thrombus (clot).” The CT report 1 indicated the report was electronically signed by Radiologist (MD 12) on 12/14/2025 at 12:40 p.m. MD 11 stated CT report 2 indicated a critical result because there was a partial obstruction of MCA. It would require communication between the radiologist and the licensed practitioner. MD 11 confirmed that there was no documentation of critical result communication on CT report 2. During an interview on 12/22/2025 at 3:37 p.m. with MD 11, MD 1 stated all radiologists were trained and knew they must communicate critical results with licensed practitioners and must document the communication that took place with whom, including the date and time on the CT imaging report. MD 11 critical results must be communicated in a timely manner, otherwise, the patient could miss the window to receive treatment. During a review of the facility’s policy and procedure (P&P) titled, “Critical Results,” dated 11/2024, the P&P indicated, “Purpose: to establish guidelines and ensure timely reporting of critical results to the physician ... Critical results are diagnostic findings so extreme that they indicate a potentially dangerous situation requiring immediate notification and action by a licensed medical practitioner. Critical results include but not limited to, diagnostic tests, imaging studies ... such findings require rapid communication of the result to a physician ... At [the facility] it is expected that no more than sixty (60) minutes shall elapse between the identification of and the reporting of a critical result ... Radiology critical results are immediately called to a licensed care provider by the radiologist. Documentation of this communication is recorded by the radiologist in the dictated report via the use of the words: CRITICAL RESULTS, followed by the phrase “Call to (Name of licensed responsible nurse)”.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff documented a complete neurological assessment (a comprehensive evaluation of the brain, spinal cord, and nerves, checking functions like mental status, motor skills, sensation, balance, coordination, and reflexes, to diagnose disorders, monitor conditions, or identify issues affecting cognitive, physical, or sensory abilities) for one of 34 sampled patients (Patient 7), when Patient 7’s pupil(black, circular opening in the center of the eye) assessment was missing from the record on 7/17/2024 at 8 p.m. This deficient practice had the potential to result in an inaccurate assessment of Patient 7’s neurological status which could potentially delay Patient 7’s treatment and care. Findings: During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During a review of Patient 7’s nursing admission assessment titled, “Admission Assessment Inquiry,” dated 7/14/2024, the admission assessment indicated, on 7/14/2024 at 10:54 a.m., Patient 7 was alert with Glasgow Coma Scale (GCS, assesses consciousness after brain injury, ranging from 3 to 15, by summing points for eye [4], verbal [5], and motor [6] responses) score of 15 out of 15 (a score of 8 or less generally indicates severe injury/coma, 9 to12 moderate, and 13 to15 mild) and NIH Stroke Scale (NIHSS, a tool used to quickly assess stroke severity, track changes, and guide treatment, with scores from 0 [no symptoms] to 42 [severe stroke]) score of 17 out of 42 (a score of 1 to 4 is minor, 5 to 15 is moderate, 16 to 20 is moderate-to-severe, and above 20 is severe). During an interview on 12/15/2025 at 10:38 a.m. with a Telemetry Registered Nurse (RN) 21, RN 21 stated the following: nurses should perform neuro assessment (neuro check) every four (4) hours for stroke patients. The neuro assessment would include checking patient’s level of consciousness (measures a person’s awareness and responsiveness to stimuli), pupils’ sizes and reaction, ability to move all extremities and strength, and Glasgow Coma Scale (GCS) while NIH Stroke Scale (NIHSS) would be done once a shift (every 12-hour shift). If there were any changes noted in neuro assessment, nurses should call Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) and notify the physician. During a concurrent interview and record review on 12/16/2025 at 10:06 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s “Daily Assessment Inquiry (nursing daily assessment),” dated 7/17/2024, was reviewed. The nursing daily assessment indicated neuro assessment was performed on 7/17/2024 as follows: -at 7:10 a.m.: Patient 7 was alert, both pupils were brisk (pupils quickly shrinking when a light is shone to them, indicating a healthy brain function) at 2 millimeters (mm, a unit of measure, in this case refer to pupil size), clear speech, bilateral (both) hand grip was light, left arm and left leg strength was weak, GCS score was 14 out of 15 (3 - opens eye to speech/ sound, 5 - oriented [knows name, place, time], alert and appropriate, 6 - obeys commands); -at 10:46 a.m.: Patient 7’s GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 1 - no verbal response, 5 - localizes to pain stimulus) without any other neurological assessment documented; -at 8 p.m.: Patient 7 was lethargic (a state of unusual drowsiness and reduced mental alertness), no pupils assessment documented, unable to perform hand grips, GCS score was 8 out of 15 (2 - opens eyes to painful stimulus, 2 - unintelligible moans, 4 - withdraws [pulls away] from painful stimulus); -at 00:40 a.m. (7/18/2024): Patient 7 was unresponsive, bilateral pupils were fixed at 4 mm, GCS score was 6 out of 15 (1 - no eye opening, 1 - no verbal response, 4 - withdraws from painful stimulus). -NM 1 stated the following: the neuro assessment (neuro check) performed at 8 p.m. was incomplete because the pupil’s assessment was missing. There was no pupil check for about 17 hours (from 7:10 a.m. to 00:40 a.m. next day). The incomplete neuro check could lead to missing identification of Patient 7’s changing neuro condition. Fixed pupils (condition where the black center of the eye does not constrict or change size in response to light, usually remaining wide open) would suggest significant neuro issues which were usually a late sign of severe neurological damage. During an interview on 12/18/2025 at 8:32 a.m. with the Director (DIR 3) of Telemetry, DIR 3 stated the following: it was the nurse’s responsibility to perform neuro assessment on patients. Nurses were required to perform a complete neuro assessment including checking the level of consciousness (describes a person’s state of wakefulness and awareness of themselves and their surroundings), orientation, pupils’ sizes and reaction, extremities movement and strength, and speech. Nurses were also required to perform a complete neuro assessment when there was a decrease in GCS score. Nurses should call RRT immediately to get quick intervention upon identifying any acute change (referring to a decline) in patient’s neuro status from baseline. During a review of the facility’s nursing “neurological assessment” form, undated, the neurological assessment included the following components: LOC (Level of consciousness), orientation, left/right pupil size and reaction, speech, left/right hand grips, left/right arm strength, left/right leg strength, swallowing ability, gait, sensory limitations and GCS score. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment - Nursing,” dated 6/2025, the P&P indicated, “The Registered Nurse must conduct a comprehensive assessment of the patient ... The scope and intensity of assessment are based on the patient’s diagnosis, the care setting, the patient’s desire of care, and the patient’s response to any previous care. Reassessments are completed at regular intervals determined by a patient’s response to care and significant changes in condition or diagnosis... B. Reassessment... 1. An RN will assess each patient’s care needs before delegating appropriate aspects of the patient’s nursing care, and patients will be reassessed by an RN at least every shift to document changes in the patient’s condition and/or diagnosis, and to determine the patient’s response to intervention. 2. Nursing reassessment of a patient will reflect at a minimum a review of patient-specific data, pertinent changes, and response to interventions. More frequent reassessment will be completed as appropriate for the patient population and/or individual patient needs. Nursing reassessment will be documented in electronic health record (EHR) under daily nursing assessment.””

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its radiology department performed a STAT (a medical abbreviation for immediately or without delay) computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) head scan (imaging test to check for blood vessels blockages or bleeding in the brain, and other brain injury) for one of 34 sampled patients (Patient 7) on 7/17/2024, in accordance with the facility’s policy and procedure for diagnostic imaging when the STAT order was placed on 7/17/2024 at 9:47 p.m. and a CT head scan was not done until 7/18/2024 at 00:51 a.m. Patient 7’s CT head scan completed on 7/18/2024 at 00:51 a.m. indicated midline shift and brain herniation. This deficient practice resulted in a delay in evaluating Patient 7’s evolving stroke and caused delay in providing timely interventions causing Patient 7 to undergo emergency right craniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) on 7/18/2024. Patient 7 was found with no brain function during the operation. Patient 7 subsequently died on 7/20/2024. Findings: During a review of Patient 7’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/14/2024, the H&P indicated, Patient 7 was admitted to the facility’s telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor due to acute (new onset) cerebrovascular accident (CVA, also known as stroke, a sudden disruption of blood flow to the brain) on 7/14/2024. The H&P also indicated Patient 7 was awake, able to talk, with left sided weakness. During an interview on 12/15/2025 at 2:39 p.m. with the Director (DIR 7) of Imaging Services, DIR 7 stated the facility’s computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan service was available 24-hour 7 days a week and STAT (a medical abbreviation for immediately or without delay) CT scan should be completed within 60 minutes from scan (scanning performed by radiology technician) to read (result interpreted by a radiologist) per national standard. During a concurrent interview and record review on 12/16/2025 at 11:16 a.m. with the Nurse Manager (NM 1) of Telemetry, Patient 7’s physician orders, dated 7/17/2024 and 7/18/2024, were reviewed. The physician orders indicated there was a STAT CT head without contrast ordered by Patient 7’s neurologist (NEURO 1) on 7/17/2024 at 9:47 p.m. with indicated reason for cerebrovascular accident (CVA), and a STAT CT head without contrast ordered by Patient 7’s intensivist (ICU 1) on 7/18/2024 at 12:27 a.m. with indicated reason for cerebrovascular accident. NM 1 stated the CT scan order placed on 7/17/2024 at 9:47 a.m. was not done. NM 1 stated there was no documentation indicating any reason for not performing the CT scan. NM 1 stated Patient 7’s CT head scan was completed on 7/18/2024 at 12:51a.m. after the second STAT CT scan order was placed. During an interview on 12/16/2025 at 4:40 p.m. with DIR 7, DIR 7 stated the following: the CT technologist must document why a CT scan was not performed. There was no documentation found to explain why Patient 7’s CT head, ordered on 7/17/2024 at 9:47 p.m., was not done by the on-duty CT technologist that night (7/17/2024). During a review of Patient 7’s CT Head without contrast report, dated 7/18/2024 at 12:51 a.m., the CT report indicated, “evolving (progressing, getting worse) right MCA (middle cerebral artery) territory infarct (type of stroke resulting from failure of blood supply) with significantly larger area involved compared to prior ... there is right to left midline shift (the displacement of brain structures from the center line, a serious sign of increased pressure inside the skull caused by things like stroke, tumors or head injury) of 12 mm (millimeters, a unit of measure) ... there appeared to be right uncal herniation (a life-threatening condition where increased pressure inside the skull forces brain tissue to shift from its normal location into another part of the brain or through openings).” During a review of Patient 7’s physician progress notes, dated 7/18/2024, documented by NEURO 1, the physician progress notes indicated, “CT was delayed but was completed showing cerebral (brain) edema (swelling) with worse midline shift. I (NEURO 1) recommended consulting NSGY (neurosurgery) for emergent craniotomy (a neurosurgical procedure to temporarily remove a piece of skull to access and operate the brain) at 1 a.m.” During a review of Patient 7’s operation notes (procedure report), dated 7/18/2024, the operation notes indicated, Patient 7 underwent right hemicraniectomy (a surgical procedure where a surgeon removes part of the skull to relieve dangerous pressure on the brain, often due to severe injury, stroke, or swelling) for massive malignant (dangerous) brain swelling following a large MCA stroke. The operation notes also indicated, “patient (Patient 7) had no brain function ... recommend brain death exam protocol (examination by doctor to confirm all brain function has permanently stopped, making the person legally dead), followed by withdrawal of care if brain death confirmed.” During a review of Patient 7’s “Death Pronouncement” note, dated 7/20/2024, the “Death Pronoucement” note indicated, Patient 7’s time of death was on 7/20/2024 at 1:01 a.m. During a review of the facility’s policy and procedure (P&P) titled, “Daily Workflow,” dated 9/2020, the P&P indicated, “STAT Examinations: 1. Request for STAT exams may be made at any time. a) the call should be made to the CT technologist ... c) the STAT exam should be done as soon as possible after the information is received by Imaging ... Priority of Examinations (Orders in which examinations are performed): 1. Code Stroke CT Brain 2. Trauma Cases - rule out bleeding 3. STAT Exams 4. ASAP or High Priority 5. ICU/CCU cases 6. Regular nursing floors ...” During a review of the facility’s policy and procedure (P&P) titled, “Diagnostic Imaging Scope of Service,” dated 5/2025, the P&P indicated, “Goals and Objectives ... to provide quality and timely customer service to all patients/customers visiting the Diagnostic Imaging Department ... turn-around times ... computerized tomography (CT) ... STAT orders within sixty (60) minutes ... Relationship with other departments ... the department works with all hospital clinical, administrative and support departments and services to provide appropriate and safe patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Stroke Center Scope of Services,” dated 5/2019, the P&P indicated, “[the facility] will provide timely and effective care to all patients with stroke symptoms, regardless age, race, gender, or insurance ... Goals and Objectives ... 1. The goal of the Primary Stroke Center (a hospital certified to provide rapid, standardized care for most emergent stroke patients) at [the facility] is to improve patient outcomes through an organized system of care. This includes standardized policies and procedures, physician resources, continuous nursing education and training, patient education, and community outreach ... 6. The Primary Stroke Center’s obligation is to ensure that the interaction is positive, productive and provides the patient with a mechanism to receive necessary ongoing health care. 7. The Primary Stroke Center is committed to the provision of quality of care consistent with [the facility’s] overall Mission, Philosophy, and Values.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 34 patients (Patient 17) was discharged from the hospital to the Skilled Nursing Facility (SNF) with applicable medical information (discharge instructions) pertaining to Patient 17’s course of rehabilitation (process of helping an individual achieve the highest level of function) and treatment, post-discharge goals of care, and treatment preferences at the time of discharge to the appropriate post-acute care service facility (a healthcare setting providing 24/7 medical care, rehabilitation [like physical/occupational therapy], and supportive services for patients needing a higher level of care after a hospital stay). This deficient practice compromised Patient 17’s well-being, safety, and had the potential for post-discharge needs to be unmet which could result in mismanagement of Patient 17’s condition, potential readmission, and deteriorating health outcomes. Findings: During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence), after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones) was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture ( a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s digital medical record (an Electronic Medical Record [(EMR]) or Electronic Health Record [EHR]-is the computerized version of a patient’s paper chart) on 12/17/2025 at 11:55 a.m. with System Analyst (IT 1), IT 1 verified that Patient 17’s discharge order, which indicated to discharge Patient 17 to Skilled Nursing Facility (SNF)- was placed on 12/25/2025 at 7:04 p.m. when Patient 17 was out for an outpatient surgical procedure. During the same record review on 12/17/2025 at 11:55 a.m. with System Analyst (IT 1), IT 1 also verified that Patient 17’s digital record contained no uploaded nursing discharge instructions (detailed guidelines given to patients upon their discharge from a hospital or healthcare facility to provide information on post-discharge care, including medications, follow-up appointments, dietary restrictions, activity limitations, and signs of potential complications with the purpose to ensure that patients have the necessary information to manage their health effectively at home and to prevent readmission due to misunderstandings or lack of information). During an interview on 12/18/2025 at 10:06 a.m., with the Manager of Acute Rehab (MN 4), MN 4 explained that the discharge process required ensuring patients were stable, with vital signs (VS, objective measurements of the body’s most basic functions-temperature, pulse [heart rate], respiration [breathing] rate, and blood pressure-that provide crucial information about a person’s general physical health, indicating how well vital organs are working and helping to detect underlying medical issues or recovery progress) obtained 1-2 hours before discharge. MN 4 also said the following, “The case manager (CM) works with the family to arrange medication and transportation, confirming and notifying the nurse and physician about the discharge destination. If there is no placement, the CM communicates this to the physician, escalating as needed to the supervisor or manager.” MN 4 stated that “a patient should have a safe discharge location and should receive discharge instructions detailing follow-up care, medication management, and any necessary education. The transfer to another facility involves communicating all patient care details to the receiving facility to ensure continuity of care.” During the same interview on 12/18/2025 at 10:06 a.m., with the Manager of Acute Rehab (MN 4), MN 4 said the following, “When a patient is discharged, they should have a place to go to. I was not aware of patient’s (Patient 17) discharge without discharge arrangements being done and without being provided discharge instructions. The patient (Patient 17) was brought back to the unit [on 6/25/2025 at 8:45 p.m.], but there was a discharge order placed by the physician [when Patient 17 returned to ARU after the outpatient surgical procedure], and when Patient 17 presented to the unit (ARU), the transport team was directed to discharge the patient (Patient 17) to the Emergency Department. That’s where the CM could follow up with Skilled Nursing Facility (SNF) placement from there. Yes, the patient (Patient 17) required Skilled Nursing Facility (SNF) placement as per MD discharge order, but we sent the patient (Patient 17) to the Emergency Department (ED), so the case management could follow up with the patient in the ED.” During an interview on 12/18/2025 at 10:20 a.m. with the Manager of Acute Rehab (MN 4), MN 4 said the following, “Transfer: Interfacility transfer: communicate with the receiving facility, diet, activity medications, anything related to patient care ... activity diet type and any equipment and PT OT if recommended ... the CM will look into it and connect the facility and make sure the SNF will provide and there will be instructions ...” During an interview on 12/18/2025 at 10:20 a.m. with the Manager of Acute Rehab (MN 4), MN 4 said, “For interfacility transfer, we need to communicate with the receiving facility about the patient’s diet, activity level, medications, and anything related to patient care. This includes the type of diet, recommended activities, any necessary equipment, and physical or occupational therapy if needed. The case manager will look into these details, connect with the facility, and ensure that the Skilled Nursing Facility (SNF) will provide the necessary instructions.” The MN 4 then said, “The interfacility transfer paperwork for patient (Patient 17) was not provided to the skilled nursing facility because patient (Patient 17) was discharged to the emergency department instead [on 6/25/2025].” MN 4 then also said that she (MN 4) was not aware of discharge instructions not being provided to patient (Patient 17) upon discharge from the Acute Rehab unit (ARU) on 6/25/2025. During a review of the facility’s policy and procedure (P&P), titled, “Hospital discharge planning,” the P&P indicated the following: “Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to their discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs... The case manager, social worker, or hospital staff shall engage the patient, and/or the patient’s representative, actively in the development of the discharge plan by incorporating the patient’s goals and preferences into the plan.” During a review of the facility’s policy and procedure (P&P), titled “Discharge Plan for Homeless Patients,” the P&P indicated the following: “Documentation of discharge planning will include completed discharge instructions with patient name and signature, documentation of the patient’s cognitive intactness, and documentation that the patient understands and agrees with the discharge plan, including medications and follow-up care.” The facility did not provide the requested “Admission, Transfer, and Discharge Policy” during the survey. During an interview on 12/18/2025, at 9:25 a.m. with, the Vice President of Quality Risk Management (VPQRM), the VPQRM stated that the facility did not have a policy for “Nursing Discharge Instructions” and lacked any other policies that describe the discharge process for patients.”

“DISCHARGE PLANNING-FREEDOM OF CHOICE CFR(s): The hospital , as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services and must, when possible, respect the patient’s or the patient’s representative goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patients. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 34 sampled patient’s (Patient 17) goals of care and treatment preference regarding discharge planning (the process of organizing a patient’s safe and smooth transition from a hospital to home or another care setting, ensuring they have the necessary care, support, and instructions for continued recovery), was taken into consideration, in accordance with the facility’s policy regarding hospital discharge planning, when Patient 17 was discharged on 6/25/2025 from the Acute Rehabilitation Unit (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) to the Emergency Department (ED, the department of a hospital responsible for providing emergency care) without Patient 17’s knowledge despite the insurance company’s approval to extend Patient 17’s stay in the ARU until 7/1/2025 while awaiting SNF (Skilled Nursing Facility, a residential facility providing a high level of medical care) placement. This deficient practice had the potential to result in psychological distress, rendering Patient 17 anxious and powerless, which can negatively impact Patient 17’s recovery and trust in the healthcare process. Findings: During a review of the complaint received by the Department of Public Health (DPH, a state agency responsible for public health, including the oversight and regulation of healthcare facilities), received on 12/09/2025, the complainant (Patient 17) stated the following: “I was illegally discharged from acute rehabilitation (ARU, a hospital setting for intensive, multidisciplinary therapy after a major medical event [like a stroke, injury, or surgery] to help patients rapidly regain independence) and dumped in the Emergency Department (ED) on June 25, 2025, I was illegally discharged from acute rehabilitation while undergoing surgery at [Organization]. After a 7-hour standoff, the supervisor falsely promised I would be admitted to an inpatient bed if I went to the ED. I was transported to the ED around 6:00 AM on June 26, 2025. I was held in the ER for approximately two days without proper admission. Because I was dumped from upstairs (referring to the ARU) and not admitted with an emergency, I was listed as the lowest priority...” During a review of Patient 17’s History and Physical (H&P), dated 6/11/2025, the H&P indicated that Patient 17 was transferred to the facility for rehabilitation services in the Acute Rehabilitation Unit (ARU), after an Open Reduction and Internal Fixation (ORIF, procedure involves the surgical method to fix broken bones) was performed on 6/4/2025 for a tibial fracture (break in the larger bone in the lower leg) and on 6/5/2025 for a radial fracture a break in the radius, one of the two bones in the forearm). During a review of Patient 17’s Discharge Summary (a document that provides a concise summary of the patient’s hospital stay and treatment, including reasons for admission, significant findings, procedures performed, the patient’s condition at discharge, and instructions for follow-up care), dated 6/26/2025, the Discharge Summary indicated that Patient 17 reached maximum medical improvement, was medically stable, and was discharged on 6/24/2025. The note also indicated that Patient 17 was given the week prior, 10 skilled nursing facilities (SNF) to choose from for transfer after discharge, but Patient 17 declined them all. The note also indicated the following: “Patient 17 was given other options... but Patient 17 chose to schedule themselves for another surgical procedure, but since this was done after discharge, the patient could no longer be readmitted to the acute rehab floor because the patient did not meet the criteria and had to go to a lower level of care such as a Skilled Nursing Facility (SNF, a healthcare facility that provides a high level of medical care and daily assistance for patients who require rehabilitation or long-term care) until their housing situation is taken care of...” During a concurrent interview and record review of Patient 17’s digital medical record (an Electronic Medical Record [EMR] or Electronic Health Record [EHR]-is the computerized version of a patient’s paper chart) on 12/17/2025 at 11:55 a.m. with System Analyst (IT 1), IT 1 verified that Patient 17’s discharge order, which indicated to discharge Patient 17 to a Skilled Nursing Facility (SNF)- was placed 6/25/2025 at 7:04 p.m. when Patient 17 was out for an outpatient surgical procedure. During the same concurrent interview and record review on 12/17/2025 at 11:55 a.m. with IT 1, IT 1 verified that Patient 17’s digital record contained no uploaded nursing discharge instructions (detailed guidelines given to patients upon their discharge from a hospital or healthcare facility to provide information on post-discharge care, including medications, follow-up appointments, dietary restrictions, activity limitations, and signs of potential complications with the purpose to ensure that patients have the necessary information to manage their health effectively at home and to prevent readmission due to misunderstandings or lack of information). During a review on 12/17/2025 at 11:28 a.m. with System Analyst (IT 1), Patient 17’s Daily Focus Assessment Report, dated 6/25/2025, was reviewed. IT 1 verified that on 6/25/2025 at 10:03 a.m., the case manager (CM) documented the following in Patient 17’s medical report: “Patient 17 needs placement to go... met with medical doctor (MD 1) who said that Patient 17 needed to be discharged into a Skilled Nursing Facility (SNF), but not able to accept the patient back (back to the ARU while Patient 17 was undergoing surgery on the same day- 6/25/2025) due to she ( Patient 17) does not meet the criteria for rehab anymore... Informed physician that SNF placement is still pending, and insurance will provide daily authorization until have accepting SNFs... received paper authorization from insurance with authorized ARU (Acute Rehab Unit) stay until 7/1/2025... placed in the patient’s chart...” During an interview on 12/18/2025 at 10:06 a.m. with the Manager of Acute Rehab (MN 4), MN 4 said the following, “When a patient is discharged, they should have a place to go to. The case manager should work on placement and will confirm and notify the nurse and physician about the discharge order specifying where the patient will be discharged to... The clarification with the case manager (CM) will be done when there is no placement, so we have to get back to the physician and say the patient has no placement. We have to escalate if the physician is pushing discharge. Escalate to the house supervisor and manager, but if I am not on site, the house supervisor has to be informed. The patient (Patient 17) was brought back to the unit [on 6/25/2025 at 8:45 p.m.], but there was a discharge order placed by the physician [when Patient 17 returned to ARU after the outpatient surgical procedure], and when Patient 17 presented to the unit, the transport team was directed to discharge the patient (Patient 17) to the Emergency Department. That’s where the CM could follow up with Skilled Nursing Facility (SNF) placement from there (from the ED). Yes, the patient (Patient 17) required Skilled Nursing Facility (SNF) placement as per MD discharge order, but we sent the patient (Patient 17) to the Emergency Department (ED), so the case management could follow up with the patient in the ED.” During a review of Patient 17’s “Daily Focus Assessment Report,” dated 6/24/2025, the Case Management (CM) note indicated that the CM had a discussion with the medical doctor regarding Patient 17’s discharge plan. The note highlighted that Patient 17’s living conditions were unsafe at home and that Patient 17 needed placement. Additionally, the note indicated that Patient 17 had a scheduled procedure for knee manipulation on 6/25/2025 and that the CM obtained confirmation for a few more days’ stay before discharge to a Skilled Nursing Facility (SNF). This note was reviewed with the System Analyst (IT 1) on 12/17/2025 at 11:02 a.m. during record reviews. During an interview on 12/18/2025 at 10:20 a.m. with Manager of Acute Rehab (MN 4), MN 4 also stated the following: “Was it a safe discharge for Patient 17? I don’t know. It was an isolated case. The patient should have had a place to go. The patient did not receive discharge instructions; they should be able to follow up on care for themselves and continue care and treatment. Patients need to know what follow-up was needed and receive education regarding medication. But the patient (Patient 17) was aware of the discharge plan (Patient 17 was aware about the discharge plan to go to a SNF but not about being discharged to the ED on 6/25/2025, following an outpatient procedure, while waiting for SNF placement) and declined everything that was offered. The order with authorization [to extend ARU stay day by day until placement is found] came late. The physician (MD 1) said to discharge the patient (Patient 17) on 6/25/2025. I’m not sure what the regulation says about this situation; I am not familiar. All I know is that the patient went to the Emergency Department (ED) and remained there while the case manager continued to work to get her (Patient 17) placement. Patient 17 was safe in the ED.” During an interview on 12/18/2025 at 12:40 p.m. with Case Managers (CM 1 and CM 2), CM 1 and CM 2 said that on 6/25/2025 Patient 17 had an outpatient procedure scheduled and CM 1 arranged for the transportation to take the patient (Patient 17) to and bring the patient (Patient 17) back to ARU (Acute Rehab Unit) after the procedure. Patient 17 was not aware of the discharge order on 6/25/2025. Patient 17 had no placement ready on 6/25/2025. In fact, Patient 17 was also homeless, as they were evicted from their apartment that day. Patient 17 was supposed to come back to the rehab unit and thought they were coming back to ARU. But once Patient 17 left for the outpatient procedure on 6/25/2025, MD 1 said Patient 17 was discharged because she (Patient 17) no longer met the criteria for admission in the ARU, as per MD 1 order...and the MD 1 said we wouldn’t take Patient 17 back. So, Patient 17 went to the procedure but could no longer come back to the unit (the ARU). MD 1 said to send Patient 17 to the ED after the procedure, but this patient had an order to go to SNF, and no SNF was ready... Patient safety was on the line. We had a discharge order but no placement, and Patient 17 was practically homeless. Patient 17 needed to go to a nursing home. The physician sent Patient 17 to the ED so they would not be on the streets. So, we did our best to hold Patient 17 in the ED, providing them with a safe place until placement was found...” During an interview on 12/18/2025 at 11:07 a.m. with Medical Doctor (MD 1), MD 1, who discharged Patient 17, said that a safe discharge implied the continuation of care. MD 1 said, “Even if there were no arrangements made for the patient, the discharge could still proceed because discharge planning begins from day one. Patients are aware of their discharge date well in advance. A safe discharge is ensured by having a comprehensive plan in place from the very start.” During the same interview on 12/18/2025 at 11:07 a.m. with medical doctor (MD 1), MD 1, who discharged Patient 17, said the following: “Sometimes we have an order and placement, but the patient refuses ... and then they will change their mind, and from the insurance standpoint ... the insurance will say the patient needs to go, so the patient has to go... Patient 17 met the criteria for discharge and no longer met the criteria for Acute Rehab Unit admission... and there was no authorization from the insurance guaranteeing that the patient (Patient 17) could stay until placement was found... (contrary to the case management notes indicating that the insurance approved daily authorization for Patient 17’s extended stay in the ARU until 7/1/2025) It was a safe discharge... I discharged to the emergency department (ED), so they could follow-up with the placement...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 8/2025, the P&P indicated that, “...Patient care shall be provided in a safe environment... to ensure that all employees and contractors fully support and ensure the rights of its patients... and shall not discriminate against any individual because of the patient’s ability or inability to pay....The patient has the right to considerate and respectful care, and to be made comfortable.... Patients have the right to effective communication and to participate in the development and implementation of their plan of care.... Patients have the right to be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from the hospital. They have the right to be involved in the development and implementation of their discharge plan...” During a review of the facility’s policy and procedure (P&P) titled, “Hospital discharge planning,” the P&P indicated the following: “Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to their discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs...The case manager, social worker, or hospital staff shall engage the patient, and/or the patient’s representative, actively in the development of the discharge plan by incorporating the patient’s goals and preferences into the plan.” The facility did not provide the requested “Admission, Transfer, and Discharge Policy” during the survey. During an interview on 12/18/2025, at 9:25 a.m. with the Vice President of Quality Risk Management (VPQRM), the VPQRM stated that the facility did not have a policy for “Nursing Discharge Instructions” and lacked any other policies that describe the discharge process for patients. During a review of the facility’s Medical Rules and Regulations (R&R), [undated], the R&R indicated that, “3.1-14 Patients shall be discharged only on a written order of the attending or alternate physician... 3.1-15 No patient should be transferred or discharged for the purpose of effecting transfer from the Hospital to another health facility unless arrangements have been made in advance for admission to such health facility and either the person legally responsible for the patient has been notified, or documented attempts over a 24-hour period have been made and a responsible person cannot be contacted.””

“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: 46333 Based on observation, interview, and record review, the facility failed to implement and enforce the facility’s surgical services policies and procedures and the equipment manufacturer’s safety instructions during a head and neck procedure for one (1) of four (4) sampled patients (Patient 1) to prevent an operating room fire (an uncontrolled ignition during surgery) when: 1.a. The facility did not ensure preoperative education (instructions given to patients before surgery) was provided to Patient 1 to avoid alcohol-based hair/skin products prior to the procedure, which increases the fire risk when heat-producing devices (such as electrosurgical instruments) are used. 1.b. The facility did not ensure the supply and use of non-flammable, water?soluble surgical jelly (a fire-resistant gel applied to hair/skin around the surgical site to reduce the chance of ignition) for high fire-risk head/neck procedures. 1.c. The facility did not ensure all operating room (OR) staff received training on OR fire-risk protocols (procedures to prevent, detect, and respond to fires in the operating room) after the fire incident on 11/4/2025. 1.d. The facility did not ensure adherence to manufacturer instructions for alcohol-based skin antisepsis (a disinfectant applied to the skin before surgery), including using the correct applicator size and allowing adequate drying time (time for the alcohol to fully evaporate before draping or using electrical equipment). 1.e. The facility did not ensure preventive maintenance (PM) checks (scheduled safety and functional inspections) on the electrosurgical generator (the “Bovie,” a machine that uses electrical energy to cut tissue or stop bleeding), were maintained, in accordance with manufacturer specifications. The Bovie was used during Patient 1’s procedure when the surgical fire was ignited. These deficient practices resulted in a surgical fire during Patient 1’s scalp cyst excision (surgical removal of a cyst, an abnormal sac of tissue on the scalp) on 11/4/2025, causing Patient 1 to sustain: Second-degree burns (which damage the epidermis [outer skin layer] and part of the dermis [deeper skin layer], resulting in pain, redness, swelling, and blistering) and Third-degree burns (which destroy the entire thickness of the skin and may extend to fat, muscle, or underlying structures, appearing white, brown, or charred, and may be painless initially due to nerve damage. These injuries often require specialized wound care and may need skin grafts). On 12/18/2025 at 2:34 p.m., the survey team called an Immediate Jeopardy (IJ, a situation where the facility’s failure to meet one or more regulatory requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Manager of Accreditation, Regulatory & Licensing (MARL), Chief Nursing Officer (CNO), and the Assistant Chief Nursing Officer (ACNO). The IJ was called because the facility did not implement and enforce surgical fire prevention protocols and manufacture safety instructions during Patient 1’s scalp cyst excision (a surgical procedure to remove a lump from the scalp) on 11/4/2025 in the operating room (OR, the hospital’s surgical suite). During a concurrent interview and record review on 12/17/2025 at 12:24 p.m., RN 10 (Registered Nurse) confirmed that Patient 1 did not receive preoperative instructions (guidance provided before surgery) about avoiding alcohol-based hair and skin products because the patient (Patient 1) could not be reached on 10/30/2025, and the “Preoperative Instruction” record contained no documentation. On 12/16/2025 at 3:37 p.m., an observation in the OR supply room with Charge Nurse (CN 10) showed that surgical jelly (a water-based gel applied to hair near the surgical site to reduce fire risk during surgery) was not available. CN 10 stated the OR did not stock surgical jelly, even though the facility’s policy required its use for head and neck procedures when oxygen (a gas used to help patients breathe) was administered. Further interview and record review on 12/17/2025 at 2:47 p.m. with the Director of Perioperative Services (DIR 4) included a review of the staff sign-in form for training on OR fire safety (after the OR fire incident involving Patient 1). The sign-in sheet for “Morning Huddle Topic: Fire Risk Protocol” showed that 14 of 20 registered nurses and 16 of 19 surgical technicians had not signed. RN 1 stated Patient 1 was prepped using a 26 mL ChloraPrep applicator (a large applicator containing an alcohol-based antiseptic solution used to clean the skin before surgery) and confirmed the solution was not allowed to dry for the time indicated in the manufacturer’s instructions. Those instructions specified that the 26 mL applicator should not be used for head and neck surgery and that drying time for hair may take up to one hour to prevent flammable vapors from igniting. Biomedical Technician (MB) stated that maintenance was performed on the electrosurgical generator (a machine used in Patient 1’ surgery that uses electrical energy during surgery to cut tissue or stop bleeding); however, the maintenance did not include all manufacturer-required checks, such as bipolar testing (a safety check to ensure the machine’s two-point electrical system works correctly for delicate procedures), visual inspection for damage, connector integrity, and internal cleaning. As a result of these deficient practices, Patient 1 sustained second- and third-degree burns (serious injuries that damage the skin and underlying tissue), smoke inhalation injury (breathing in harmful smoke during a fire), and airway injury (damage to the windpipe and surrounding structures), requiring transfer to a specialized burn center for advanced care. On 12/22/2025 at 5:32 p.m., the Immediate Jeopardy (IJ) was removed in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), and the Manager of Accreditation, Regulatory & Licensing (MARL), with the Chief Nursing Officer (CNO) participating by phone, after the facility submitted an acceptable IJ Removal Plan (a corrective action plan to address the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated the following actions: The facility implemented corrective measures to prevent surgical fires and address system failures. Preadmission Testing (PAT) nurses (nurses who contact patients before surgery to provide instructions) were re-educated through one-on-one coaching and signed attestations on the revised preoperative education process, which now requires at least two attempts to contact patients before surgery. If the patient cannot be reached, instructions must be sent through the doctor’s office, and written confirmation is required before the procedure. Cases will be canceled if this documentation is missing. Surgical technicians (staff who assist during surgery) and operating room (OR) nurses received re-education through daily huddles, signed attestations, and posting of the Surgical Safety Checklist, emphasizing the use of non-flammable water-soluble surgical jelly (a gel applied to hair near the surgical site to reduce fire risk) for high fire-risk head and neck surgeries, following standards from the Association of Perioperative Registered Nurses (AORN). Policies titled, “OR Fire Prevention and Response” and “Skin Antisepsis and Prepping of Patient,” were revised to include surgical jelly use and proper drying times for skin prep agents (solutions used to clean the skin before surgery) according to manufacturer instructions. The OR now maintains a supply of surgical jelly in the Omnicell (an automated medication and supply cabinet), and staff were educated on its location and access without requiring an order. Fire Risk Assessments and checklists are completed during the “timeout” process (a safety pause before surgery) to confirm jelly use and start a timer for skin prep drying as directed by the manufacturer. Monthly audits verify compliance with jelly application for head and neck procedures, and results are reported to the Surgery Committee and Quality Management Committee. Additional measures include education on correct applicator size and drying times for skin prep agents, updating surgeon preference cards (lists of supplies and tools preferred by each surgeon) to restrict the use of 26 mL ChloraPrep applicators (large applicators containing alcohol-based antiseptic solution) for head and neck procedures, and replacing them with 3 mL sponges (smaller applicators that reduce fire risk). Central supply ensures smaller prep sizes are always available. Biomedical staff (technicians who maintain medical equipment) were trained to use the Computerized Maintenance Management System (CMMS, a software tool for tracking equipment maintenance) to generate monthly preventive maintenance reports and follow Original Equipment Manufacturer (OEM) guidelines. The preventive maintenance checklist was revised to include six-month frequency checks and complete testing of monopolar and bipolar components (safety checks for two different electrical modes used in electrosurgery). Audits confirm 100% completion of all required maintenance steps. These actions collectively aim to strengthen staff competency, enforce policy compliance, ensure supply availability, and maintain equipment safety to prevent serious adverse outcomes. Findings: 1.a. During a review of Patient 1’s Operative Report (a formal surgical record documenting the procedure), dated 11/4/2025, the report indicated that Patient 1 had noticed a lump (a localized swelling or mass) on the scalp (the skin covering the skull) that was increasing in size and requested removal. The report further indicated: “As soon as the mass was excised (surgically removed) from the scalp, smoke (visible vapor from combustion) was noted coming from the drape (a sterile cloth used to cover the patient during surgery), and the drape was quickly removed. A fire (uncontrolled combustion producing heat and flames) was noted under the drape, and the patient sustained a burn (injury caused by heat) over the right and left face (front part of the head), chin (area below the lower lip), and anterior neck area (front portion of the neck).” During a review of Patient 1’s Operative Note (a detailed account of the surgical procedure and findings), documented by the internal medicine consultant on 11/4/2025, the report indicated: “This was an emergent intraoperative (occurring during surgery) consultation for airway evaluation (assessment of the breathing passage) following an operating room fire. For upper airway evaluation, direct laryngoscopy (a procedure using a scope to view the throat and vocal cords) was performed. Findings: Partial-thickness facial burns (second-degree burns affecting the outer skin layer [epidermis] and part of the underlying layer [dermis]) were noted. The uvula (small tissue at the back of the throat) and pharyngeal mucosa (lining of the throat) were intact without edema (swelling) or ulceration (open sore). Some soot (black residue from smoke) was present, but no obvious ulceration. The airway (breathing passage) was to be closely monitored postoperatively (after surgery) for potential delayed edema or inhalation injury (damage caused by breathing in smoke or fumes).” During an interview on 12/16/2025 at 11:05 a.m. with the Director of Perioperative Services (DPS), the DPS stated that on 11/4/2025, Patient 1 experienced a surgical fire (an uncontrolled ignition during surgery) during an elective procedure (a planned, non-emergency surgery) while under MAC anesthesia (Monitored Anesthesia Care, a type of sedation where the patient remains responsive) with an open oxygen source (oxygen delivered without a sealed airway device). The combination of oxygen delivery via mask (supplemental oxygen provided through a face mask), use of electrocautery (a surgical instrument that uses electrical current to cut tissue or stop bleeding), and alcohol-based prep solution (ChloraPrep, a skin disinfectant containing alcohol) created a high-risk environment for ignition (conditions that increase the likelihood of fire). During a concurrent interview and record review on 12/17/2025 at 12:24 p.m. with Registered Nurse (RN) 10 from the Patient Admission Testing Unit, Patient 1’s “Preoperative Instruction (written or verbal directions given to a patient before surgery),” was reviewed. RN 10 stated that Patient 1 was scheduled to have surgery on the scalp (operation on the skin covering the skull) on 11/4/2025. RN 10 confirmed that on 10/30/2025, a call was made to Patient 1, but Patient 1 could not be reached. RN 10 further confirmed that Patient 1 did not receive preoperative instructions (guidance provided before surgery to reduce risks and prepare the patient) prior to surgery. During a concurrent interview and record review on 12/17/2025 at 2:47 p.m. with the Nurse Manager of Perioperative Services (MP), the facility policy titled, “Skin Antisepsis and Prepping of Patient,” was reviewed. The policy indicated the following: -Patients must be instructed to bathe or shower with antiseptic soap the night before surgery or the morning of surgery. -Patients undergoing surgery on the head should be instructed to perform preoperative shampoos before surgery. -Patients must be instructed not to apply alcohol-based hair or skin products. MP stated that the reason for instructing patients not to use alcohol-based hair or skin products is because alcohol increases the risk of fire during surgery. 1.b. During a concurrent observation and interview on 12/16/2025 at 3:37 p.m. with Operating Room (OR) Charge Nurse (CN) 10 in the OR supply room, it was noted that no surgical jelly was available. CN 10 stated that the OR never stocks surgical jelly. CN 10 showed the supply room and confirmed that surgical jelly was not available to coat patients’ hair prior to surgery for high fire-risk cases. During an interview on 12/16/2025 at 4:32 p.m. with Registered Nurse (RN) 1 (the circulating nurse [a registered nurse in the operating room who manages the overall environment and ensures patient safety during surgery] during the fire incident in the OR on 11/4/2025), RN 1 stated they did not coat Patient 1’s hair near the surgical site, such as the eyebrows, mustache, and beard, with non-flammable surgical jelly (a fire-resistant gel applied to hair/skin around the surgical site to reduce the chance of ignition). RN 1 further confirmed that Patient 1 had a thick set of hair and facial hair. During a concurrent interview and record review on 12/16/2025 at 11:45 a.m. with the Director of Perioperative Services (DPS), the facility’s policy and procedure (P&P) titled, “Skin Antisepsis and Prepping of Patient,” dated 7/25/2025, was reviewed. The DPS confirmed the policy indicated: “If oxygen or nitrous oxide (a colorless gas used medically for pain relief and anesthesia) is being administered during head and neck surgery, coat hair near the surgical site (eyebrows, mustaches, beards) with a non-flammable water-soluble surgical jelly.” DPS confirmed that surgical jelly was not used for Patient 1. 1.c. During a concurrent interview and record review on 12/17/2025 at 2:47 p.m. with the Manager of Perioperative Services (MP), the sign-in sheet titled, “Morning Huddle Topic: Fire Risk Protocol,” was reviewed. MP stated that after the operating room (OR) fire incident, the facility began retraining OR staff on OR fire safety prevention (procedures to prevent, detect, and respond to fires during surgery) and reviewing new implementations to the facility’s policy titled, “OR Fire Prevention and Response.” MP stated the facility made changes to the policy to indicate that ChloraPrep (an alcohol-based antiseptic solution used to disinfect the skin before surgery) will not be used for surgeries with the surgical site above the xiphoid (the lowest part of the sternum [breastbone], located near the upper abdomen). However, MP confirmed that not all OR staff received the required training. Specifically, 14 of the 20 registered nurses (RNs) (licensed nurses who provide patient care and assist during surgery) and 16 of the 19 surgical technicians (trained personnel who assist surgeons by preparing instruments and maintaining the sterile field) did not receive the training. 1.d. During an interview on 12/17/2025 at 11:24 a.m. with Registered Nurse (RN) 1, RN 1 stated that Patient 1 was having surgery to the area in the back of the head (posterior scalp). RN 1 stated the patient had facial hair (hair on the face such as beard and mustache) and full hair coverage on the scalp, with only the surgical site shaved to approximately the size of a tennis ball (about 2.7 inches in diameter). RN 1 stated they waited for 3 minutes for the antiseptic solution to dry before draping (covering the patient with sterile cloths) Patient 1 for surgery. RN 1 further stated that the facility did not supply the smaller ChloraPrep applicator (a device used to apply an alcohol-based antiseptic solution to disinfect the skin before surgery). During a concurrent interview and record review on 12/17/2025 at 2:47 p.m. with the Director of Perioperative Services (DPS), the manufacturer’s instructions for the 26 mL ChloraPrep applicator used on Patient 1 were reviewed. The DPS confirmed the instructions indicated: Warnings: -Do not use 26 mL applicator for head and neck surgery (procedures involving the scalp, face, or neck). -Do not use on an area smaller than 8.4 in. x 8.4 in. - Solution contains alcohol (a flammable substance) and gives off flammable vapors; avoid getting solution into hairy areas. -Hair may take up to 1 hour to dry. -Do not drape or use an ignition source (such as cautery [an electrosurgical device that uses electrical current to cut tissue or stop bleeding] or laser) until solution is completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair). DPS stated they were unaware that the 26 mL ChloraPrep applicator (a device used to apply an alcohol-based antiseptic solution to disinfect the skin before surgery) should not be used in hair-bearing areas (areas of the body with hair, such as the scalp or face). DPS further stated the facility will ensure that the smaller ChloraPrep applicator (10.5 mL applicator, designed for smaller surgical sites) will be available for use. 1.e. During a concurrent interview and record review on 12/17/2025 at 10:12 a.m. with Biomedical Technician (MB), the maintenance record for the cautery machine (an electrosurgical generator [a device that uses electrical current to cut tissue or stop bleeding]) used in Patient 1’s surgery, was reviewed. - The record titled, “Work Orders Summary: Incoming Inspection,” dated 5/10/2024, indicated initial equipment installation and inspection. MB confirmed this was when the cautery machine was first installed. - The record titled, “Scheduled Work Order,” dated 10/21/2025, indicated the set values versus measured output were tested, and the coagulation mode (a function that uses electrical current to stop bleeding) was tested. MB stated that six?month maintenance (scheduled inspection and servicing) including checks for damage to the power cord and plug; proper mating and absence of damage to accessory connectors; external or internal damage to the unit; accumulation of lint or debris within the unit or heat sink; and control panel cuts, punctures, or dents, was not performed every six months between October 2024 and October 2025, resulting in an 11?month gap. MB also confirmed the maintenance record did not include all manufacturer?required testing, such as bipolar testing (a procedure that verifies the functionality and safety of the bipolar mode, which uses two electrodes to deliver electrical current for precise tissue coagulation). During a concurrent interview and record review on 12/17/2025 at 10:30 a.m. with MB, the “Service Manual: System 2450 Electrosurgical Generator,” was reviewed. The manual indicated: Preventive Maintenance Requirements: -Visual inspection at least every six months, including checks for: 1. Damage to the power cord and plug 2. Proper mating and absence of damage to accessory connectors 3. Any obvious external or internal damage to the unit 4. Any accumulation of lint or debris within the unit or heatsink 5. Control panel cuts, punctures, or dents -Output power testing for monopolar and bipolar modes (monopolar uses one electrode for cutting/coagulation; bipolar uses two electrodes for precise coagulation). -MB confirmed that maintenance was not completed according to the Service Manual specifications, as the bipolar test was not done. During an interview on 12/22/2025 at 10:16 a.m. with the Vice President of Quality and Risk Management (VPQRM), the VPQRM stated that the facility’s process when equipment was involved in an unusual occurrence (an unexpected event that could cause harm) was to sequester the equipment (remove it from use and isolate it), tag it “Do Not Use,” and call Biomedical for evaluation (request inspection and testing by biomedical engineering staff). VPQRM confirmed that the facility did not have a written policy describing this process and instead adopted the policy of the former biomedical contractor. The VPQRM further stated that after the equipment involved in the operating room (OR) fire (a surgical fire, which is an uncontrolled ignition during surgery) was sequestered, the facility did not obtain the testing results from the former biomedical contracted company. During a review of the facility’s adopted policy and procedure (P&P) titled, “Medical Equipment Management Plan,” dated July 2025, the P&P indicated: “All of the high-risk equipment (devices that could cause serious harm if they fail, such as electrosurgical generators) listed in [Name of Facility] Medical Equipment Inventory is subjected to a carefully controlled regimen of performance assurance and safety testing (verification that equipment functions safely and effectively) and manufacturer-specified scheduled maintenance (preventive maintenance performed according to the manufacturer’s instructions). The procedures and intervals for preventive maintenance are determined by the manufacturer’s specifications... The procedures for the periodic performance and safety testing have been developed by [Name of Contracted Biomedical Company] (or, in some cases, by other service providers) and are based on the manufacturer’s published performance specifications and current nationally recognized safety standards.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body was met, as evidenced by: 1. The facility’s governing body (GB, the group of individuals legally responsible for overseeing the hospital’s operations and ensuring compliance with health and safety regulations) failed to provide oversight of the Engineering Department (the team responsible for maintaining the hospital’s physical infrastructure, including plumbing, electrical systems, and structural repairs) and the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) to ensure that repair services were delivered in a manner that protected the health and safety of 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) daily, including staff in the Emergency Department (ED, the hospital area for treating urgent and serious conditions). The facility’s GB failed to ensure the Engineer Department and Infection Prevention Department implemented required environmental safety measures, such as: -Environmental assessment by Infection Prevention Services (a team responsible for identifying and preventing the spread of infections in healthcare settings), -Containment (physical barriers to isolate the work area and prevent the spread of contaminants), -Ventilation (airflow systems to reduce airborne particles and maintain air quality), and -Environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), prior to and during plumbing repairs (starting 9/09/2025 through 10/15/2025) involving wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems). This deficient practice resulted in staff (staff working in the ED Admitting/phlebotomy area) and 57 of the 83 sampled patients (Patients 27 through 83) daily (from 9/9/2025 through 10/15/2025), being exposed to hazardous environmental conditions such as sewer-like odors, smoke from cutting of piping during repair in the ED admitting area. Staff reported symptoms including headaches, nausea, cough, and in one case (Admitting Representative [AR 7]), required medical evaluation and treatment. Additionally, the second ongoing repair process (of a leak piping) in the ED Nursing Station posed a potential risk for further staff and patient exposure, increasing the likelihood of serious adverse health outcomes. (Refer to A-0083) This deficient practice resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure that 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members, who were present daily in the affected areas (Emergency Department’s Admitting/Phlebotomy area, the section where patients are registered and blood samples are collected) and the Nursing Station (a central hub in a hospital where nurses coordinate patient care), were informed of safety risks and the measures implemented to mitigate risks during repair construction (activities aimed at restoring or fixing defects, damage, or failures in a building’s structure). The facility did not post the required Infection Prevention Construction Permit signage (a sign posted at a construction or renovation site that provides a clear, documented summary of the required safety and infection control measures based on a formal Infection Control Risk Assessment [ICRA, process used to evaluate and mitigate the risk of infection transmission during construction]) during plumbing repairs conducted from 09/09/2025 through 10/15/2025, in accordance with the facility’s policies titled, “Environment of Care Safety Management Plan” and “Infection Prevention Measures During Construction and Renovation Projects.” This deficient practice violated patients’ rights of 57 patients (Patients 27 to 83) to be informed of safety risks while hospitalized and to receive care in a safe and sanitary environment. (Refer to A-0116) 2. The facility failed to ensure Admitting Department (a hospital section responsible for processing patient admissions) staff provided a copy of the facility’s condition of services (a contract that outlines a patient’s responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights [the fundamental legal and ethical protections that guarantee individuals receive respectful, dignified, and high-quality healthcare]) and patient rights information copy to one of 83 sampled patients (Patient 5), in accordance with the facility’s admitting and registering procedure, when Patient 5 was admitted to the facility on 11/1/2025. This deficient practice resulted in Patient 5 not knowing and not being able to exercise his (Patient 5’s) patient rights during the hospitalization. Patient 5 expressed concerns about being discharged without a clear care plan or understanding of what to expect upon returning home. (Refer to A-0117) 3. The facility failed to ensure one of 83 sampled patients (Patient 9) spouse and designated primary representative (RP 1) was able to exercise their rights on behalf of Patient 9, when RP 1 was not contacted by the facility regarding Patient 9’s mortuary’s (funeral home) “Authorization for Release of Remains” form. In accordance with the facility’s policy regarding “Decedent Affairs (the administrative process of handling matters related to a deceased person).” Instead, Patient 9’s next of kin and second representative (RP 2) was contacted and thus RP 2 signed Patient 9’s mortuary’s (funeral home) “Authorization for Release of Remains” form without the knowledge of RP 1. The nursing office also failed to ensure that the primary representative (RP 1) was contacted first. This deficient practice led to Patient 9’s RP 1 not being able to exercise their right and legal authority to make decisions on behalf of Patient 9. (Refer to A-0131) 4. The facility failed to ensure a safe patient-care environment for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) when it conducted plumbing repairs in an active Emergency Department (ED) patient-care areas without implementing required containment measures (physical barriers designed to prevent the spread of dust, debris, and contaminants during construction), without completing an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to determine infection-control precautions required during construction or maintenance), and without providing ventilation or air-filtration controls, including High-Efficiency Particulate Air (HEPA filtration, a mechanical filtering system that captures small airborne particles) or negative air pressure (a ventilation technique that keeps air flowing into, but not out of, a contaminated area). This deficient practice exposed patients and staff to hazardous environmental conditions, including airborne particles (microscopic solid or liquid substances suspended in air), sewer-like odors (strong odors produced by leaking wastewater piping), wet drywall with brown/black discoloration suggestive of mold (fungal growth capable of releasing spores), smoke, and water diverted from ceiling leaks into a clinical hand-washing sink, increasing the risk of exposure to waterborne pathogens (disease-causing microorganisms transmitted through contaminated water) and environmental contaminants (harmful biological or chemical substances present in the environment). (Refer to A-0144) 5. The facility failed to fully implement the methods and mechanisms required to ensure that patients are free from all forms of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), in accordance with the facility’s policy and procedure regarding abuse, for two of 83 sampled patients (Patients 1 and 8) when: 5.a. The facility did not conduct a thorough investigation, when Patient 1 alleged that a male registered nurse (RN 1) pushed her (Patient 1) onto the bed and held her down, then locked her (Patient 1) in the room all night long. This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm. (Refer to A-0145) 5.b. The facility did not interview or assess Patient 8 (Patient 1’s roommate) to verify if Patient 8 witnessed any type of abuse or if Patient 8 sustained abuse or injury by RN 1. This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 48212 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure nursing staff performed head-to-toe assessments (a comprehensive physical examination that systematically evaluates a patient’s body from head to feet to establish a baseline, monitor changes, and identify health issues. This includes checking vital signs [temperature, heart rate, blood pressure], assessing the skin, and examining all body systems like the respiratory, cardiovascular, neurological, and gastrointestinal systems. The assessment helps providers understand the patient’s current health status and needs) for two of 83 sampled patients (Patients 1 and 8), in accordance with the facility’s policy and procedure regarding nursing assessments and reassessments. This deficient practice had the potential for the inability of nursing staff to identify changes in patients’ condition. (Refer to A-0395) 2. The facility failed to provide one of seven sampled staff members (Registered Nurse [RN] 1) orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit (M/S, department for patients who need close attention but are not critically ill) and to evaluate RN 1’s competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization’s standards and protocols), when RN 1 started working in the M/S unit on 7/12/2025, in accordance with the facility’s policies regarding orientation and competency assessment. This deficient practice had the potential for RN 1’s inability to perform unit specific duties and placed patients’ health and safety at risk. (Refer to A-0397) 3. The facility failed to ensure that the nursing office confirmed one of 83 sampled patient’s (Patient 9’s) spouse and primary representative (RP 1) information was documented on Patient 9’s mortuary’s “Authorization for Release of Remains,” in accordance with the facility’s policy and procedure (P&P) titled, “Decedent Affairs.” This deficient practice led to Patient 9’s next of kin and secondary representative (RP 2) to sign the form instead of RP 1, who had the legal authority to do so. (Refer to A-0398) 4. The facility failed to ensure one of 83 sampled patient’s (Patient 9) physician was notified of Patient 9’s changes in mental status and blood pressure (BP, amount of force needed to move blood throughout the body and organs, with normal range of 120/90 millimeters of Mercury [mmHg, a unit of measurement]), in accordance with the facility’s policy and procedure (P&P) titled, “Provider Notification.” This deficient practice resulted in a delay of Patient 9’s care, when Patient 9 remained in the medical surgical unit for more than 24 hours before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for closer monitoring and blood pressure support. (Refer to A-0398) 5. The facility failed to ensure its nursing staff assessed a patient’s ability to void (urinate) after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal for one of 83 sampled patients (Patient 5), in accordance with the facility’s policy and procedure regarding foley catheter removal. This deficient practice had the potential to put Patient 5 at risk for urinary retention (inability to completely empty the bladder) and urinary tract infection (UTI, an infection in any part of the urinary system). (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Physical Environment was met, as evidenced by: 1. The facility failed to ensure a safe and sanitary environment in the Emergency Department (ED, the hospital area for treating urgent and serious conditions) for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff. The facility failed to implement required infection control and environmental safety measures during plumbing repairs in the ED Admitting and Phlebotomy areas (the section of the ED where patients are registered and blood samples are collected) as required by facility’s policy titled, “Infection Prevention Measures During Construction and Renovation Projects,” and failed to notify the Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities) as required by the FREER Manual- Revised August 2025 (a regulatory guide published by the California Department of Health Care Access and Information [HCAI], It provides instructions for healthcare facilities on how to manage construction, maintenance projects, and helps outlines the necessary steps to obtain clearances, permits, and approvals) , published by HCAI. This deficient practice resulted in approximately 60 patients per day and multiple staff members being exposed to hazardous environmental conditions during the repair period from 09/09/2025 through 10/15/2025. These conditions included sewer-like odors, airborne particles (microscopic solid or liquid substances suspended in the air that may pose respiratory risks), and visible mold-like substances (fungal growths that can release spores and cause health issues). Staff reported experiencing symptoms such as headaches, nausea, coughing, and respiratory distress (difficulty breathing or shortness of breath). One staff member required medical evaluation and treatment (clinical assessment and care provided by a licensed healthcare professional). (Refer to A-0701) This deficient practice resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Infection Prevention/Control/Antibiotic Stewardship Program was met, as evidenced by: 1. The facility failed to implement its infection prevention and control program in a manner that protected 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) from potential infection risks while these patients were treated in the Emergency Department (ED). The facility did not have a policy or procedure to address cross-contamination risks associated with leaking piping in patient care areas and failed to conduct an Infection Control Risk Assessment (ICRA) when a leak was identified in the ED. Clinical staff continued to use a handwashing sink where water from a ceiling leak was actively diverted into the basin. There was no signage indicating restricted use of the sink, and the Infection Prevention Department was not notified. This deficient practice placed 57 of the 83 sampled patients (Patients 27 - 83) at risk of exposure to waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) and environmental contaminants (harmful substances present in the surrounding environment), increasing the potential for transmission of infectious agents (organisms such as bacteria, viruses, or fungi that can cause disease). (Refer to A-0749) 2. The facility failed to ensure one of seven (7) sampled staff members (Admitting Supervisor [Sup 1]) had annual tuberculosis (TB, an infectious disease that affects the lungs) testing, in accordance with the facility’s policy and procedure regarding tuberculosis screening for employees. This deficient practice had the potential to spread tuberculosis if TB status of an employee was unknown, which may infect patients, staff, and visitors in the hospital. (Refer to A-0749) 3. The facility failed to maintain a clean and sanitary environment (a clean, safe, and healthy space that minimizes the risk of disease by managing and controlling factors like preventing human contact with harmful substances to break the cycle of disease transmission) and prevent potential sources of infection for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members who were present in the affected area (Emergency Department’s Admitting/phlebotomy, which involves the initial administrative processing and the critical first step of diagnostic testing for patients presenting to the emergency room) daily, when: 3.a. The facility did not consult the Infection Preventionist (IP, a healthcare professional responsible for overseeing infection prevention and control activities) for an assessment prior to initiating construction repairs (the process of fixing or restoring an existing structure to its original or functional condition by replacing or renewing its components) following water damage. This deficient practice resulted in no assessment or safety recommendations from the Infection Prevention Department (IPD) prior to the Engineering Department starting the repair project, potentially placing patients and staff at risk of exposure to contaminants released during construction. (Refer to A-0750) 3.b. The facility did not implement appropriate environmental controls, such as providing ventilation (the intentional movement of air to dilute or remove airborne contaminants) to the affected area during the repair of drywall (a construction material used for interior walls, which can harbor mold [a type of fungus that can pose health risks] when wet) and tile with visible dark brown staining. These actions were not performed in accordance with the facility’s “Environment of Care Safety Management Plan” and “Infection Prevention Measures During Construction and Renovation Projects” policy and procedures. This deficient practice had the potential to expose patients, staff, and visitors to airborne contaminants (microscopic particles or biological agents suspended in the air that may cause illness) and HAIs (Healthcare-Associated Infections, conditions acquired by patients while receiving treatment in a healthcare setting), increasing the overall infection risk (the likelihood of exposure to and transmission of infectious agents). (Refer to A-0750) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 46333 Based on observation, staff interviews, and record review, the facility’s governing body (GB, the group of individuals legally responsible for overseeing the hospital’s operations and ensuring compliance with health and safety regulations) failed to provide oversight of the Engineering Department (the team responsible for maintaining the hospital’s physical infrastructure, including plumbing, electrical systems, and structural repairs) and the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) to ensure that repair services were delivered in a manner that protected the health and safety of 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) daily, including staff in the Emergency Department (ED, the hospital area for treating urgent and serious conditions). The facility’s GB failed to ensure the Engineer Department and Infection Prevention Department implemented required environmental safety measures, such as: -Environmental assessment by Infection Prevention Services (a team responsible for identifying and preventing the spread of infections in healthcare settings), -Containment (physical barriers to isolate the work area and prevent the spread of contaminants), -Ventilation (airflow systems to reduce airborne particles and maintain air quality), and -Environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria) prior to and during plumbing repairs (starting 9/09/2025 through 10/15/2025) involving wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems). This deficient practice resulted in staff (staff working in the ED Admitting/phlebotomy area) and 57 of the 83 sampled patients (Patients 27 through 83) daily (from 9/9/2025 through 10/15/2025), being exposed to hazardous environmental conditions such as sewer-like odors, smoke from cutting of piping during repair in the ED admitting area. Staff reported symptoms including headaches, nausea, cough, and in one case (Admitting Representative [AR 7]), required medical evaluation and treatment. Additionally, the second ongoing repair process (of a leak piping) in the ED Nursing Station posed a potential risk for further staff and patient exposure, increasing the likelihood of serious adverse health outcomes. On 11/6/2025 at 4:13 p.m., the survey team called a second Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), and Risk Management Accreditation, Regulatory & Licensing. The facility’s Governing Body failed to have oversight of the Engineering Department and Infection Prevention (IP) processes to ensure that services were provided in a safe and effective manner. This failure had potentially exposed 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) to harmful substances released during construction or repair activities. These substances included tiny airborne particles (tiny solid particles or little liquid drops that float around in the air), such as disease-causing bacteria (tiny organisms that can multiply in the body, release poisons, or damage tissues, causing illness), viruses (infective agents), and fungi (organisms capable of causing disease), which could be inhaled and cause infections. Despite repeated staff complaints, no action was taken to relocate staff or patients, and the unsafe conditions persisted from 9/9/2025 through 10/15/2025. The facility permitted construction activities in patient care areas without completing an Infection Control Risk Assessment (ICRA, a formal, structured process used to evaluate and mitigate the risk of infection transmission during construction, renovation, maintenance, or repair activities when these occur in or near patient care areas), notifying the infection prevention team (a group of healthcare professionals who work to stop the spread of germs and infections in a medical facility. They make sure the environment is clean and safe for patients, staff, and visitors.) or conducting environmental testing (checking the air and surfaces in a hospital area for things that could be dangerous to health, such as mold [a type of fungus that grows in damp places and can cause breathing problems], dust [tiny particles that can carry germs or irritate the lungs], or bacteria [tiny organisms that can cause infections]). As a result, 57 of the 83 sampled patients (Patients 27 through 83), and staff per day were exposed to hazardous environmental conditions. Staff and patients reported persistent sewer-like odors, visible mold-like substances, and symptoms including headaches, nausea (a feeling of sickness with an inclination to vomit), and respiratory distress (difficulty in breathing). At least one staff member required medical evaluation and treatment. On 11/7/2025 at 5:29 p.m., the Second Immediate Jeopardy (IJ) was removed in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO), and Vice President of Quality (VPQ). The survey team verified and confirmed the elements of the IJ Removal Plan (interventions to correct the deficient practice) through observation, interview, and record review while onsite. The IJ Removal Plan indicated that the Governing Board is responsible for ensuring the safety of patients and employees. This includes ensuring all Environment of Care and Safety issues involving the Engineering Department and Infection Prevention Departments are carried out timely and appropriately. Environment of Care (EOC) Safety Log: This log was created to track issues, hazards, and mitigation actions. The Safety Officer is responsible for updating the log after completing Environment of Care Safety Rounds. The log will be included in the Governing Board Packet for review. The Safety Officer ensured that the leak above the ED Nurses’ Station, classified as a utility failure from an air handling unit, was entered into the log. Containment was placed, and a swab test was completed on November 7, 2025. Environment of Care Safety Dashboard (EOCSD): This dashboard was created to report all repair and construction projects to the EOC Committee, the Infection Control Committee, and the Governing Board Committee. It ensures compliance with risk assessments before initiating projects. The Director of Engineering updates the dashboard monthly with metrics such as the number of open/pre-construction projects, closed projects, compliance with ICRAs and PCRAs, environmental testing compliance, and the percentage of projects completed within the timeline. Monthly Review: The dashboard will be reviewed monthly with the Chief Operating Officer to ensure compliance with risk assessments and validate that repairs, construction projects, and safety issues are appropriately accounted for and reported. Construction/Repair Tracking Dashboard: This dashboard includes all projects moving forward, including the ED Leak at the Nursing Station. The Director of Engineering logs projects onto the dashboard, which is reviewed bi-weekly with representatives from Infection Prevention, Engineering, and the Chief Operating Officer. The information is cross-referenced with the total number of work orders in the database to ensure accuracy. Education on Tools: Education on the use and interpretation of the Environment of Care Safety Tool, Dashboard, and Construction/Repair Tracking tool was provided to the Governing Board on November 7, 2025, by the Chief Operating Officer. The Chief Operating Officer ensures the accuracy of these tools before presenting them to the Governing Board for monthly review. Findings: During an interview on 10/23/2025 at 2:10 p.m. with Engineering staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August. The engineering department inspected the area and suspected it was coming from the sink drain, so a plumbing engineer poured chemicals into the drain. However, ENG 2 stated that the odor was not resolved. On 9/9/2025, they opened the wall by the sink and discovered a leaking pipe. ENG 2 stated that the drywall was wet and had dark brown and black spots, which had to be cut out. Despite the repair to the sink area, the odor persisted. Later, they discovered another pipe leaking above the ceiling, which was the source of the odor. They had to remove the ceiling tile and cut through the piping to remove the damaged pipe. ENG 2 confirmed that the repair started 9/9/2025 and was completed on 10/31/2025 without construction barriers (temporary, physical partitions that separate construction zones from patient care areas to control the spread of dust, debris, and disease-causing agents ensuring patient safety and maintaining a sterile environment). During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Nurse Manager of the Emergency Department (EDM) in the ED Nursing Station (the central area in the Emergency Department where nurses coordinate patient care and documentation), a plastic covering was observed above the ceiling, positioned over a sink. A piece of tubing extended from the ceiling, through the plastic covering, and into the sink. The EDM confirmed that this setup was related to a second active leak (in addition to two previously identified leaks in the admitting/phlebotomy area). The EDM confirmed the leak occurred in early July this year. The EDM described the leak as forming a paint bubble “the size of a dinner plate” on the ceiling. There was no signage posted to indicate that the sink should not be used. The EDM stated that no instructions had been provided by the Infection Preventionist (a healthcare professional responsible for preventing the spread of infections in the facility) or the Engineering Department (the team responsible for maintaining the hospital’s physical infrastructure, including plumbing and repairs) regarding the use of the sink. EDM confirmed the facility was currently using the space for patient care, and that they never closed off this area. There was no signage displayed indicating that an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and reduce the risk of infection transmission during any construction, renovation, or maintenance work that occurs in or near patient care areas) completed by Infection Control Department. During an interview on 11/04/2025 at 10:50 a.m. with Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 stated that during the repair process, the Engineering Department (the team responsible for maintaining the hospital’s physical infrastructure, including plumbing and repairs) only covered the computers in the area. AR 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up. AR 1 further stated that one staff member required hospital evaluation due to symptoms. AR 1 reported that this concern was communicated to the former Admitting Manager (MA). However, AR 1 stated that the MA did not provide any directions to staff, as she was no longer employed at the facility after the report was made. During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up during the repair work. Phleb 1 further stated that no directives were issued to stop using the area during the construction activities. During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that no containment (physical barriers used to isolate the work area and prevent the spread of contaminants) or air filtration (equipment used to remove airborne particles and maintain air quality) was set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure. During a record review of the facility’s “Organizational Chart (a diagram that shows the structure of an organization, including departments and reporting relationships),” which was undated, the organizational chart indicated that the Director of Engineering (the individual responsible for overseeing the hospital’s physical infrastructure and maintenance operations) reported to the Chief Operating Officer (COO, the executive responsible for managing the hospital’s daily operations). The chart further indicated that the COO reported directly to the Chief Executive Officer (CEO, the highest-ranking executive responsible for overall hospital administration), and the CEO reported directly to the Governing Body (the group legally responsible for overseeing the hospital’s operations and ensuring compliance with health and safety regulations). During an interview on 11/4/2025 at 2:17 p.m. with the Chief Operating Officer (COO, the executive responsible for managing the hospital’s daily operations), the COO stated that due to the fact they were concentrating on getting the repair done, the COO confirmed that the required environmental safety measures, such as containment (physical barriers to isolate the work area), ventilation (airflow systems to reduce airborne particles), and environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), were not verified prior to or during plumbing repairs conducted from 09/09/2025 through 10/31/2025. These repairs involved cutting into wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems). During the same interview on 11/4/2025 with the COO, the COO also stated that, initially, they (facility administrative team) were not aware that staff had reported symptoms. The COO later became aware of the reports but was unsure of the exact date this information was received. The COO confirmed that they did not report to the Chief Executive Officer (CEO, the highest-ranking executive responsible for overall hospital administration) that staff had reported symptoms including headaches, nausea, and coughing. The COO also confirmed that one staff member, identified as Admitting Representative (AR 7), required medical evaluation and treatment due to these symptoms. During a concurrent interview and record review on 11/04/2025 at 2:04 p.m. with the Director of the Engineering Department (DED, the individual responsible for overseeing the hospital’s physical infrastructure and maintenance operations), the work order submitted by the Director of Phlebotomy/Laboratory Services on 09/09/2025, was reviewed. The work order indicated that there was an unusual odor coming from the sink inside the Emergency Room (ER) draw station (a designated area where blood samples are collected), describing it as a “sewage smell” and requesting that engineering staff investigate. The DED stated that after engineering staff opened the wall near the sink in the Admitting/Phlebotomy Station (the area where patients are registered and blood is drawn), they identified a leaking pipe and repaired it. However, the odor persisted. During the same interview on 11/04/2025 at 2:04 p.m. with the DED, the DED further stated that on 08/19/2025, they sent an engineering plumber to the Emergency Department (ED) admitting area (the section of the ED where patients are initially processed), where a second leaking pipe was identified above the ceiling. The DED confirmed that he (DED) instructed the engineer to repair the leaking pipe above the ceiling, and that the final repair was completed by 10/31/2025, as documented in the work order. DED also confirmed that there was another active leak above the ED Nursing Station (the central area in the ED where nurses coordinate patient care and documentation), which had been ongoing since 7/07/2025. He (DED) stated that this repair was on hold, pending fabrication of replacement piping, which would need to be soldered or welded into the existing system above the ceiling. During an interview on 11/4/2025 at 2:17 p.m., with the Director of Engineering (DED) and the Chief Operations Officer (COO), the COO confirmed that repairs began on 9/9/2025 without notifying Department of Health Care Access and Information (HCAI, department oversees a wide range of programs and regulatory functions, including responsible for reviewing and approving construction plans, permits, and safety clearances for health care facilities. This includes ensuring compliance with seismic safety standards and infection control protocols during construction or renovation projects). During an interview on 11/4/2025 at 2:30 p.m. with the Chief Operating Officer (COO), the COO confirmed there was no environmental testing for mold or air quality testing conducted before, during, or after the repairs. During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), the ES confirmed that no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and reduce the risk of infection transmission during any construction, renovation, or maintenance work that occurs in or near patient care areas.) was completed. The ES also confirmed that the Infection Prevention Department (the team responsible for identifying, monitoring, and preventing the spread of infections within the facility) was not involved in either the admitting area or nursing station repair projects. The ES stated that environmental testing, when conducted, would check for: -Spores (tiny, invisible fungal particles that float in the air and can cause respiratory issues), -Asbestos (a group of minerals that are not visible to the eye; when disturbed, asbestos fibers can become airborne and, if inhaled at high levels, may cause lung damage and potentially lead to cancer), and -Other airborne particles (substances suspended in the air that may pose health risks). The ES stated that the ICRA form must be completed whenever construction or repair work occurs in a patient care area. The ES further stated that the proper process should involve relocating patients from the affected area before beginning any repair work. During a concurrent interview and record review on 11/4/2025 at 3:15 p.m. with the Chief Operating Officer (COO) and the Director of Engineering and Design (DED), the FREER Manual (Revised August 2025), published by the California Department of Health Care Access and Information (HCAI), was reviewed. The manual indicated that plumbing repairs involving the replacement or rearrangement of valves, pipes, or fixtures are not considered Excluded Work (routine maintenance that does not require regulatory reporting). These types of repairs were classified as New Work (construction or repair activities that alter the original configuration of building systems) and therefore required submission of the OSHPD-102 form (a regulatory form used to notify HCAI of construction or repair work in healthcare facilities) and formal review by HCAI (California Department of Health Care Access and Information) prior to the start of work. The COO stated they were not aware that piping exchange (replacement of plumbing pipes) requires reporting to HCAI. During an interview on 11/4/2025 at 3:30 p.m. with the Vice President of Revenue Cycle Management (VP), VP stated that they were not aware of the issue and did not receive a report from admitting leaders regarding the odor. During an interview on 11/4/2025 at 4:08 p.m. with the Infection Prevention Manager (IPM), IPM confirmed that the department was not informed about the project, nor were they aware of the presence of a strong sewer-like odor or wet drywall with brown and dark spots, which the IPM indicated would have suggested the presence of mold and required further testing. During an interview on 11/05/2025 at 3:22 p.m. with the CEO, the CEO stated that during Daily Safety Meetings (routine meetings involving department leaders to discuss safety-related issues), major repair work performed by the Engineering Department was typically discussed. The CEO recalled hearing about the repair project but was unsure of the specific date. The CEO stated that the COO reported a leak that required calling in a vendor for the Nursing Station repair (the central area in the Emergency Department where nurses coordinate patient care and documentation). However, regarding the Admitting Area’s sink and ceiling repair (the section of the Emergency Department where patients are first registered and processed), the CEO was unsure when the report was received but was aware that the area had been repaired. During the same interview on 11/5/2025 at 3:22 p.m. with the CEO, the CEO confirmed that major repairs should be reported to both the CEO and the Governing Body. The CEO stated that if they had been made aware of issues such as staff complaints of strong odors, headaches, or nausea, the appropriate departments would have been notified to consider closing the affected area and rerouting patients before initiating repairs. During the same interview on 11/5/2025 at 3:22 p.m. with the CEO, the CEO also confirmed that while they received general reports indicating when repairs would take place, they did not receive detailed information about the nature or scope of the repairs. The CEO stated that the GB relied on the COO and the Director of Engineering to ensure compliance with safety protocols during demolition, construction, or general maintenance projects, and to ensure the involvement of the Infection Prevention Department to protect patient and staff safety. During a review of the Facility’s Governing Board Bylaws, dated 2025, the Bylaws indicated the following: “General Functions and Responsibilities of the Governing Board: Specific Powers. The Hospital Governing Board shall be delegated the following rights and responsibilities...Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital; Participate in the strategic planning initiatives for the Hospital ... Enforce policy relating to the general conduct of the Hospital to ensure compliance with the requirements of all applicable federal and state laws and accrediting bodies; Periodically review the Hospital’s activities to ensure that it is operating in a manner consistent with the accomplishment of its stated purposes ...” During a review of the facility’s policy and procedure (P&P) titled, “Environment of Care Safety Management Plan,” dated 10/23/2024, the P&P indicated the following: The EOC Safety Management Plan provides a framework for managing the environment of care and addresses six areas of the environment of care: safety, security, hazardous materials and waste, fire safety, medical equipment and utility systems. Separate management plans are available for the Emergency Management and Life Safety programs. The objective of the EOC Safety Management Plan is to provide a guideline for the development of a safety management program that will enable the hospital: -To comply with all relevant safety standards and regulations -To develop or maintain effective program elements that contribute to an overall reduction in workplace injuries and improved patient safety -To improve employee performance through effective safety education and training -To develop standards to monitor, assess, measure and improve EOC performance -To monitor the effectiveness of the safety program The CEO is responsible for assuring the existence and effectiveness of a comprehensive safety program by providing the vision, leadership, financial and administrative support to facilitate the ongoing activities of the EOC committee ... The Governing Board receives regular reports of the activities of the hospital safety management program from the Environment of Care (EOC) Committee. The members of the Governing Board review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance to the Chief Executive Officer (CEO) or administrative liaison. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation projects,” dated 10/24/2018, the P&P indicated, “Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins. Responsibilities: Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled. Notify all affected departments/services when there is planned/unplanned disruption in water supply and assist in providing alternate sources ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted ... Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure that 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members, who were present daily in the affected areas (Emergency Department’s Admitting/Phlebotomy area, the section where patients are registered and blood samples are collected) and the Nursing Station (a central hub in a hospital where nurses coordinate patient care), were informed of safety risks and the measures implemented to mitigate risks during repair construction (activities aimed at restoring or fixing defects, damage, or failures in a building’s structure). The facility did not post the required Infection Prevention Construction Permit signage (a sign posted at a construction or renovation site that provides a clear, documented summary of the required safety and infection control measures based on a formal Infection Control Risk Assessment [ICRA, process used to evaluate and mitigate the risk of infection transmission during construction]) during plumbing repairs conducted from 09/09/2025 through 10/15/2025, in accordance with the facility’s policies titled, “Environment of Care Safety Management Plan” and “Infection Prevention Measures During Construction and Renovation Projects.” This deficient practice violated patients’ rights of 57 patients (Patients 27 to 83) to be informed of safety risks while hospitalized and to receive care in a safe and sanitary environment. Findings: During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department’s Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated, “An unusual odor is emitting from the sink located inside the Emergency Room draw station.” During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, “Searched in the ceiling and found some cast iron pipe and fittings completely corroded (a pipe that has deteriorated due to chemical reactions, leading to a breakdown of its material) and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings.” During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated, on 09/09/2025, engineering staff opened the wall near the sink in the Emergency Department (ED) and discovered a leaking pipe. ENG 2 stated that the drywall (a construction material used for interior walls that can harbor mold when wet) was saturated and exhibited dark brown and black discoloration, which had to be cut out. Despite the initial repair to the sink area, ENG 2 stated that the odor persisted. A subsequent inspection revealed a second leaking pipe located above the ceiling, which was identified as the source of the odor. ENG 2 stated that ceiling tiles were removed, and the damaged pipe was cut out and replaced. During an interview on 11/04/2025 at 10:50 a.m. with Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 confirmed that during the repair process there was no signage posted regarding infection control risk assessment. During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that there was no signage posted regarding the safety assessment completed to the construction site. AR 7 confirmed there was no air filtrations system (equipment used to remove airborne particles and maintain air quality) set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure. During an interview on 11/4/2025 at 2:17 p.m. with the Chief Operating Officer (COO, the executive responsible for managing the hospital’s daily operations), the COO stated the process was the engineering department would reach out to the Infection Prevention Department (IPD) prior to initiating a repair construction in a patient care area, so the IPD could perform an Infection Control Risk Assessment (ICRA, a risk assessment tool used to determine the class of infection control precautions required for a construction or renovation project. It evaluates factors such as the type of work, proximity to patient care areas, and patient risk groups. The ICRA process results in a classification such as Class I-IV). The COO stated due to the fact that they were concentrating on getting the repair done, the COO confirmed that required environmental safety measures, such as containment (physical barriers to isolate the work area), ventilation (airflow systems to reduce airborne particles), and environmental testing (checking air and surfaces for harmful substances such as mold, dust, or bacteria), were not verified prior to or during plumbing repairs conducted from 09/09/2025 through 10/31/2025. These repairs involved cutting into wet drywall (a construction material used for interior walls) that had visible brown and dark discoloration, which may have indicated the presence of mold (a type of fungus that grows in damp areas and can cause respiratory problems). During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the Infection Prevention Department (IPD) had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, “Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- {HEPA} filter to capture at least 99.97% of tiny particles {down to 0.3 microns} like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don’t spread to vulnerable patients) projects.” IPM stated prior to initiating repair construction in a patient care area, an Infection Control Risk Assessment (ICRA) which was a risk assessment tool used to determine the class of infection control precautions required for a construction, should be completed by IPD. It evaluates factors such as the type of work, proximity to patient care areas, and patient risk groups. The IPM stated the ICRA process results in a classification such as Class I - IV. The IPM further stated that after the ICRA has been assessed and determined the Class, the Infection Prevention Construction Permit was required for projects classified as Class III or IV. IPM further stated there should have been an Infection Prevention Construction Permit posted at the site for both repair projects (ED Nursing station and Admitting/Phlebotomy area). IPM stated the permit confirms that: The ICRA has been reviewed and approved. Required controls such as HEPA filtration, containment barriers, and signage were in place. IPM stated that the Infection Prevention Department must sign off on the project before work begins. The IPM stated that the IPD should have been informed of both repair projects, because there must be an ICRA assessment completed prior to initiating the repair in the patient care area. The IPM stated that staff could have been exposed to bacteria. During a review of the facility’s policy titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ...Infection Prevention Department will: Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input. Provide written recommendations, as appropriate ... Infection Prevention Permits: Construction/renovation activities require consultation with the Infection Prevention Practitioner ...An Infection Prevention Construction Permit (Appendix A) is required when the construction activity and risk level indicate that Class 111 and Class IV control procedures are required. When an Infection Prevention Construction Permit is required, it must be obtained from the Infection Prevention department before beginning any demolition or construction work. Decisions regarding classification of construction activities rest with the Infection Prevention department. The Infection Prevention Construction Permit must be displayed at the entrance to the work area during the entire construction period. Review and sign Infection Prevention Construction Permit, prior to beginning work. During a review of the facility’s policy and procedure (P&P) titled, “Environment of Care Safety Management Plan,” dated 10/23/2024, the P&P indicated, “The Director of Facilities, in concert with Administration and Infection Prevention, will ensure planning for remodels, renovations, alterations, modifications and new facilities takes into consideration patient safety, diagnosis and treatment facilities and special services appropriate to the needs of the community ... Areas used by the patient are safe, clean, functional, and comfortable. This includes lighting, ventilation and cleanliness. Areas are free from offensive odors ...Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation and general maintenance projects ...When planning for demolition, construction, renovation or general maintenance, the hospital will conduct a pre-construction risk assessment for air quality requirements, infection control and sanitation, utility requirements, noise, vibration, dust and other hazards that affect care, treatment and services. The hospital takes action based on the risk assessment to minimize risks during construction, such as: Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided otherwise contracted. Inspect project during the course of construction, at completion and prior to occupancy of area.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure Admitting Department (a hospital section responsible for processing patient admissions) staff provided a copy of the facility’s condition of services (a contract that outlines a patient’s responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights [the fundamental legal and ethical protections that guarantee individuals receive respectful, dignified, and high-quality healthcare]) and patient rights information copy to one of 83 sampled patients (Patient 5), in accordance with the facility’s admitting and registering procedure, when Patient 5 was admitted to the facility on 11/1/2025. This deficient practice resulted in Patient 5 not knowing and not being able to exercise his (Patient 5’s) patient rights during the hospitalization. Patient 5 expressed concerns about being discharged without a clear care plan or understanding of what to expect upon returning home. Findings: During a review of Patient 5’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/2/2025, the H&P indicated Patient 5 was admitted to the facility from an outside hospital with left sided flank (the side of the body between the ribs and hips) pain on 11/1/2025. The H&P also indicated Patient 5 was pending surgery to treat nephrolithiasis (kidney stones). During a review of the complaint received by the Department of Public Health (DPH, the state agency responsible for protecting public health and ensuring patient safety in healthcare facilities), dated 11/6/2025, the complaint indicated the following: Patient 5 had a procedure of ureteroscopy (a medical procedure to break up or remove kidney stones) with ureteral-stent (a small, flexible tube placed inside the ureter [the duct connecting from the kidney to the bladder] to allow urine to flow) placement on 11/3/2025 around 5 p.m. Patient 5 was told by on duty night shift nurse same evening (11/3/2025) that he (Patient 5) was discharged (to go home) and would become financially responsible for any additional stay leaving him (Patient 5) no option to refuse discharge. The complaint also indicated Patient 5 did not speak with any physician prior to discharge and was not involved in discharge plan of care (a comprehensive guide created by a healthcare team to ensure a patient has a smooth and safe transition from hospital to home or other lower level of care), and not aware of what to expect after being discharged home. During a concurrent interview and record review on 11/7/2025 at 9:08 a.m. with the Nurse Manager (NM 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, Patient 5’s electronic medical record (EMR) from 11/1/2025 to 11/3/2025, was reviewed. Patient 5’s EMR indicated there was no “Condition of Services (a contract that outlines a patient’s responsibilities and consent for hospital services. Key elements typically include informed consent for medical treatment, financial responsibilities, and patient rights)” on file. NM 1 stated that admitting department should upload a scanned copy of “Condition of Services” to EMR but there was no “Condition of Services” found in Patient 5’s EMR. During an interview on 11/7/2025 at 4:15 p.m. with the Director (DIR 2) of Admitting, DIR 2 stated the admitting department was responsible for giving the “Condition of Service” and patient’s rights and responsibilities notices and obtaining patient’s signature for direct admits (patient directly transferred from an outside hospital). DIR 2 stated the signed copy would be scanned and uploaded to a patient’s EMR. During an interview on 11/7/2025 at 5:05 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated there was no “Condition of Services” found in Patient 5’s EMR and MARL was unsure if Patient 5 was informed and aware of his (Patient 5’s) rights as a patient. During a review of the facility’s policy and procedure (P&P) titled, “Registration Process, Patient,” dated 6/2022, the P&P indicated, “At the time of registration and/or admission, the patient or the patient’s legal representative shall acknowledge receipt by signing the following consent forms: a. conditions of services ... f. Patient Rights ... 4. Patients also receive a copy of all the forms upon completion of registration 5. Upon admission to the hospital, patients receive a Patient Folder and Visitors Guide to help orient them to the hospital.” During a review of the facility’s policy and procedure (P&P) titled, “Patients Rights and Responsibilities,” dated 8/2025, the P&P indicated, “Patient Rights ... The patient has the right to ... 1. Considerate and respectful care, and to be made comfortable ... 20. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and option following discharge from the hospital. They have the right to be involved in the development and implement of their discharge plan ... Procedure: 1. Upon admission to [the facility], either through the Admitting Department or the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), the admitting person shall provide written information of an individual’s rights under state law to make decisions regarding medical care including the right to accept or refuse treatment and the right to formulate advance directives (written statement of a person’s wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor).”

“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: 50516 Based on interview and record review, the facility failed to ensure one of 83 sampled patients’ (Patient 9’s) spouse and designated primary representative (RP 1) was able to exercise their rights on behalf of Patient 9, when RP 1 was not contacted by the facility regarding Patient 9’s mortuary’s (funeral home) “Authorization for Release of Remains” form. In accordance with the facility’s policy regarding “Decedent Affairs (the administrative process of handling matters related to a deceased person).” Instead, Patient 9’s next of kin and second representative (RP 2) was contacted and thus RP 2 signed Patient 9’s mortuary’s (funeral home) “Authorization for Release of Remains” form without the knowledge of RP 1. The nursing office also failed to ensure that the primary representative (RP 1) was contacted first. This deficient practice led to Patient 9’s RP 1 not being able to exercise their right and legal authority to make decisions on behalf of Patient 9. Findings: During a record review of Patient 9’s “History and Physical (H&P),” dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9’s medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure). The record did not indicate Patient 9 had a durable power of attorney (DPOA, legal document where a patient designates someone to make decisions for them if unable to). During a record review Patient 9’s “Face sheet (front page of the chart that contains a summary of basic information about the patient),” dated 11/1/2024, the Face sheet indicated Patient 9 had a spouse (RP 1) and next of kin (RP 2) listed as emergency contacts. During a record review of Patient 9’s “Progress Note SOAP (subjective, observation, assessment, plan),” dated 10/31/2024, the Progress Note indicated Patient 9’s RP 1 was recognized as the spouse and was involved in Patient 9’s plan of care. During a record review of Patient 9’s “Notice of Death,” dated 11/2/2024, the record indicated Patient 9’s RP 1 was made aware of Patient 9’s death. During an interview on 11/3/2025 at 2:30 p.m. with Registered Nurse (RN) 2, RN 2 stated an emergency contact would be the spouse or the designated decision maker, children, and blood relatives. RN 2 stated she would contact the spouse or designated decision maker first if there was no DPOA and acknowledged patients’ rights applied to them. During a concurrent interview and record review on 11/6/2025 at 10:42 a.m. with House Supervisor (HS), Patient 9’s “Mortuary Release Form,” dated 11/4/2024, was reviewed. The record indicated the release was signed by the mortuary, and on the mortuary’s form for “Authorization for Release of Remains,” Patient 9’s RP 2 was listed as the “Representative,” the relationship was marked as “Next-of-Kin (Closest Living Relative),” and RP 2 signed the form. Patient 9’s RP 1 was not listed on this form, and the facility did not contact RP 1 to sign the form. During a continued interview and record review on 11/6/2025 at 10:42 a.m. with HS, HS stated the next of kin was considered the emergency contact. HS stated the next of kin was usually the spouse, parent, or other living relative. HS stated she would have gone with RP 1 and RP 1 should have signed the document. HS also stated nursing office was responsible for making sure the form received from the mortuary was correct, and they would check for discrepancies such as name or to update information. During a review of the facility’s policy and procedure (P&P) titled, “Decedent Affairs,” dated 7/27/2022, the P&P indicated, “Prior to releasing remains to mortuary transporter, the Nursing Office shall ensure that the “Release Authorization” form is completed in full by the mortuary and is properly signed. The following relatives may sign a “Release Authorization” (listed in order of who may consent). a. An agent named in the Advanced Directive b. Surviving spouse/domestic partner c. Adult child (in the case of multiple adult children, one child may sign if they represent the wishes of the majority of the adult children) d. Surviving parent e. Adult sibling (in the case of multiple adult siblings, one sibling may sign if they represent the wishes of the majority of the adult siblings) f. Surviving adults in degree of kinship.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 8/27/2025, the P&P indicated, “The patient has the right to: 11. Formulate advance directives. This includes designating a decision maker if they become incapable of understanding a proposed treatment or become unable to communicate their wishes regarding care. The decision maker may be any adult over the age of 18, including but is not limited to a spouse, unmarried partner of the same or opposite sex, parent, sibling, child or friend. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medical care on their behalf.””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure a safe patient-care environment for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) when it conducted plumbing repairs in an active Emergency Department (ED) patient-care areas without implementing required containment measures (physical barriers designed to prevent the spread of dust, debris, and contaminants during construction), without completing an Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to determine infection-control precautions required during construction or maintenance), and without providing ventilation or air-filtration controls, including High-Efficiency Particulate Air (HEPA filtration, a mechanical filtering system that captures small airborne particles) or negative air pressure (a ventilation technique that keeps air flowing into, but not out of, a contaminated area). This deficient practice exposed patients and staff to hazardous environmental conditions, including airborne particles (microscopic solid or liquid substances suspended in air), sewer-like odors (strong odors produced by leaking wastewater piping), wet drywall with brown/black discoloration suggestive of mold (fungal growth capable of releasing spores), smoke, and water diverted from ceiling leaks into a clinical hand-washing sink, increasing the risk of exposure to waterborne pathogens (disease-causing microorganisms transmitted through contaminated water) and environmental contaminants (harmful biological or chemical substances present in the environment). Findings: During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM), in the Emergency Department Nursing Station, a transparent plastic sheet was observed taped across the ceiling with a drainage tube discharging water into a hand-washing sink used by clinical staff. Water was visible inside the plastic. The EDM stated the leak had been present since early July 2025, that there was no signage to indicate restricted use of the sink, and that no Infection Control Risk Assessment (ICRA) had been completed. During a review of the work order for the Emergency Department Admitting/Phlebotomy area, dated 09/09/2025, the work order indicated “An unusual odor is emitting from the sink located inside the Emergency Room draw station.” During a review of a follow-up work order entered by Engineering (Plumbing) on 09/11/2025, the work order indicated “Searched in the ceiling and found some cast iron pipe and fittings completely corroded (deterioration of metal due to chemical reaction) and cracked, causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings.” During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated a strong sewer-like odor had been reported in late August 2025. ENG 2 stated that on 09/09/2025 the wall near the sink was opened and wet drywall with dark brown and black spots suggestive of mold (fungal growth capable of producing spores) was found and removed. ENG 2 stated the odor persisted until a second leaking pipe above the ceiling was discovered. ENG 2 stated the ceiling tiles were removed, and pipe sections were cut and replaced without construction containment barriers. ENG 2 stated repairs occurred from 09/09/2025 through 10/31/2025 without ventilation or filtration systems in place. During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated a sewer-like odor persisted for approximately two and a half months in the ED Admitting/Phlebotomy area and caused staff headaches and nausea. AR 1 stated that patients also complained of the odor. AR 1 stated no containment barriers, air-filtration systems, or infection-control oversight were in place during the repairs, and that one staff member required hospital evaluation. During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated patients continued to be seen in the area during repairs and complained of the odor. Phleb 1 stated no containment barriers or ventilation systems were used. During an interview on 11/05/2025 at 11:05 a.m. with the Admitting Representative (AR 7), AR 7 stated the ED Admitting area had a strong sewer odor from 09/09/2025 until 10/15/2025. AR 7 stated the repair work produced significant smoke in the room, that only a 10-inch by 10-inch window was available for ventilation, and that no air filtration or containment barriers were used. AR 7 stated she developed coughing, difficulty breathing, headaches, and nausea, was prescribed antibiotics twice, required a stronger inhaler, and took time off from work. During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED stated repairs began on 09/09/2025 without notifying the Infection Prevention Department (the program responsible for preventing healthcare-associated infections) or the Department of Health Care Access and Information (HCAI, the California agency responsible for construction oversight in healthcare facilities). The DED stated a second leak above the ED Nursing Station had been present since 07/07/2025 and remained unrepaired. During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), the ES stated no Infection Control Risk Assessment (ICRA) was completed and the Infection Prevention Department was not involved in either repair project. During an interview on 11/04/2025 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM stated the Infection Prevention Department had not been notified of either project. The IPM stated both projects would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- {HEPA} filter to capture at least 99.97% of tiny particles {down to 0.3 microns} like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don’t spread to vulnerable patients), requiring HEPA filtration (stands for High-Efficiency Particulate Air and is a type of mechanical air filter that can trap at least 99.97% of airborne particles 0.3 microns in size), containment barriers, and air sampling (testing air for contaminants such as mold spores or bacteria). The IPM stated staff could have been exposed to bacteria. During a review of the facility’s policy and procedure titled, “Environment of Care Safety Management Plan,” dated 10/23/2024, the policy indicated a pre-construction risk assessment must be completed, and that repairs require collaboration with Infection Prevention regarding air quality, odor, and infection-control risks. The policy indicated HEPA filtration and containment barriers are required during such projects. During a review of the facility’s policy and procedure titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the policy indicated the Infection Prevention Department must be notified prior to repair projects, an ICRA must be completed, containment barriers and air-filtration systems must be implemented, and an Infection Prevention Construction Permit must be obtained prior to beginning work.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility did not fully implement the methods and mechanisms required to ensure that patients are free from all forms of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), in accordance with the facility’s policy and procedure regarding abuse, for two of 83 sampled patients (Patients 1 and 8) when: 1. The facility did not conduct a thorough investigation, when Patient 1 alleged that a male registered nurse (RN 1) pushed her (Patient 1) onto the bed and held her down, then locked her (Patient 1) in the room all night long. 2. The facility did not interview or assess Patient 8 (Patient 1’s roommate) to verify if Patient 8 witnessed any type of abuse or if Patient 8 sustained abuse or injury by RN 1. This deficient practice resulted in a lack of thorough investigation by the facility and the inability to determine whether or not abuse occurred, which placed other patients at risk of potential abuse or harm. Findings: During an interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated that on 10/29/2025 at around 9:30 a.m., she (NM 1) was informed by a staff nurse and charge nurse that Patient 1 alleged that at 4 a.m. on 10/29/2025, a nurse (RN 1, registry nurse [a type of temporary or contract nurse that works through a staffing agency - also known as a nurse registry, to fill short-term staffing needs at various healthcare facilities]) pushed her (Patient 1) down on her bed and locked her in the room. NM 1 spoke to Patient 1’s family member (FM 1), who reported that at 4 a.m., Patient 1 tried to wander out of the room (Patient 1’s room), then RN 1 pushed Patient 1 on to the bed and held Patient 1 down, for an unspecified amount of time. RN 1 proceeded to lock Patient 1 inside the room. Per NM 1, FM 1 stated she (FM 1) asked Patient 1 for more details, and it turned out that RN 1 was sitting outside Patient 1’s room, in the hallway during the night shift. NM 1 said that FM 1 spoke to Patient 8, who shared the room with Patient 1. According to FM 1, Patient 8 stated that RN 1 could have talked in a gentler manner to Patient 1. Per NM 1, FM 1 did not believe the incident happened as Patient 1 described it. FM 1 did not wish to call the police department. During the same interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM1 said that she (NM 1) did not interview Patient 1, because Patient 1 did not speak English. NM 1 reported the incident to the house supervisor, who informed her (NM 1) that RN 1 was a registry nurse and would not return. NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1’s roommate) to verify if she (Patient 8) witnessed any mistreatment against Patient 1. In addition, Patient 8 was not assessed for any injuries. NM 1 stated she (NM 1) did not get a chance to interview RN 1 or any other potential witnesses, such as other staff on the unit. NM 1 stated there was currently no conclusion to the investigation. The incident had been escalated to the house supervisor and the Director of the Medical Surgical Unit, and to the Human Resources Department. In addition, the incident was reported through the hospital’s event reporting system. During an interview on 11/3/2025 at 3:15 p.m. with the Director of the Medical Surgical Unit (DIR 1), DIR 1 stated the following: On 10/29/2025 at 9:30 a.m., FM 1 reported that a nurse (RN 1), during the night shift, was being rough with Patient 1. DIR 1 instructed NM 1 to investigate the allegation. DIR 1 notified the nursing office of the allegation. The investigation was completed by NM 1. Patient 1 was assessed and there were no bruises present. DIR 1 stated he (DIR 1) did not know that only one person (FM 1) had been interviewed during the investigation. DIR 1 stated he (DIR 1) was not aware that only one person (FM 1) had been interviewed and no staff working during the night shift were interviewed. DIR 1 stated that interviewing only one person was not a complete investigation. A complete investigation should be done to verify if the allegation was valid. Potential witnesses, such as other patients and staff should have been interviewed to verify if someone saw or hear something. A timeline of the allegation should have been done. That was not the proper way to conduct an investigation (referring to the incomplete investigation by NM 1). DIR 1 said the allegation was reported to the department of human resources. DIR 1 stated he (DIR 1) thought the allegation or incident was closed instantly. DIR 1 did not know the conclusion or the results of the investigation. During an interview on 11/4/2025 at 2 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated she (MARL) was informed of Patient 1’s allegation of abuse on 10/29/2025 at 12 noon. MARL said she (MARL) did not get a chance to interview Patient 1 because NM 1 informed her that Patient 1 had already been discharged. MARL stated she did not speak with Patient 1’s roommate (Patient 8) and no other staff members were interviewed. MARL was not sure if Human Resources department investigated the incident (Patient 1’s allegation of abuse). At the time of the interview on 11/4/2025, MARL said the facility was unable to determine if the allegation was substantiated (means that an investigation has found enough evidence to prove the claim is true). MARL also stated the facility terminated the contract with RN 1, who was a registry nurse. During a concurrent interview and record review on 11/4/2025 at 2:36 p.m. with NM 1, Patient 1’s medical record, was reviewed. NM 1 verified Patient 1 had actually been discharged on 10/29/2025 at 3:24 p.m., not at 11 a.m., as previously thought, because when she spoke with FM 1, at 11 a.m., Patient 1 was dressed, packed and ready to go. So, NM 1 assumed Patient 1 had been discharged at 11 a.m. During an interview on 11/5/2025 at 3:30 p.m. with NM 1, NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1’s roommate) regarding the abuse allegation, nor was Patient 8 assessed for any possible injury. In addition, NM 1 stated she (NM 1) miscommunicated with the Manager of Accreditation, Regulatory & Licensing (MARL), when NM 1 informed MARL that Patient 1 had been discharged at 11 a.m. on 10/29/2025, when in fact Patient 1 was discharged at 3:24 p.m. During a concurrent interview and record review on 11/5/2025 at 3:30 p.m. with the MARL, Patient 1’s discharge summary, was reviewed. The MARL stated she was informed of the incident through the hospital’s event reporting system on 10/29/2025 at 11 a.m. MARL also said she spoke with NM 1, who informed her (MARL) that Patient 1 had been discharged at 11 a.m., which was the reason why MARL did not interview Patient 1. The MARL reviewed Patient 1’s discharge summary which indicated that Patient 1 had actually been discharged at 3:24 p.m., not 11 a.m., on 10/29/2025. The MARL stated there were no other investigations related to Patient 1’s allegation. During an interview on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG stated the following about Registered Nurse (RN 1). RN 1 was originally hired as a traveler nurse (a registered nurse who takes short-term assignments, to fill staffing needs) in the medical-surgical intensive care unit (a specialized healthcare unit that provides intensive care to critically ill patients who have undergone surgery or have complex medical conditions) on 6/9/2025. On 7/12/2025, RN 1 converted to a registry nurse (a nurse who worked for a staffing agency to fill temporary or contract positions). The MHR stated that RN 1 was currently suspended while waiting for the registry agency to conclude its’ investigation of the allegation of abuse. The MHR and the SHRG stated that they (MHR and SHRG) did not interview RN 1, nor did they conduct their own investigation into the allegation. They (MHR and SHRG) were waiting to get feedback from the registry agency. The SHRG stated that the investigation should be a collaborative effort, however, the SHRG was not aware that only one person (FM 1) had been interviewed during the investigation. The SHRG stated that other staff and patients should have been interviewed to see if there were any witnesses of the alleged abuse. During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body’s needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor. During a review of Patient 1’s nurse’s notes, documented by RN 5 and NM 1, titled, “Daily Focus Assessment Report,” dated 10/29/2025, the nurse’s notes indicated the following: -At 10 a.m., MD (physician) was notified of the following: Patient (Patient 1) reported to staff that night shift male staff members were “manhandling” the patient (Patient 1), “pushed her onto her bed,” and “locked her in her room.” “Patient (Patient 1) denies any injury, but prefers to have female nursing staff going on ...” -At 10:38 a.m., Spoke with family member (FM 1) ...at length regarding alleged abuse ...FM 1 summarized her mom’s (Patient 1) allegation, stating that Patient 1 stated she (Patient 1) was pushed onto the bed and locked in her room all night. FM 1 stated that Patient 1 said the nurse was sitting outside her room all night and may have perceived herself to be locked in. FM 1 stated that Patient 1 had been on morphine (a strong pain killer) that night and wondered if that caused a lot of her (Patient 1) confusion. FM 1 did not feel that the nurse was intentionally doing anything wrong but that was her mom’s (Patient 1) perception. FM 1 stated if Patient 1 had a female nurse, FM 1 does not think this (allegation of abuse) would have occurred as Patient 1 was more comfortable to female than males ... -At 10:44 a.m., family member (FM 1) stated that she (FM 1) only wanted to provide feedback about giving staff more education on de-escalation (It involves methods like active listening, empathy, and verbal communication to calm a patient, and it helps create a safer environment for both patients and staff) of confused elderly females ...FM 1 is happy with care provided and kept restating that she (FM 1) does not want anyone to get in trouble ...I (NM 1) reassured FM 1 that we are looking into the event because patient safety is our top priority ... -At 10:44 a.m., FM 1 declined escalating (to report the abuse allegation) to the police department. During a review of Patient 1’s “Patient Discharge Instruction,” dated 10/29/2025 at 2:49 p.m., the Patient Discharge instructions indicated Patient 1 was given instructions regarding activity, diet, and medication. During a review of Patient 8’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/19/2025, the H&P indicated Patient 8 had “medical problems significant for gastric and colon adenocarcinoma (cancer in the stomach and large intestines) ... diabetes mellitus type 2 (high sugar in the blood), who presented ... for symptoms of acute abdominal pain, nausea (an unpleasant feeling of sickness in the stomach accompanied by the urge to vomit), and vomiting starting two (2) days prior to presentation.” During a review of the facility’s policy and procedure (P&P) titled, “Abuse: Prevention, Identification, Investigation, and Protection,” dated 8/27/2025, the P&P indicated the following: In accordance with our covenant of promoting and ensuring patients’ rights, the Hospital is committed to take those steps within its control to prevent and protect patients from abuse and to investigate any suspected or actual incidence of abuse to patients. The Hospital shall make certain that all alleged violations are immediately and thoroughly investigated, and shall prevent further potential abuse while the investigation is in progress ...Procedure: 1. If there is an allegation of patient abuse, the patient/resident will immediately be evaluated and assessed to make certain they are healthy, safe and uninjured. 2. The alleged offender will be immediately removed from the vicinity of the patient and all patient care areas ... 3. All patients/residents within the area/vicinity of the alleged abuse will be assessed to ensure no one else is impacted.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team, in which the Risk Manager (RM) was a member, failed to ensure proper data collection and analysis of patient safety events, when the facility failed to thoroughly investigate and analyze an unusual occurrence (any occurrence which threatens the welfare, safety, or health of patients, personnel or visitors) involving patient allegation abuse for one of 83 sampled patients (Patient 1). Patient 1 alleged that a registered nurse (RN 1) pushed her (Patient 1) onto the bed, held her down and locked her in the room (Patient 1’s room which is shared with another patient [Patient 8]). This deficient practice had the potential for patients to be at higher risk of harm and a missed opportunity to identify areas of improvement, track trends, or implement systemic changes and ensure patient safety. Findings: During an interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated that on 10/29/2025 at around 9:30 a.m., she (NM 1) was informed by a staff nurse and charge nurse that Patient 1 alleged that at 4 a.m. on 10/29/2025, a nurse (RN 1, registry nurse [a nurse who works through a private agency that places nurses in temporary positions]) pushed her (Patient 1) down on her bed and locked her in the room. NM 1 spoke to Patient 1’s family member (FM 1), who reported that at 4 a.m., Patient 1 tried to wander out of the room, then RN 1 pushed Patient 1 on to the bed and held Patient 1 down for an unspecified amount of time. RN 1 proceeded to lock Patient 1 inside the room. During the same interview on 11/3/2025 at 2:45 p.m. with the Nurse Manager (NM 1) for the Medical surgical Unit, NM 1 stated FM 1 asked Patient 1 for more details regarding Patient 1’s allegation, and it turned out that RN 1 was sitting outside Patient 1’s room, in the hallway during the night shift. NM 1 said FM 1 spoke to Patient 8, who shared the room with Patient 1. NM 1 relayed that according to FM 1, Patient 8 stated that RN 1 could have talked in a gentler manner to Patient 1. Per NM 1, FM 1 did not believe the incident happened as Patient 1 described it. FM 1 did not wish to call the police department. NM 1 did not interview Patient 1, because Patient 1 did not speak English. NM 1 said she (NM 1) reported the incident to the house supervisor, who informed her (NM 1) that RN 1 was a registry nurse and would not return. NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1’s roommate) to verify if she (Patient 8) witnessed or suffered any abuse from RN 1. In addition, Patient 8 was not assessed for any injuries or signs of abuse. NM 1 stated she (NM 1) did not get a chance to interview RN 1 or any other potential witnesses, such as other staff on the unit. NM 1 stated there was currently no conclusion to the investigation. The incident had been escalated to the house supervisor and the Director of the Medical Surgical Unit, and to the Human Resources Department. In addition, the incident was reported through the hospital’s internal reporting system. During an interview on 11/3/2025 at 3:15 p.m. with the Director of the Medical Surgical Unit (DIR 1), DIR 1 stated the following: On 10/29/2025 at 9:30 a.m., FM 1 reported that a nurse (RN 1), during the night shift, was being rough with Patient 1. DIR 1 instructed NM 1 to investigate the allegation. DIR 1 notified the nursing office of the allegation. The investigation was conducted by NM 1. Patient 1 was assessed and there were no bruises present. DIR 1 stated he (DIR 1) was not aware that only one person (FM 1) had been interviewed during the investigation and no staff working during the night shift were interviewed. DIR 1 stated that interviewing only one person was not a complete investigation. A complete investigation should be done to verify if the allegation was valid. Potential witnesses, such as other patients and staff should have been interviewed to verify if someone saw or heard something. A timeline of the allegation should have been done. DIR 1 said the manner in which NM 1 proceeded with the investigation was not the proper way to conduct an investigation. DIR 1 stated the allegation was reported to the facility’s department of human resources. DIR 1 stated he (DIR 1) thought the allegation or incident was closed instantly. DIR 1 did not know the conclusion or the results of the investigation. During an interview on 11/4/2025 at 2 p.m. with the Manager of Accreditation, Regulatory & Licensing (MARL), MARL stated she (MARL) was informed of Patient 1’s allegation of abuse on 10/29/2025 at 12 noon. MARL did not get a chance to interview Patient 1 because NM 1 informed MARL that Patient 1 had already been discharged. MARL stated she did not speak with Patient 1’s roommate (Patient 8) and no other staff members were interviewed. MARL was not sure if Human Resources investigated the allegation. At the time of the interview on 11/4/2025, MARL said the facility was unable to determine if the allegation was substantiated (means that an investigation has found enough evidence to prove the claim is true). The facility terminated the contract with RN 1, who was a registry nurse. During an interview on 11/5/2025 at 3:30 p.m. with NM 1, NM 1 stated she (NM 1) did not interview Patient 8 (Patient 1’s roommate) regarding the abuse allegation, nor was Patient 8 assessed for any possible injury. In addition, NM 1 stated she (NM 1) miscommunicated with the Manager of Accreditation, Regulatory & Licensing (MARL), when NM 1 informed MARL that Patient 1 had been discharged at 11 a.m. on 10/29/2025, when in fact Patient 1 was discharged later that day (10/29/2025) at 3:24 p.m. During an interview on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG stated the following about Registered Nurse (RN 1). The MHR said that RN 1 was currently suspended while waiting for the registry agency to conclude its’ investigation of the allegation of abuse. The MHR and the SHRG stated that they (MHR and SHRG) did not interview RN 1, nor did the facility’s Human Resources Department (manages the organization’s employees for the entire employee lifecycle) conduct their own investigation of the abuse allegation. The MHR and SHRG stated they were relying on the registry agency (who employed RN 1) to conduct the investigation and were waiting to get feedback from the registry agency as to the results of the investigation. The SHRG stated that the investigation should have been a collaborative effort, however, the SHRG was not aware that only one person (FM 1) had been interviewed during the investigation. The SHRG stated that other staff and patients should have been interviewed to see if there were any witnesses to the alleged incident. During an interview on 11/6/2025 at 2:53 p.m. with the MARL, the MARL stated the following: MARL was informed of the abuse allegation made by FM 1 on 10/29/2025 at approximately 8:45 a.m., by the Risk Manager (RM) and via the facility’s internal incident reporting system. “The Risk Manager (RM) triaged (the process of assessing and prioritizing) the incident and forwarded it to me (MARL). I (MARL) contacted the Nurse Manager (NM 1) and asked if Patient 1 was still on the unit. NM 1 stated Patient 1 had been discharged, on 10/19/2025 at 11 a.m.” MARL said NM 1 was in charge of the investigation. MARL stated the investigation should have included interviewing other staff present on the unit during the time of the alleged allegation. In addition, the Human Resources Department (HRD) should have conducted their own investigation. HRD should determine whether or not the allegation was substantiated. HRD placed RN 1 on a “Do not send” list. The MARL stated the investigation was closed when Patient 1 was discharged on 10/29/2025 and there was no conclusion to the investigation. There was no team involvement to investigate the allegation. No root cause analysis (assessment conducted to prevent recurrence of an event by identifying reason[s] underlying an undesirable condition or problem in the system) was done. The incident was just reported to the regulatory agency as an “unusual occurrence” under adverse events (a patient safety that resulted to harm to a patient) on 10/29/2025 at 4:48 p.m. During an interview on 11/6/2025 at 3:15 p.m. with the Vice President of Quality and Risk Management (VPQRM), the VPQRM stated the allegation of abuse was forwarded to the Human Resources Department for investigation. VPQRM was not part of the investigation. The VPQRM stated that the Risk Manager (RM) was responsible for the investigation. During an interview on 11/6/2025 at 3:22 p.m. with the Risk Manager (RM), the RM stated the following: NM 1 was designated to conduct the investigation into the abuse allegation made by Patient 1. NM 1 spoke to FM 1, who did not want to escalate the allegation. FM 1 believed the incident did not occur as Patient 1 described. Patient 1 may have believed she (Patient 1) was trapped. The RM stated HRD was involved in the investigation, however, RM was not aware that HRD was relying on the Registry Agency (a business that acts as a referral service for nurses) to conduct the investigation. RM reviewed the facility’s policy regarding adverse events and unusual occurrences and stated that HRD should conduct their own investigation. In addition, the RM was not aware that only one person (FM 1) had been interviewed to investigate the abuse allegation. The RM stated that Patient 1’s roommate (Patient 8) should have been interviewed, as well, to determine if Patient 8 witnessed or also suffered any abuse by RN 1. Other staff on the unit should have been interviewed to determine if they saw anything (abuse). The RM stated that the investigation could have been better. Interviewing one person did not constitute a thorough investigation, per the facility’s policy. The investigation was insufficient and therefore, the allegation could not be substantiated. During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body’s needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor. During a review of Patient 1’s nurse’s notes titled, “Daily Focus Assessment Report,” dated 10/29/2025, the nurse’s notes indicated the following: -At 10 a.m., MD (physician) was notified of the following: Patient (Patient 1) reported to staff that night shift male staff members were “manhandling” the patient (Patient 1), “pushed her onto her bed,” and “locked her in her room.” “Patient (Patient 1) denies any injury, but prefers to have female nursing staff going on ...” -At 10:38 a.m., “Spoke with family member (FM 1) ...at length regarding alleged abuse ...FM 1 summarized her mom’s (Patient 1) allegation, stating that patient (Patient 1) said she was pushed onto the bed and locked in her room all night. FM stated that patient (Patient 1) said the nurse was sitting outside her room all night and may have perceived herself to be locked in. Family member (FM 1) stated that patient (Patient 1) has been on morphine (a strong pain killer) and family member (FM 1) wonders if that caused a lot of her (Patient 1) confusion. Family member (FM 1) does not feel that the nurse was intentionally doing anything wrong but her mom’s (Patient 1) perception. Family member (FM 1) stated if patient (Patient 1) had a female nurse, family (FM 1) does not think this (allegation of abuse) would have occurred as patient (Patient 1) is more comfortable to female than males ...” -At 10:44 a.m., FM 1 stated that she (FM 1) only wanted to provide feedback about giving staff more education on de-escalation of confused elderly females ...FM 1 is happy with care provided and kept restating that she (FM 1) does not want anyone to get in trouble ... “I (NM 1) reassured FM 1 that we are looking into the event because patient safety is our top priority ...” -At 10:44 a.m., FM 1 declined escalating to the police department. During a review of Patient 1’s “Patient Discharge Instruction,” dated 10/29/2025 at 2:49 p.m., the Patient Discharge instructions indicated Patient 1 was given instructions regarding activity, diet, and medication. During a review of the facility’s policy and procedure (P&P) titled, “Adverse Events and Unusual Occurrences: Governmental Reporting,” dated 8/27/2025, the P&P indicated the following: “The purpose of this policy is to establish a process through which all incidents, adverse events and sentinel events, can be identified, understood and diminished or eliminated, when possible; to reduce likelihood of similar events from recurring. Definition(s): Adverse Event: A patient safety event that resulted in harm to the patient. Immediate Crisis Management: The process by which HPMC immediately respond to an event, which includes actions within 24 hours of the event to: attend to the needs of the patient and staff involved, secure the area, gather facts and notify all appropriate people. Incident Response Team: is a rapid response team that may consist of (but not limited to) the Risk Management Department, Quality Department, Chief Executive Officer, Chief Nursing Officer, Vice President of Human Resources, Manager of Patient Relations, and House Supervisor. The team will oversee the immediate crisis management (including investigation) and the root cause analysis process. It is the Policy of the Hospital to respond to all adverse events and sentinel events with an immediate investigation and response which would include a thorough and credible root cause analysis (RCA) to identify the underlying causes and the opportunities for improvement to the systems and processes that will reduce the probability of such event recurring. It is the policy of the Hospital to comply with the requirements for reporting unusual occurrences and adverse events as required by federal and state law ...An event shall be completed and reported via the Event Reporting System (ERS). Event reports may be received by different individuals within the Hospital. These individuals must immediately contact the Manager of Risk Management (or designee) and provide information regarding the adverse event. The Manager of Risk Management (or designee) will investigate the situation/event to collect all pertinent information. The Manager of Risk Management (or designee) will consult with the Human Resources Department, department leader, and any other pertinent personnel ...The Risk Management Department (or designee) will lead a multidisciplinary team in the completion of the root cause analysis to include: identification of “root” causes and contributing factors, development of risk reduction strategies, action plans and measurement strategies for improvement, “quick fixes” are immediately implemented. Any occurrence ...or unusual occurrence which threatens the welfare, safety, or health of patients ...shall be reported as soon as reasonably practicable ...to the local health officer ...Examples of unusual occurrences which require reporting include ...suspected criminal acts by patients, employees or visitors that adversely affect delivery of patient care.” During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment / Performance Improvement Plan (QAPI) 2025,” dated 6/25/2025, the P&P indicated the following: “The purpose of the organizational Quality Assessment and Performance Improvement Plan (QAPI Plan) at (name of the facility) is to ensure that the Governing Body, medical staff, and professional service staff demonstrate a consistent endeavor to deliver safe, effective, and optimal patient care and services in an environment of minimal risk. In keeping with (name of the facility) mission to provide “Quality Care with Compassion and Respect,” the organizational QAPI Plan allows for a hospital-wide systematic, coordinated, continuous, and data-driven approach to improving performance focusing upon processes and mechanisms that address these values. Goals: The primary goals of the (name of the facility) QAPI Plan are based on annual performance and are to: Continually and systematically plan, design, measure, assess, and improve performance of priority focus areas and patient safety, to improve healthcare outcomes, and to reduce and prevent medical/health care errors. Actions: To achieve these goals the plan strives to: Incorporate quality and performance improvement throughout the facility. Provide a systematic mechanism for (name of the facility) staff, departments, and professions to function collaboratively in their efforts toward performance improvement...Plan and incorporate processes for conducting thorough and credible comprehensive systematic assessments (root cause analyses), focusing on process and system factors in response to sentinel events and other critical incidents as defined by the hospital. Immediate actions to take in the event of a potential or actual adverse patient-related incident may include but not necessarily be limited to the following actions to protect the patient population: Immediately remove or eliminate the source of harm, hazard or threat to the welfare, health, or safety of patients. Perform a physical and mental assessment of the patient by a registered nurse to ensure any patient negative effect is identified and addressed as necessary. Should the incident be related to caregiver actions, immediately remove the caregiver from patient care...After immediate actions are concluded, conduct an apparent or root cause analysis to identify apparent and/or root causes of the event and establish corrective actions accordingly. These actions may include, but may not be limited to, process and policy revisions, education and training.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure nursing staff performed head-to-toe assessments (a comprehensive physical examination that systematically evaluates a patient’s body from head to feet to establish a baseline, monitor changes, and identify health issues. This includes checking vital signs [temperature, heart rate, blood pressure], assessing the skin, and examining all body systems like the respiratory, cardiovascular, neurological, and gastrointestinal systems. The assessment helps providers understand the patient’s current health status and needs) for two of 83 sampled patients (Patients 1 and 8), in accordance with the facility’s policy and procedure regarding nursing assessments and reassessments. This deficient practice had the potential for the inability of nursing staff to identify changes in patients’ condition. Findings: During a concurrent interview and record review on 11/4/2025 at 2:36 p.m. with the Nurse Manager (NM 1) for the medical surgical unit, Patient 1’s medical record on patient assessment, was reviewed. The NM 1 stated that patients should be assessed every shift, when there were changes in a patient’s condition, or after having surgery in order to identify changes in a patient’s condition, act upon those changes and notify the physician. NM 1 verified that Patient 1’s pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025. During a review of Patient 1’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/28/2025, the H&P indicated the following: Patient 1 had a history of hypothyroidism (thyroid does not make enough thyroid to meet the body’s needs), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood). Patient 1 had a chronic right inguinal hernia (when part of the intestine or fatty tissue pushes through a weak spot in the abdominal shall into the groin area) as well. Patient 1 has had persistent pain at her right inguinal hernia. Patient 1 was admitted to the medical surgical floor. During a review of Patient 1’s “Daily Assessment Inquiry,” dated from 10/27/2025 through 10/30/2025, the Report indicated Patient 1’s pain, mental, respiratory, heart, gastrointestinal (stomach and intestines), or genitourinary (urinary) status, was not assessed by a nurse during the night shift, from 10/28/2025 through 10/29/2025. During a concurrent interview and record review on 11/5/2025 at 3:14 p.m. with NM 1, Patient 8’s assessment record, was reviewed. NM 1 verified that Patient 8’s pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025. NM 1 stated it was the standard of care to assess patients every shift to monitor patients for any changes of condition and to escalate any issues to the physician in a timely manner. During a review of Patient 8’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/19/2025, the H&P indicated “patient (Patient 8) had medical problems significant for gastric and colon adenocarcinoma (cancer in the stomach and large intestines) ... diabetes mellitus type 2 (high sugar in the blood), who presented ... for symptoms of acute abdominal pain, nausea (an unpleasant feeling of sickness in the stomach accompanied by the urge to vomit, and vomiting starting two (2) days prior to presentation. During a review of Patient 8’s “Daily Assessment Inquiry,” dated from 10/28/2025 through 10/29/2025, the Report indicated Patient 8’ pain, mental, respiratory, heart, gastrointestinal, or genitourinary status was not assessed by a nurse during the night shift from 10/28/2025 through 10/29/2025. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment, Nursing,” dated 6/25/2025, the P&P indicated the following: Purpose: To determine the care required to meet a patient’s initial needs as well as continued needs as the patient responds to care delivered. Reassessment: 1. An RN (registered nurse) will assess each patient’s care needs before delegating appropriate aspects of the patient’s nursing care, and patients will be reassessed by an RN at least every shift to document changes in the patient’s condition and/or diagnosis, and to determine the patient’s response to interventions. 2. Nursing reassessments of a patient will reflect at a minimum a review of patient-specific data, pertinent changes, and response to interventions ...Nursing reassessments will be documented in electronic health record (EHR) under daily nursing assessment.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to provide one of seven sampled staff members (Registered Nurse [RN] 1) orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit (M/S, department for patients who need close attention but are not critically ill) and to evaluate RN 1’s competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization’s standards and protocols), when RN 1 started working in the M/S unit on 7/12/2025, in accordance with the facility’s policies regarding orientation and competency assessment. This deficient practice had the potential for RN 1’s inability to perform unit specific duties and placed patients’ health and safety at risk. Findings: During a concurrent interview and record review on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), Registered Nurse (RN) 1’s personnel file, was reviewed. The MHR and SHRG stated the following about Registered Nurse (RN 1): RN 1 was originally hired as a traveler nurse (a registered nurse who takes short-term assignments, to fill staffing needs) in the medical-surgical intensive care unit (a specialized healthcare unit that provides intensive care to critically ill patients who have undergone surgery or have complex medical conditions) on 6/9/2025. On 7/12/2025, RN 1 converted to a registry nurse (a nurse who worked for a staffing agency to fill temporary or contract positions) and was assigned to work in the medical surgical unit (department for patients who need close attention but are not critically ill). During the same concurrent interview and record review on 11/6/2025 at 10:30 a.m. with the Manager of Human Resources (MHR) and the Senior Human Resources Generalist (SHRG), the MHR and SHRG reviewed RN 1’s personnel file and stated there was no evidence that RN 1 received an orientation (A structured, unit-specific orientation helps nurses understand and adhere to the specific policies, procedures, and safety protocols of that unit, which reduces errors and improves patient outcomes) to the medical surgical unit, nor any evidence that RN 1’s competency (a process to evaluate their knowledge, skills, and abilities in order to ensure they can provide high-quality, safe patient care. This evaluation goes beyond basic education and includes assessing their proficiency in specific clinical tasks, using hospital equipment, and adhering to the organization’s standards and protocols) was evaluated. The MHR stated that orientation and competency should be done on the unit to ensure nursing staff know what to do and were able to function at appropriate levels. The MHR also said an initial evaluation for RN 1 was not done and should have been done on the first day RN 1 worked on the unit on 7/12/2025. The evaluation was done on 10/29/2025, the last day RN 1 worked. The MHR stated that as of 10/29/2025, RN 1 was suspended while waiting for the registry agency to conclude its’ investigation for an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse), which involved RN 1. During an interview on 11/6/2025 at 10:45 a.m. with the Health Care Educator (HCE) and the Director of Education (DOED), the HCE and DOED stated that they (HCE and DOED) did not provide any education or competencies to registry nurses. Unit orientation, competency and initial evaluation should be performed by the unit in which the registry nurse worked. During an interview on 11/6/2025 at 4:01 p.m. with the Nurse Manager (NM 1) for the medical surgical (M/S) unit, NM 1 stated she (NM 1) did not know if RN 1 was oriented to the M/S unit or if a competency assessment was done for RN 1. NM 1 stated Unit orientation and evaluation of competency should be done to ensure RN 1 was able to care for patients, safely. During a review of the facility’s policy and procedure (P&P) titled, “Competency Assessment,” dated 8/27/2025, the P&P indicated the following: Competency - The integration of knowledge, skills, and abilities to ensure effective job performance. Competency is validated by demonstration of observable and measurable behaviors which are critical to ensure successful performance. Competency is demonstrated by the ability to successfully perform the expectations of one’s job. Departmental Competencies - Competencies specific to a department. Typically, the department head and leadership are responsible for developing these competencies with assistance from the Education department based on the patient population to the specific area. Policy: All staff and contractors who interact with patients will demonstrate competency as required by regulatory standards ...state, federal and hospital policy. All departments must have a process to evaluate staff competency at the time of hire and ongoing for the duration of their employment ...Initial competency assessment process continues with the organizational, departmental, and job specific orientation and training of personnel. Basic competencies will be assessed during orientation to the department/job and for employees in clinical areas, prior to the independent delivery of patient care by the employee. Individual departments/services with the assistance of the Education department will define the competencies and job expectations for each position ...Each supervisor/manager/administrative director will be responsible for ensuring that the competency of all employees is assessed, maintained, demonstrated, and improved continually. Admin (Administrative) Directors/Managers/Supervisors are responsible for: 1. Developing department wide and job specific competencies in collaboration with the Education Department ... 2. Ensuring their staff are competent to perform clinical duties. 3. Documenting employee competency ... 4. Providing ongoing employee feedback concerning competency. 5. Communicating with education when in-service training and educational programs are needed based on competency data. 6. Working with Education and Human Resources to ensure up to date and accurate competency files ... During a review of the facility’s blank checklist titled, “New Employee Orientation - Unit Checklist Tour,” the checklist indicated, the form must be completed and signed on New Employee Orientation Day during the employee’s department tour. Employees that do not meet the orientation requirements will be suspended from duty until checklist is signed and returned to HR (Human Resources).”

“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: 50516 Based on interview and record review, the facility failed to: 1.a. Ensure that the nursing office confirmed one of 83 sampled patient’s (Patient 9’s) spouse and primary representative (RP 1) information was documented on Patient 9’s mortuary’s “Authorization for Release of Remains,” in accordance with the facility’s policy and procedure (P&P) titled, “Decedent Affairs.” This deficient practice led to Patient 9’s next of kin and secondary representative (RP 2) to sign the form instead of RP 1, who had the legal authority to do so. 1.b. Ensure one of 83 sampled patient’s (Patient 9) physician was notified of Patient 9’s changes in mental status and blood pressure (BP, amount of force needed to move blood throughout the body and organs, with normal range of 120/90 millimeters of Mercury [mmHg, a unit of measurement]), in accordance with the facility’s policy and procedure (P&P) titled, “Provider Notification.” This deficient practice resulted in a delay of Patient 9’s care, when Patient 9 remained in the medical surgical unit for more than 24 hours before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for closer monitoring and blood pressure support. 2. Ensure its nursing staff assessed a patient’s ability to void (urinate) after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal for one of 83 sampled patients (Patient 5), in accordance with the facility’s policy and procedure regarding foley catheter removal. This deficient practice had the potential to put Patient 5 at risk for urinary retention (inability to completely empty the bladder) and urinary tract infection (UTI, an infection in any part of the urinary system). Findings: 1.a. During a record review of Patient 9’s “History and Physical (H&P),” dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9’s medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure). The record did not indicate Patient 9 had a durable power of attorney (DPOA, legal document where a patient designates someone to make decisions for them if unable to). During a record review Patient 9’s “Facesheet (front page of the chart that contains a summary of basic information about the patient),” dated 11/1/2024, the Facesheet indicated Patient 9 had a spouse (RP 1) and next of kin (RP 2) listed as emergency contacts. During a record review of Patient 9’s “Progress Note SOAP (subjective, observation, assessment, plan),” dated 10/31/2024, the “Progress Note SOAP” indicated Patient 9’s RP 1 was recognized as the spouse and was involved in Patient 9’s plan of care. During a record review of Patient 9’s “Notice of Death,” dated 11/2/2024, the record indicated Patient 9’s RP 1 was made aware of Patient 9’s death. During an interview on 11/3/2025 at 2:30 p.m. with Registered Nurse (RN) 2, RN 2 stated an emergency contact would be the spouse or the designated decision maker, children, and blood relatives. RN 2 stated she would contact the spouse or designated decision maker first if there was no DPOA. During a concurrent interview and record review on 11/6/2025 at 10:42 a.m. with House Supervisor (HS, nurse who oversees the hospital, patients, and emergencies), Patient 9’s “Mortuary Release Form,” dated 11/4/2024, was reviewed. The record indicated the release was signed by the mortuary. The form also included the mortuary’s form for “Authorization for Release of Remains,” where Patient 9’s RP 2 was listed as the “Representative,” the relationship was marked as “Next-of-Kin (Closest Living Relative),” and RP 2 signed the form. Patient 9’s RP 1 was not listed and did not sign the form. During the same interview and record review on 11/6/2025 at 10:42 a.m. with HS, HS stated the next of kin was considered the emergency contact. HS stated the next of kin was usually the spouse, parent, or other living relative. HS stated she would have gone with RP 1 (as the primary contact person) and RP 1 should have been the one to sign the document (Authorization for Release of Remains) instead of RP 2. HS also stated the nursing office was responsible for making sure the form received from the mortuary was correct, and they would check for discrepancies such as name or to update information so that the correct family contact was notified. During a review of the facility’s policy and procedure (P&P) titled, “Decedent Affairs,” dated 7/27/2022, the P&P indicated, “Prior to releasing remains to mortuary transporter, the Nursing Office shall ensure that the “Release Authorization” form is completed in full by the mortuary and is properly signed. The following relatives may sign a “Release Authorization” (listed in order of who may consent). a. An agent named in the Advanced Directive b. Surviving spouse/domestic partner c. Adult child (in the case of multiple adult children, one child may sign if they represent the wishes of the majority of the adult children) d. Surviving parent e. Adult sibling (in the case of multiple adult siblings, one sibling may sign if they represent the wishes of the majority of the adult siblings) f. Surviving adults in degree of kinship.” 1.b. During a record review of Patient 9’s “History and Physical (H&P),” dated 10/29/2024, the H&P indicated Patient 9 was admitted to the facility for weakness and pain. Patient 9’s medical history included stroke (loss of blood flow to a part of the brain) and hypertension (HTN, high blood pressure). During a record review of Patient 9’s “Daily Assessment Inquiry,” dated 11/1/2024, the record indicated at 8:20 a.m., Patient 9 had trouble breathing and was placed on oxygen, was drowsy, and Patient 9’s nurse received orders to transfer Patient 9 to the ICU. During a record review of Patient 9’s “Progress Note SOAP,” dated 11/1/2024, the record indicated Patient 9 was transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hemodynamic (body’s fluid volume) support. During an interview on 11/6/2025 at 10:42 a.m. with House Supervisor (HS, nurse who oversees the hospital, patients and emergencies), HS stated for neurological or blood pressure changes, nurses should call the doctor, and everyone knows about it. HS stated the staff know the protocol and if they can’t get in touch with the doctor, they can escalate to the HS, who can call the doctor. HS also stated if the nurses did not call the doctor, it’s a “medical error” and the patient could deteriorate. During a concurrent interview and record review on 11/6/2025 at 11:55 a.m. with Nurse Manager (NM) 1, Patient 9’s “Daily Focus Assessment Report,” dated 10/29/2024 to 11/1/2024, was reviewed. The record indicated Patient 9 was alert on these dates except for 10/31/2024 at 9:06 p.m., when Patient 9 was confused. NM 1 stated she would be concerned if Patient 9 was alert and then became confused. NM 1 stated the nurses were expected to call the provider or call a rapid response (RRT, a group of trained team professionals who provide immediate assistance when patient’s condition suddenly worsens) when there is a change in patient’s condition. NM 1 confirmed she (NM 1) did not see any notification to the physician about Patient 9’s confusion. During a concurrent interview and record review on 11/6/2025 at 2:48 p.m. with NM 1, Patient 9’s “Vitals Inquiry,” dated 10/31/2024, was reviewed. The record indicated on 10/31/2024 at 12:00 a.m., Patient 9’s BP was 88/53. Patient 9’s BP was checked four hours later at 4:00 a.m. and it was 109/61. NM 1 stated the BP was too low (at 12 a.m.- 88/53) and should have been rechecked. NM 1 stated Patient 9’s condition could have worsened and led to a RRT (Rapid Response team activation). NM 1 confirmed there was no notification to the physician of Patient 9’s low BP. During a review of the facility’s policy and procedure (P&P), titled “Provider Notification,” dated 8/27/2025, the P&P indicated, “The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the medical staff regarding significant changes or deterioration in the patient’s condition including abnormal labwork results. If providers do not respond, nurses are responsible for escalating the issue through the proper channels ...For changes in patient condition the nurse notifies the responsible provider utilizing appropriate channels and chain of command, using SBAR (situation, background, assessment, recommendation) report ...Document in the medical record the date, time and name of each provider notified, actions taken and/or patient’s response to treatment.” 2. During a review of Patient 5’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/2/2025, the H&P indicated Patient 5 was admitted to the facility from an outside hospital with left sided flank (the side of the body between the ribs and hips) pain on 11/1/2025. The H&P also indicated Patient 5 was pending surgery to treat nephrolithiasis (kidney stones). During a review of Patient 5’s “Operative Report (surgery report),” dated 11/3/2025, the “Operative Reported” indicated on 11/3/2025, Patient 5 underwent left ureteroscopy (a medical procedure to break up or remove kidney stones) with double J stent (a then J-shaped tube placed inside the ureter [the duct connecting from the kidney to the bladder] to allow urine to flow) placement. The “Operative Report” also indicated a foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed during the procedure and to be removed when Patient 5 was alert and awake. During a concurrent interview and record review on 11/7/2025 at 9:23 a.m. with the Nurse Manager (NM 1) of Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery) Unit, Patient 5’s “Nursing Assessment,” dated 11/3/2025, was reviewed. The “Nursing Assessment” indicated Patient 5’s foley catheter was removed on 11/3/2025 at 9:30 p.m. NM 1 stated the following: nurse should wait for Patient 5 to void after foley catheter (Foley catheter [brand name] for urinary indwelling catheter - a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) removal to make sure Patient 5 was able to void and there was no urinary retention (inability to completely empty the bladder). There was no nursing documentation to show Patient 5 was able to void (to urinate) after foley catheter removal prior to discharge. There was potential risk for Patient 5 not being able to void after getting home and suffering urinary retention and infection leading to Patient 5’s return to hospital. During a review of the facility’ s policy and procedure (P&P) titled, “Nurse-Driven Indwelling Urinary Catheter (a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) Management,” dated 6/2023, the P&P indicated, “Following removal of the indwelling urinary catheter, the nurse shall assess the patient’s ability to void ... Following the removal of the indwelling urinary catheter, the patient’s urine output must be monitored closely to be sure he/she is voiding in good amounts and without difficulty.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment in the Emergency Department (ED, the hospital area for treating urgent and serious conditions) for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff. The facility failed to implement required infection control and environmental safety measures during plumbing repairs in the ED Admitting and Phlebotomy areas (the section of the ED where patients are registered and blood samples are collected) as required by facility’s policy titled, “Infection Prevention Measures During Construction and Renovation Projects,” and failed to notify the Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities) as required by the FREER Manual- Revised August 2025 (a regulatory guide published by the California Department of Health Care Access and Information [HCAI], It provides instructions for healthcare facilities on how to manage construction, maintenance projects, and helps outlines the necessary steps to obtain clearances, permits, and approvals) , published by HCAI. This deficient practice resulted in approximately 60 patients per day and multiple staff members being exposed to hazardous environmental conditions during the repair period from 09/09/2025 through 10/15/2025. These conditions included sewer-like odors, airborne particles (microscopic solid or liquid substances suspended in the air that may pose respiratory risks), and visible mold-like substances (fungal growths that can release spores and cause health issues). Staff reported experiencing symptoms such as headaches, nausea, coughing, and respiratory distress (difficulty breathing or shortness of breath). One staff member required medical evaluation and treatment (clinical assessment and care provided by a licensed healthcare professional). On 11/5/2025 at 4:24 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Vice President of Quality (VPQ), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Manager of Accreditation, Regulatory & Licensing (MARL), and Chief Nursing Officer (CNO). The facility failed to ensure that appropriate safety measures were implemented, prior to repair work involving plumbing and cutting through wet drywall (a construction material used for interior walls) that had brown and dark spots. During an interview on 11/04/25 at 4:08 p.m. with the Manager of Infection Prevention (a healthcare professional responsible for preventing and controlling infections in the facility), the Manager of Infection Prevention confirmed that the brown and dark spots could have indicated the presence of mold (a type of fungus that can pose health risks), which should have been tested and treated. The repair work took place in a patient care area that included a phlebotomy station (a designated area where healthcare professionals collect blood samples from patients) and the admitting area (the section of a hospital where patients are first registered and processed for care). The initial repair was prompted by staff reports of a sewer-like odors (a smell similar to raw sewage) in the admission/phlebotomy station, which caused headaches among staff working in the area. Additionally, a second repair project was ongoing at the Emergency Department (ED, the hospital area for treating urgent and serious conditions) Nursing Station (the central area in the ER where nurses coordinate patient care and documentation). The facility failed to ensure that the following safety measures and assessments were in place: -Establishing containment (setting up physical barriers) around the repair area to prevent the spread of debris and contaminants (substances that may be harmful to health) throughout the patient care environment. -Posting signage (putting up warning or informational signs) indicating that the repair project had been assessed by Infection Prevention Services. -Notifying the Department of Health Care Access and Information (HCAI, a California state agency responsible for healthcare facility oversight) to obtain necessary clearances, plan approvals, and building permits. -Conducting environmental testing (analyzing air and surfaces for harmful substances) after brown and dark spots were identified on drywall, to confirm that the ED admitting area was free of contaminants, air pollutants, or disease-causing organisms. -Informing facility leadership (administrative decision-makers) of staff reports regarding a sewer-like odor, which persisted from 9/9/2025 through 10/15/2025. As a result of these failures, 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) and staff were potentially exposed to environmental contamination (the presence of harmful substances in the environment). These individuals had been present daily in the phlebotomy station located in the ED admitting area during the repair period (from 9/9/2025 to 10/15/2025). On 11/7/2025 at 5:28 p.m., the first Immediate Jeopardy (IJ) was removed in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO), and Vice President of Quality (VPQ). The survey team verified and confirmed the elements of the IJ Removal Plan through observation, interview, and record review while onsite. The IJ Removal Plan included several key components: Communication and Pathway Algorithm: Created for use between the Administrative Nursing Supervisor (ANS), Engineering Department, and Infection Prevention Department during repairs and construction. In-Service Training: Conducted on the communication and pathway algorithm with ANS, Engineering, and Infection Prevention departments. Education was tracked using a standardized sign-in roster and added to new employee onboarding. Biweekly Construction Update Meetings: Included the Infection Prevention Department and affected department leaders to ensure communication on all repair and construction activities. The Director of Engineering was responsible for this. Pre-Construction Risk Assessment (PCRA): Implemented on 11/5/2025, led by the Engineering Department with required participation from Infection Prevention, Safety Officer, and leadership from affected areas. This included assessments for construction activities, noise, air quality, life safety measures, infection control, vibration, utility, flooding, and security. The Director of Engineering was responsible for this. Monthly Audits: Conducted to ensure all construction projects have a PCRA and reported to the Quality Management Committee and Environment of Care Committee. The Director of Engineering was responsible for this. Policy Modification: The Infection Prevention policy was modified to include guidelines on patient and staff movement during construction activities. The Chief Nursing Officer was responsible for this. Safeguards for Patients and Staff: Implemented in the second area, including plastic barriers and air quality testing. The Manager of Infection Prevention and the Director of Engineering were responsible for this. Third-Party Vendor Consultation: The Engineering Department consulted a third-party vendor on air quality testing and swabbing. The Director of Engineering was responsible for this. Supervisor Training: In-serviced on Chain of Command, Escalation of Concern, Authority to Restore Patient Safety, and Standard of Behavior policies. Education was tracked using a standardized sign-in roster. The Director of Education was responsible for this. Findings: During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department’s Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated: “An unusual odor is emitting from the sink located inside the Emergency Room draw station.” During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, “Searched in the ceiling and found some cast iron pipe and fittings completely corroded and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings.” During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August 2025. On 09/09/2025, engineers opened the wall near the sink in the Emergency Department (ED) Admitting area (the patient registration section of the ED) and discovered a leaking pipe and wet drywall (a construction material used for interior walls) with dark brown and black spots, which ENG 2 stated had to be cut out. ENG 2 further stated that this was not the source of the sewer-like odor. ENG 2 stated that the actual source of the odor was identified as another leaking pipe located above the ceiling of the Admitting/Phlebotomy area (the section where patients are registered and blood samples are collected). ENG 2 confirmed that the repair began on 09/09/2025 and was completed on 10/31/2025 without the use of construction barriers (temporary physical partitions used to isolate construction zones and prevent the spread of contaminants). During a concurrent observation and interview conducted on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM) in the Emergency Department (ED) Nursing Station (the central area where nurses coordinate patient care), a transparent plastic sheet was observed taped across the ceiling, with a drainage tube discharging into a hand-washing sink. Water was visible inside the transparent plastic. The EDM confirmed that a second leak above the ED Nursing Station remained under repair and stated that the leak had been present since early July 2025. No signage was posted to restrict use of the sink, and no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) had been completed. During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that the sewer-like odor persisted for approximately 2½ months and caused staff symptoms including headaches and nausea. AR 1 stated that patients also complained of the odor during blood draws. AR 1 confirmed that no containment (physical barriers to isolate the work area), air filtration (equipment used to remove airborne particles), or infection control oversight was present during the repairs. During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that no directive was issued to stop using the area. Phleb 1 confirmed that no containment was in place. During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED confirmed that the repairs began on 9/09/2025 without notifying Infection Prevention or Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities). The DED also confirmed that a second leak above the ED Nursing Station had been ongoing since 7/07/2025 and remained unrepaired due to pending pipe fabrication. During a concurrent interview and record review on 11/4/2025 at 3:15 p.m. with the COO and the DED, the FREER Manual (Revised August 2025), published by the California Department of Health Care Access and Information (HCAI), was reviewed. The manual indicated that plumbing repairs involving the replacement or rearrangement of valves, pipes, or fixtures were not considered Excluded Work (routine maintenance that does not require regulatory reporting). These types of repairs were classified as New Work (construction or repair activities that alter the original configuration of building systems) and therefore required submission of the OSHPD-102 form (a regulatory form used to notify HCAI of construction or repair work in healthcare facilities) and formal review by HCAI (California Department of Health Care Access and Information) prior to the start of work. The COO stated they were not aware that piping exchange (replacement of plumbing pipes) required reporting to HCAI. During an interview on 11/5/2025 at 11:05 a.m. with AR 7, AR 7 stated the ED admitting area had a strong sewer odor starting 9/9/2025 until 10/15/2025. AR 7 stated she did not feel safe in that area. AR 7 stated there was lot of smoke in the room when ENG 2 was in the room working on the ceiling. AR 7 stated there was one small window 10 x10 inches open for ventilation, and there was no placement of containment or air ventilation (a temporary control measure used to contain and remove airborne contaminants from the work area and prevent their spread to sensitive patient care areas). AR 7 stated she was not told to work in another area and was not informed of the work being done. AR 7 stated she had headaches, felt nauseated, and had to see a doctor for cough and trouble breathing; AR 7 was given antibiotics twice, used a stronger inhaler, and took days off from work. During a concurrent interview and record review on 11/5/2025 At 11:30 a.m. with the Director (DPL) of Phlebotomy/Lab Services (SPL), the Census Report (data that tracks the number of patients in a facility at a specific time or over a period), dated from 9/9/2025 through 10/31/025, was reviewed. The report indicate approximately 60 patients were seen per day at the phlebotomy /blood draw area. The DPL confirmed that there were about 60 patients seen daily in the Phlebotomy/Lab Services (SPL) during the repair construction on 9/9/2025 through 10/31/2025. During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), ES confirmed that no Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) was completed and that the Infection Prevention Department was not involved in either the admitting area or nursing station repair projects. ES stated that environmental testing, when conducted, would typically check for spores (tiny fungal particles that float in the air), asbestos (a group of minerals that can cause lung damage when inhaled), and other airborne contaminants. During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the infection prevention team had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, “Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- HEPA filter to capture at least 99.97% of tiny particles (down to 0.3 microns) like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don’t spread to vulnerable patients) projects, requiring HEPA filtration (stands for High-Efficiency Particulate Air and is a type of mechanical air filter that can trap at least 99.97% of airborne particles 0.3 microns in size), containment barriers, and air sampling.” The IPM explained that, had the team been informed, they would have recommended air sampling, confinement of the area, and relocation. The IPM confirmed that no air sampling or surface testing had been conducted since the completion of the work. The IPM stated that staff could have been exposed to bacteria. During a concurrent interview and record review on 11/6/2025 at 4:08 p.m. with the IPM, the “Infection Control Construction Permit” form, undated, was reviewed. The form indicated the following requirements for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings): 1. Notify Infection Control: Inform the Infection Prevention department before beginning any work. 2. Isolate HVAC System: Shut off or isolate the heating, ventilation, and air conditioning (HVAC) system in the work area to prevent contamination of the air ducts. 3. Install Critical Barriers or Control Cube: Set up physical barriers (e.g., plastic sheeting or temporary walls) or use a containment cube to isolate the construction zone before work begins. 4. Maintain Negative Air Pressure: Use air filtration units equipped with HEPA (High-Efficiency Particulate Air) filters to keep the air pressure lower inside the work area than outside, preventing dust and contaminants from escaping. 5. Do Not Remove Barriers Prematurely: Keep barriers in place until the project is fully completed and the area has been thoroughly cleaned by the Environmental Services Department. 6. Use HEPA-Filtered Vacuums: Clean the area using vacuums equipped with HEPA filters to trap fine particles. 7. Wet Mop with Disinfectant: Clean floors and surfaces using a disinfectant solution and wet mopping technique to reduce airborne dust. 8. Careful Removal of Barriers: Remove temporary barriers slowly and carefully to minimize the spread of dust and debris. 9. Contain Construction Waste: Place all construction debris in tightly sealed containers before transporting it through the facility. 10. Cover Transport Carts: Ensure that carts or containers used to move waste are covered and sealed with tape. 11. Remove or Isolate HVAC System (Duplicate of #2): Reiterates the need to isolate HVAC systems in the work area. 12. Place Dust Mats: Install sticky or absorbent mats at the entrance and exit of the work area to capture dust from shoes and equipment. -The IPM stated that the repair work conducted in the Emergency Department (ED) Admitting and Phlebotomy area, from 9/3/2025 to 10/31/2025, should have been classified as Class III. IPM stated that for any Class III construction or repair project, the Infection Prevention department must be notified in advance so that an environmental risk assessment can be conducted. During a review of the facility’s policy and procedure (P&P) titled, “Environment of Care Safety Management Plan,” dated 10/23/2024, the P&P indicated the following: A pre-construction risk assessment is completed by Engineering and Infection Prevention prior to any building projects ...Employee concerns are vital to a robust risk assessment process. Employees are encouraged to report any unsafe or potentially unsafe condition that is found on hospital grounds. Concerns may be voiced to an employee’s supervisor, the Human Resources department, the Safety Officer, Risk Manager, Compliance Hotline or the EOC Chairperson ... Facilities must collaborate with Infection Prevention to manage risks associated with air quality, odor, and infection control during repairs. The policy required the use of HEPA filters and proper containment ... The Director of Facilities, in concert with Administration and Infection Prevention, will ensure planning for remodels, renovations, alterations, modifications and new facilities takes into consideration patient safety, diagnosis and treatment facilities and special services appropriate to the needs of the community ... Areas used by the patient are safe, clean, functional, and comfortable. This includes lighting, ventilation and cleanliness. Areas are free from offensive odors ... Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation and general maintenance projects ... When planning for demolition, construction, renovation or general maintenance, the hospital will conduct a pre-construction risk assessment for air quality requirements, infection control and sanitation, utility requirements, noise, vibration, dust and other hazards that affect care, treatment and services. The hospital takes action based on the risk assessment to minimize risks during construction, such as: 1. Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted. 2. Inspect project during the course of construction, at completion and prior to occupancy of area. 3. Provide education on Infection Prevention protocol for construction and renovation to general contractor and prime contractors and their personnel, as appropriate. During a review of the facility’s policy procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Risk assessments will be conducted and permits signed before construction begins. Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted. Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate. Infection Prevention Department will: a. Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input. b. Provide Infection Prevention Construction Permit (Appendix A), as required. c. Provide construction/renovation projects with a risk category of Class 111 and/or IV with containment inspection/approval by Infection Prevention prior to start of work. 4. Barriers required per class: Class II: 1) seal unused doors with duct tape 2) block off and seal air vents c. Class 111: 1) All in Class II, and in addition: 2) Airtight plastic barrier extending from floor to ceiling with seams sealed with duct tape to prevent dust and debris from escaping or drywall barriers erected with joints covered or sealed. These barriers must also be provided at elevator shafts or stairways within the field of construction. 3) Airtight plastic barriers are to be placed at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of air and debris when utilizing as a return air plenum/duct. 4) When openings are made into existing ceilings or access panels are opened in occupied areas for work above ceilings, provide polystyrene enclosure around ladder, sealing off opening, fitted tightly to ceiling and floor. 5) Any ceiling access panels opened for investigation beyond sealed areas will be replaced immediately when unattended. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation projects,” dated 10/24/2018, the P&P indicated, “Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins. Responsibilities: Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled. Notify all affected departments/services when there is planned/unplanned disruption in water supply and assist in providing alternate sources ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted ... Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate.””

“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: 46333 Based on observation, interview, and record review, the hospital failed to: 1. Implement its infection prevention and control program in a manner that protected 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83) from potential infection risks while these patients were treated in the Emergency Department (ED). The facility did not have a policy or procedure to address cross-contamination risks associated with leaking piping in patient care areas and failed to conduct an Infection Control Risk Assessment (ICRA) when a leak was identified in the ED. Clinical staff continued to use a handwashing sink where water from a ceiling leak was actively diverted into the basin. There was no signage indicating restricted use of the sink, and the Infection Prevention Department was not notified. This deficient practice placed 57 of the 83 sampled patients (Patients 27 - 83) at risk of exposure to waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) and environmental contaminants (harmful substances present in the surrounding environment), increasing the potential for transmission of infectious agents (organisms such as bacteria, viruses, or fungi that can cause disease). 2. Ensure one of seven (7) sampled staff members (Admitting Supervisor [Sup 1]) had annual tuberculosis (TB, an infectious disease that affects the lungs) testing, in accordance with the facility’s policy and procedure regarding tuberculosis screening for employees. This deficient practice had the potential to spread tuberculosis if TB status of an employee was unknown, which may infect patients, staff, and visitors in the hospital. Findings: 1. During a concurrent observation and interview on 11/04/2025 at 11:55 a.m. with the Emergency Department Manager (EDM) in the Emergency Department (ED) Nursing Station (the central area where nurses coordinate patient care), a sink was observed in active use by clinical staff for hand hygiene. A transparent plastic sheet was observed taped across the ceiling, with a drainage tube discharging into a hand-washing sink. Water was visible inside the transparent plastic. The EDM confirmed that the leak had been present since early July 2025. No signage was posted to restrict use of the sink, and no Infection Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) had been completed. During an interview on 11/4/2025 at 12:00 p.m. with Director of the Engineering Department (DED) in the nurse station’s sink area, DED stated that a leak was identified in early July, caused by erosion of the piping above the nurse station. The DED explained that this would be a major repair project requiring fabrication of the defective pipe and welding it in place. The DED confirmed that a piece of tubing, extending from the ceiling into the sink at the nurse station was installed by the Engineering Department to divert the leaking water into the sink. The DED also confirmed that the Infection Prevention Department was not notified regarding the continued use of the sink while the tubing was actively discharging leaked water into it. During a review of the ED’s “Work Order (a formal document or request used to initiate, track, and complete maintenance or repair tasks for equipment, facilities, and safety issues),” dated 7/7/2025, the work order indicated, “Incident, hazard, recall, critical air handler leaking from the ceiling in E.R. by the Tube Station.” During a concurrent interview and record review on 11/6/2025 at 10:22 a.m. with the Infection Prevention Manager (IPM), the facility’s policy and procedure (P&P), “Infection Prevention Measures During Construction and Renovation,” dated 10/24/2018, was reviewed. The P&P indicated the following: -The Environment of Care (EOC) Safety Management Plan outlines the methods and practices used to design, implement, and monitor a program to minimize safety risks for patients and all others who enter. The objective of the EOC Safety Management Plan is to provide a guideline for the development of a safety management program that will enable the hospital: -To develop standards to monitor, assess, measure, and improve EOC performance. -To monitor the effectiveness of the safety program. -Department leaders are responsible for providing a safe working environment for staff and safe provisions for the care of patients through full implementation of established EOC programs and activities. Leaders ensure department compliance with Environment of Care policies and procedures and develop department-specific safety policies and procedures. The EOC committee is responsible for monitoring the review of organizational safety policies and procedures on a triennial basis. Policies are available to all employees on the hospital intranet site. IPM stated that the facility’s Environment of Care (EOC) and the Infection Prevention Department are responsible for ensuring that the facility follows its written policies to stop infections from spreading inside the hospital and to other places. IPM confirmed that the facility does not have a P&P that addresses the prevention of the spread of waterborne pathogens (disease-causing microorganisms that are transmitted through contaminated water) or mold during a water leak. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the P&P indicated, “Engineers, Infection Prevention personnel, Nursing staff, EVS staff and contractors will establish and observe Infection Prevention protocols during demolition, construction, renovation or general maintenance projects. Risk assessments will be conducted and permits signed before construction begins.” 2. During a concurrent interview and record review on 11/6/2025 at 11:18 a.m. with the Employee Health Nurse (EHN), the EHN reviewed the Admitting Supervisor’s (Sup 1) personnel file and stated the following: Sup 1 was hired on 1/8/2024. Initial TB (Tuberculosis, an infectious disease that affects the lungs) testing was conducted on 12/14/2023. Sup 1 was due for annual TB testing on 12/2024, however, the test was not done because there were issues with the vendor. EHN stated Sup 1 resigned on 10/3/2025. Sup 1 continued to work at the facility from 12/2024 to 10/3/2025 without the annual TB testing. During the same interview on 11/6/2025 at 11:18 a.m. with the Employee Health Nurse (EHN), the EHN stated that employees were required to be tested for TB upon hire and annually to detect if employees had TB. Employees were at high risk for contracting TB because of the population of patients that came to the Emergency Department. Annual testing was necessary to identify employees with TB and to start treatment, if necessary, to prevent the spread of infection. During a review of Sup 1’s health file, the health file indicated Sup 1 was tested for TB on 12/14/2023. Sup 1 was hired on 1/8/2024. Sup 1 resigned on 10/3/2025. During a review of the facility’s policy and procedure (P&P) titled, “Tuberculosis Screening, Employee,” dated 8/27/2025, the P&P indicated the following: Purpose: To ensure the employee is free and clear of active infection during the pre-placement health process and for the duration of employment. Annual Screening: Medical duration will continue for the duration of employment ... Quantiferon (test for tuberculosis [an infectious disease that affects the lungs]).”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment (a clean, safe, and healthy space that minimizes the risk of disease by managing and controlling factors like preventing human contact with harmful substances to break the cycle of disease transmission) and prevent potential sources of infection for 57 of the 83 sampled patients (Patients 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, and 83), and staff members who were present in the affected area (Emergency Department’s Admitting/phlebotomy, which involves the initial administrative processing and the critical first step of diagnostic testing for patients presenting to the emergency room) daily, when: 1. The facility did not consult the Infection Preventionist (IP, a healthcare professional responsible for overseeing infection prevention and control activities) for an assessment prior to initiating construction repairs (the process of fixing or restoring an existing structure to its original or functional condition by replacing or renewing its components) following water damage. This deficient practice resulted in no assessment or safety recommendations from the Infection Prevention Department (IPD) prior to the Engineering Department starting the repair project, potentially placing patients and staff at risk of exposure to contaminants released during construction. 2. The facility did not implement appropriate environmental controls, such as providing ventilation (the intentional movement of air to dilute or remove airborne contaminants) to the affected area during the repair of drywall (a construction material used for interior walls, which can harbor mold [a type of fungus that can pose health risks] when wet) and tile with visible dark brown staining. These actions were not performed in accordance with the facility’s “Environment of Care Safety Management Plan” and “Infection Prevention Measures During Construction and Renovation Projects” policy and procedures. This deficient practice had the potential to expose patients, staff, and visitors to airborne contaminants (microscopic particles or biological agents suspended in the air that may cause illness) and HAIs (Healthcare-Associated Infections, conditions acquired by patients while receiving treatment in a healthcare setting), increasing the overall infection risk (the likelihood of exposure to and transmission of infectious agents). Findings: 1. During an interview on 10/23/2025 at 2:10 p.m. with Engineering staff (ENG 2), ENG 2 stated that a strong sewer odor was reported in late August. The engineering department inspected the area and suspected it was coming from the sink drain, so a plumbing engineer poured chemicals into the drain. However, ENG 2 stated that the odor was not resolved. On 9/9/2025, they opened the wall by the sink and discovered a leaking pipe. ENG 2 stated that the drywall was wet and had dark brown and black spots, which had to be cut out. Despite the repair to the sink area, the odor persisted. Later, they discovered another pipe leaking above the ceiling, which was the source of the odor. They had to remove the ceiling tile and cut through the piping to remove the damaged pipe. ENG 2 confirmed that the repair started 9/9/2025 through 10/31/2025 when the repair was completed. ENG 2 confirmed that the repair was completed without construction barriers (temporary, physical partitions that separate construction zones from patient care areas to control the spread of dust, debris, and disease-causing agents ensuring patient safety and maintaining a sterile environment). During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 stated that during the repair process, the Engineering Department (the team responsible for maintaining the hospital’s physical infrastructure, including plumbing and repairs) only covered the computers in the area. AR 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up. AR 1 further stated that one staff member required hospital evaluation due to symptoms. AR 1 reported that this concern was communicated to the former Admitting Manager (MA). However, AR 1 stated that the MA did not provide any directions to staff, as she (MA) was no longer employed at the facility after the report was made. During an interview on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no physical barriers or containment (structures used to isolate the work area and prevent the spread of contaminants) were set up during the repair work. Phleb 1 further stated that no directives were issued to stop using the area during the construction activities. During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that no containment (physical barriers used to isolate the work area and prevent the spread of contaminants) or air filtration (equipment used to remove airborne particles and maintain air quality) was set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure. During an interview on 11/04/2025 at 2:04 p.m. with the Director of Engineering (DED), the DED confirmed that the repairs in the emergency département’s Admitting/phlebotomy area began on 09/09/2025 without notifying Infection Prevention or Department of Health Care Access and Information (HCAI, the state agency responsible for reviewing and approving construction plans and safety protocols in healthcare facilities). The DED also confirmed that a second leak above the ED Nursing Station had been ongoing since 7/07/2025 and remained unrepaired due to pending pipe fabrication. The DED also confirmed that the Infection Prevention Department was not notified prior to the engineering department placing an apparatus to divert the leaking water into the sink at the ED’s Nursing station. During an interview on 11/05/2025 at 2:10 p.m. with the Engineering Supervisor (ES), ES confirmed that no Control Risk Assessment (ICRA, a structured, multidisciplinary process used to evaluate and mitigate infection risks during construction or maintenance in patient care areas) was completed and that the Infection Prevention Department was not involved in either the admitting area or nursing station repair projects. During an interview on 11/04/25 at 4:08 p.m. with the Infection Prevention Manager (IPM), the IPM confirmed that the Infection Prevention Department (IPD) had not been informed of either project and had not been made aware of the issue regarding the black and brown spots, which were suggestive of mold. The IPM stated, “Both would have been classified as Class III ICRA (Infection Control Risk Assessment, a specific level of stringent precautions for healthcare construction/renovation, requiring active dust control like HEPA vacuums [uses a specialized vacuum with a High-Efficiency Particulate Air- HEPA filter to capture at least 99.97% of tiny particles (down to 0.3 microns) like dust, pollen, mold], sealing vents, negative air pressure, sealed waste containers, and thorough post-work cleaning before barriers are removed, used for moderate-to-high dust activities or higher-risk patient areas, ensuring dust/pathogens don’t spread to vulnerable patients) projects, requiring HEPA filtration (High Efficiency Particulate Air, a type of mechanical air filter, designed to trap airborne particles), containment barriers (temporary, often modular structures used to isolate construction zones from patient areas, preventing the spread of dust, debris, and airborne contaminants), and air sampling (the process of collecting and analyzing airborne particles, like dust, mold, and bacteria, to protect patients and staff from potential contamination and infection) and relocation.” The IPM stated that the IPD should have been informed of both repair projects, because there must be an ICRA assessment completed prior to initiating the repair in the patient care area. The IPM stated that staff could have been exposed to bacteria. During a concurrent interview and record review on 11/6/2025 at 4:08 p.m. with the IPM, the “Infection Control Construction Permit” form, undated, was reviewed. The form indicated, “Requirement for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings): Notify Infection Control: Inform the Infection Prevention department before beginning any work.” IPM stated, “If a project is classified as Class III or IV, an Infection Prevention Construction Permit is required before work begins, along with documented infection control measures and oversight.” During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the P&P indicated the following: To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Risk assessments will be conducted and permits signed before construction begins. Engineering Department will: Notify the Infection Prevention department and review all projects with the Infection Prevention Manager prior to beginning the project. Notify Environmental Services prior to beginning project regarding requirements for personnel and supplies to ensure project and adjacent areas are cleaned/disinfected/pest controlled ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted. Obtain Infection Prevention Construction Permit from Infection Prevention before construction/renovation begins. Infection Prevention Permit must be obtained whether work is performed by external contractor or by hospital employees. Obtain signatures of responsible party from general contractor and any prime contractor or hospital project manager, as appropriate. Infection Prevention Department will: Review all construction/renovation plans. An Infection Control Risk Assessment (ICRA) must be completed for all projects (Appendix A). Infection Prevention will determine class with Engineering input. 2. During a review of the work order (a formal request for maintenance or repair services) for the Emergency Department’s Admitting/Phlebotomy area (patient registration and blood collection), dated 9/9/2025, the work order indicated, “An unusual odor is emitting from the sink located inside the Emergency Room draw station.” During a review of a follow-up work order entered by the Engineer Plumbing (ENG) 1, dated 9/11/2025, the work order indicated, “Searched in the ceiling and found some cast iron pipe and fittings completely corroded (a pipe that has deteriorated due to chemical reactions, leading to a breakdown of its material) and cracked causing major sewer gas odors. Replaced several sections of the cast iron pipe and fittings.” During an interview on 10/23/2025 at 2:10 p.m. with Engineering Staff (ENG 2), ENG 2 stated that a strong sewer-like odor (a smell similar to raw sewage, which may indicate plumbing failure or contamination) was reported in late August 2025. On 09/09/2025, engineering staff opened the wall near the sink in the Emergency Department (ED) and discovered a leaking pipe. ENG 2 stated that the drywall (a construction material used for interior walls that can harbor mold when wet) was saturated and exhibited dark brown and black discoloration, which had to be cut out. Despite the initial repair to the sink area, ENG 2 stated that the odor persisted. A subsequent inspection revealed a second leaking pipe located above the ceiling, which was identified as the source of the odor. ENG 2 stated that ceiling tiles were removed, and the damaged pipe was cut out and replaced. ENG 2 confirmed they did not use a ventilation system (equipment designed to circulate and filter air to reduce airborne contaminants) during the repair work which occurred from 09/09/2025 through 10/31/2025. During an interview on 11/04/2025 at 10:50 a.m. with the Admitting Representative (AR 1), AR 1 stated that there had been a persistent sewer-like odor (a smell similar to raw sewage) in the Emergency Department (ED) Admitting/Phlebotomy area (the section of the ED where patients are registered and blood samples are collected) for approximately two and a half months. AR 1 reported that the odor caused symptoms among staff, including headaches and nausea, and that patients also expressed discomfort due to the strong smell. AR 1 further stated that one staff member required hospital evaluation due to symptoms. During an interview conducted on 11/04/2025 at 11:49 a.m. with Phlebotomist (Phleb 1), Phleb 1 stated that patients continued to be seen in the affected area during the repair period and that patients complained of a strong odor during blood draws. Phleb 1 confirmed that no air ventilation system was set up during the repair in the ED admitting/phlebotomy area. During an interview on 11/05/2025 at 11:05 a.m. with AR 7, AR 7 stated that during the repair work on 09/09/2025, there was a significant amount of smoke in the room while work was being performed in the ceiling. AR 7 confirmed that there were no air filtrations system (equipment used to remove airborne particles and maintain air quality) set up during the repair. AR 7 reported experiencing symptoms including coughing and difficulty breathing and stated that they had to miss work due to illness resulting from the exposure. During a concurrent interview and record review on 11/6/2025 with the Infection Prevention Manager (IPM), the “Infection Control Construction Permit” form, undated, was reviewed. The form indicated the following requirements for Class III construction activity (moderate to high-risk construction or renovation work in healthcare settings): Isolate HVAC System: Shut off or isolate the heating, ventilation, and air conditioning (HVAC) system in the work area to prevent contamination of the air ducts ... Maintain Negative Air Pressure: Use air filtration units equipped with HEPA (High-Efficiency Particulate Air) filters to keep the air pressure lower inside the work area than outside, preventing dust and contaminants from escaping ... Use HEPA-Filtered Vacuums: Clean the area using vacuums equipped with HEPA filters to trap fine particles.” IPM stated that there should a set-up of an air ventilation system, especially when staff and patients were reporting a strong sewer like odor. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention Measures During Construction and Renovation Projects,” dated 10/24/2018, the P&P indicated, “ To prevent the acquisition of healthcare associated infections related to environmental contamination in patients/visitors/healthcare workers during hospital demolition, construction and renovation ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted.” During a review of the facility’s policy and procedure (P&P) titled, “Environment of Care Safety Management Plan,” dated 10/23/2024, the P&P indicated the following: A pre-construction risk assessment is completed by Engineering and Infection Prevention prior to any building projects ... Facilities must collaborate with Infection Prevention to manage risks associated with air quality, odor, and infection control during repairs. The policy required the use of HEPA filters and proper containment ... Ensure that barrier materials as required are constructed and maintained properly, HEPA filtered vacuum and portable HEPA filter units for control of airborne contamination are provided unless otherwise contracted.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by: 1. The facility’s Governing Body failed to provide oversight to ensure patients receive complete emergency services, including maternal (the process of continuously observing a pregnant person’s vital signs and physical indicators to assess their health and well-being during pregnancy, and as well as monitoring fetal health and uterine activity [tracking contraction -the tightening of the organ muscles where the unborn baby develops, which can be signs of labor]) and fetal monitoring (the process of tracking a baby’s heart rate and other indicators during pregnancy to assess the baby’s well-being and identify potential problems) for one (1) of 30 sampled patients (Patient 2), in accordance with the facility’s policy regarding Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies) assessment standards. This deficient practice had the potential for patients with pregnancy-related emergencies not to receive complete evaluations, placing patients at risk for undetected complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0063) 2. The facility’s Governing Body failed to provide oversight to ensure emergency services were integrated and coordinated between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery Department (L&D, the hospital unit for pregnancy and childbirth emergencies) for one of 30 sampled patients (Patient 2), who was 32 weeks pregnant. Specifically, the facility failed to ensure L&D communicated results of obstetric evaluations, obtained physician order prior to transfer of Patient 2 back to the ED, performed nurse-to-nurse hand off (direct communication of patient status and care needs), and ensure ED staff received and acted on L&D findings by checking fetal heart tones (the process of tracking a baby’s heart rate) after Patient 2 returned to the ED from L&D. This deficient practice had the potential for patient transfers or discharges without necessary communication or documentation between departments to result in delayed or inappropriate treatment leading to patient harm and/or death. This deficient practice also placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0063) 3. The facility’s Governing Body failed to provide oversight to ensure patient medical records were accurate and contained consultative evaluations (specialist reviews and findings), in accordance with the facility’s medical staff rules and regulations, for one of 30 sampled patients (Patient 2). This deficient practice had the potential for patient records not to reflect consultative findings or accurate risk assessments, which may lead to patient harm. This deficient practice also had the potential risk of not being able to address in a timely manner possible serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), or intrauterine demise (the baby dying before birth). (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 26), was assessed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk and ensure appropriate interventions were implemented, in accordance with the facility’s policy regarding patients at risk for elopement. This deficient practice had the potential to place Patient 26 and other patients at risk of harm such as accidents or injury from being hit by a car, falling and breaking bones, and/or death. (Refer to A-0144) 2. The facility failed to ensure one of one sampled set of Emergency Exit double doors (Door #1), had a working alarm to notify staff of when the door was opened, which could impact 30 of 30 sampled patients, in accordance with the facility’s policy regarding environmental rounds. This deficient practice had the potential to place patients in harm when a functioning security system to alarm staff is not available and consequently may increase the risk patient elopement. (Refer to A-0144) 3. The facility failed to ensure staffed followed their “Sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) Utilization Policy,” for one of 30 sampled patients (Patient 12), when staff was assigned to be a sitter for Patient 12 and at the same time was assigned to assist other patients thus unable to maintain a “line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)” of Patient 12. This deficient practice had the potential for Patient 12 to injure self and/or others due to hospital staff not being able to maintain constant observation to ensure a safe environment. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that a registered nurse (RN, a licensed healthcare professional who has completed advanced training in nursing and passed a state licensing exam) supervised and evaluated nursing care for one (1) of 30 sampled patients (Patient 2). Specifically, the triage assessment (initial check to decide how urgent a patient’s condition is) did not reflect the results of the C-SSRS (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), in accordance with the facility’s policy regarding suicide (thoughts of ending one’s own life) prevention. This deficient practice had the potential to miss the opportunity to identify important risk factors and may delay the implementation. (Refer to A-0395) 2. The facility failed to develop an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 1) to address Patient 1’s high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for delayed recognition and intervention of fall risks, which could result in additional falls and physical injury (such as broken bones [fractures] or head trauma [brain injury from a blow or impact]). It also had the potential to affect all patients admitted with fall risks who do not receive individualized care planning. (Refer to A-0396) 3. The facility failed to ensure staff followed their “Central Line: Insertion, Maintenance, and Care Policy” for one of 30 sampled patients (Patient 11), when staff incorrectly placed a CHG Foam disc patch (a hydrophilic foam disc dressing impregnated with Chlorhexidine Gluconate [CHG] used to prevent bloodstream infection) for Patient 11 with a PICC line (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period). This deficient practice had the potential for Patient 11’s PICC line to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper placement of CHG foam disc. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure medical records were accurately written or documented for one (1) of 30 sampled patients (Patient 2), in accordance with the facility’s policy regarding suicide (thoughts of ending one’s own life) prevention. Specifically, the triage assessment (an initial assessment to decide how urgent a patient’s condition is) indicated “No suicidal risk,” which did not reflect the results of the Columbia Suicide Severity Rating Scale (C-SSRS, a standard tool used be healthcare staff to evaluate suicidal thoughts and behaviors), which showed the patient answered “Yes” to having thoughts of dying and “Yes” to having thoughts of killing herself.” This deficient practice had the potential to result in patients with suicidal ideation (thoughts of ending one’s own life) not being properly identified or monitored, leading to delayed or missed safety interventions. This could result in patients harming themselves or others. (Refer to A-0438) 2. The facility failed to ensure that medical record entries were properly documented, in accordance with facility’s “Correction of Errors/Omission in Medical Records” policy and procedure, for five (5) of 30 sampled patients (Patient 1, Patient 3, Patient 4, Patient 7, and Patient 10). This was evidenced by the sitter documentation (sitter Observation Form, a monitoring tool used when staff provide continuous one-to-one observation of a patient) for Patient 1, and restraint documentation (Restraint Flowsheet, record used to monitor the safe application, release, and care of patients in restraints [any manual method, physical or mechanical device, material, or equipment used to restrict a patient’s freedom of movement]) for Patients 3, 4. 7, and 10. This deficient practice had the potential to cause miscommunication among healthcare providers and place patients at risk for medical treatment error (mistakes in care such as missed interventions, delays, or incorrect treatments). (Refer to A-0450) 3. The facility failed to ensure that one (1) of 30 sampled patient’s (Patient 2), medical record contained the results of consultative evaluations and appropriate findings by clinical staff. Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term), considered a high-risk because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal stimulant drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). This deficient practice resulted in the discharge of Patient 2 to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without documentation of obstetric (pregnancy-related) consultation findings or confirmation of the baby’s well-being. This deficient practice also had the potential risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0464) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Emergency Services was met, as evidenced by: 1. The facility failed to ensure one (1) of 30 sampled patients (Patient 2), who presented to the Emergency Department (ED-hospital unit for urgent and life-threatening care) and Labor & Delivery (L&D-hospital unit for pregnancy and childbirth emergencies), received required assessments and physician examinations in accordance with the facility’s policy and procedures, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department.” Patient 2, was 32 weeks pregnant (about 8 months long, not yet full term), considered high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). In L&D, Patient 2 did not receive triage (an initial check to decide urgency of care), a Maternal-Fetal Triage Index (MFTI, scoring tool used to determine urgency of a pregnant patient’s condition), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby’s health], fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2’s transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses). When Patient 2 returned to the ED, staff did not check her (Patient 2) unborn baby’s heart rate (fetal heart tones). Patient 2 later discharged to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without confirmation of Patient 2’s own condition or the well-being of her (Patient 2) unborn baby. This deficient practice had the risk of serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (The baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-1101) 2. The facility failed to ensure proper integrated communication between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery (L&D, hospital unit for pregnancy and childbirth emergencies) for one (1) of 30 sampled patients (Patient 2), 32 weeks pregnant (about 8 months long, not yet full term), considered a high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). Specifically, the facility failed to: -Ensure L&D staff documented and communicated results of obstetric evaluations (such as triage [an initial check to decide urgency of care], vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating]), maternal or perinatal assessment (assessment of mother and baby’s health), fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). -Ensure L&D staff obtained and communicated physician orders before transferring Patient 2 back to the ED. -Ensure L&D staff provided nurse-to-nurse hand off (direct communication of patient status and care needs) when sending Patient 2 back to the ED. -Ensure ED staff received and acted on L&D findings by checking fetal heart tones after Patient 2 returned from L&D. -Ensure continuity of care so that maternal and fetal well-being was assessed and communicated before Patient 2 was discharged to a psychiatric facility (a healthcare institution that specializes in the diagnosis, treatment, and care of individuals with mental health disorders). These deficient practices placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-1103) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46333 Based on interview and record review, the Governing Body (the facility’s Board of Directors or equivalent leadership group legally responsible for hospital operations and patient safety) failed to provide oversight to ensure the facility’s staff protects patients and provides safe and quality patient care. The Governing Body failed to: 1. Ensure patients receive complete emergency services, including maternal (the process of continuously observing a pregnant person’s vital signs and physical indicators to assess their health and well-being during pregnancy, and as well as monitoring fetal health and uterine activity [tracking contraction -the tightening of the organ muscles where the unborn baby develops, which can be signs of labor]) and fetal monitoring (the process of tracking a baby’s heart rate and other indicators during pregnancy to assess the baby’s well-being and identify potential problems) for one (1) of 30 sampled patients (Patient 2), in accordance with the facility’s policy regarding Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies) assessment standards. This deficient practice had the potential for patients with pregnancy-related emergencies not to receive complete evaluations, placing patients at risk for undetected complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). 2. Ensure emergency services were integrated and coordinated between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery Department (L&D, the hospital unit for pregnancy and childbirth emergencies) for one of 30 sampled patients (Patient 2), who was 32 weeks pregnant. Specifically, the facility failed to ensure L&D communicated results of obstetric evaluations, obtained physician order prior to transfer of Patient 2 back to the ED, performed nurse-to-nurse hand off (direct communication of patient status and care needs), and ensure ED staff received and acted on L&D findings by checking fetal heart tones (the process of tracking a baby’s heart rate) after Patient 2 returned to the ED from L&D. This deficient practice had the potential for patient transfers or discharges without necessary communication or documentation between departments to result in delayed or inappropriate treatment leading to patient harm and/or death. This deficient practice also placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). 3. Ensure patient medical records were accurate and contained consultative evaluations (specialist reviews and findings), in accordance with the facility’s medical staff rules and regulations, for one of 30 sampled patients (Patient 2). This deficient practice had the potential for patient records not to reflect consultative findings or accurate risk assessments, which may lead to patient harm. This deficient practice also had the potential risk of not being able to address in a timely manner possible serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), or intrauterine demise (the baby dying before birth). Findings: 1. During a review of Patient 2’s ED record titled, “History and Present illness, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation and abdominal discomfort (general stomach pain without a clear cause). The record also indicated an ultrasound (a scan that uses sound waves to see inside the body) confirmed Patient 2 was 32 weeks and 5 days pregnant. During a record review of Patient 2’s record titled, “ED physician Hand Off Note,” dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2’ L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/21/2025 at 12:08 p.m., with Interim SLD (Supervisor of Labor and Delivery), Patient 2’s record “Triage (an initial check to decide urgency of care),” dated 8/17/2025, was reviewed. The record indicated Patient 2 was scratching, and kicking, and the Non-Stress Test (NST, is a noninvasive prenatal test that monitors the baby’s heart rate in response to its own movements and contractions) monitor had to be physically held in place for 20 minutes, but the nurse was unable to hold the Toco transducer (Toco, the device used during an NST and other fetal monitoring to measure the timing and duration of uterine contractions detecting changes in abdominal wall tension). SLD confirmed that an NST was attempted; however, the reading was not completed. During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the SLD, Patient 2’s L&D Emergency Room record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” was reviewed. SLD confirmed the following: - No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented. - No vital signs (temperature, blood pressure, heart rate, respiration rate, oxygen saturation, or pain score). - No maternal or perinatal assessment - No physical medical screening exam -No provider orders to transfer Patient 2 back to the ED. - No nurse-to-nurse hand-off report from the L&D nurse to the ED nurse During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2’s ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff checked fetal heart tones (the baby’s heartbeat measured with a handheld Doppler device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available. During a concurrent interview and record review with on 8/22/2025 with RN 13, Patient 2’s “ED Physician Hand Off Note,” dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby’s well-being. During a concurrent interview and record review on 8/22/2025 at 10:00 a.m. with RN 15, Patient 2’s NST, was reviewed. RN 15 stated the reading was not clear as there were many missed spaces (gaps of no reading). RN 15 stated “from this reading, we cannot say for certain whether the patient is having contractions or not.” RN 15 also stated “with this reading, there should be a repeat test done as the test is inconclusive.” During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2’s NST, was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 confirmed that when there was no fetal monitoring, vital signs, triage assessments, or physician medical screening exams completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death. During a concurrent interview and record review of 8/21/2025 at 12:20 p.m. with the interim Supervisor of Labor and Delivery (SLD, a supervising nurse temporarily overseeing the childbirth unit), Patient 2’s L&D Emergency Room record (8/17/2025 from 2:22 a.m. to 3:10 a.m.), was reviewed. SLD confirmed there was no documentation of vital signs (temperature, [body heat measurement, used to detect infection], heart rate [pulse, beats in one minute], blood pressure [force of blood against vessel walls], respiration rate [breaths per minute], oxygen saturation [percentage of oxygen in the blood], and pain assessment [patient’s self-report pain rating], no Maternal-Fetal Triage Index (MFTI, an acuity scoring tool for pregnant patients), no maternal or perinatal assessment, no obstetric provider medical screening exam (MSE, a physician exam to identify emergency conditions), and no provider orders for transfer back to the Emergency Department (ED, urgent and life-threatening care unit). During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA), the Governing Body’s minutes (the official written record of a meeting held by a governing body) from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department,” dated 12/15/2024, the P&P indicated, “(Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient’s presenting complaint and condition. Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. The patient’s physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage/Charge RN Responsibilities: Perform an assessment by identifying the patient’s immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. Mercury) and proteinuria (a condition where excessive amounts of protein are present in the urine) greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation (the period of time during which a fetus [unborn baby] develops in the uterus, from conception to birth) admitted through Emergency Department requiring perinatal screening examination ...” During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept.,” dated 4/26/2023, the P&P indicated, “Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient’s health or fetus’ (estimated gestational age >20 weeks) health in serious jeopardy ... Identify patient’s immediate needs as follows; does the patient have any of the following: Pregnancy > 20 weeks gestation with or without pregnancy-related complaint ... Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE). The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ...” During a review of the facility’s policy and procedure (P&P) titled, “Antepartum Testing.,” dated 10/27/2021, the P&P indicated, “To provide guidelines for the noninvasive determination of fetal well-being by observing the response of fetal heart rate to fetal movement or Nonstress Test (NST) ... The nurse will notify the physician of all abnormal test results and obtain follow-up orders, documenting actions and results ...” During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board by-laws indicated, “ The Governing Board is responsible for compliance with The Joint Commission (“TJC”) standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital’s goals, policies and programs ...” During a review of the facility’s “Quality Assessment/Performance Improvement Plan (QAPI) 2025,” dated 6/25/2025, the plan indicated, “ The (Name of the facility) Governing Board: 1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization. 2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained 3. Acts strategically to ensure the delivery of high-quality care and services. 4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. 2. During a record review of Patient 2’s medical record titled, “ED physician Hand Off Note,” dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note also indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim SLD (Supervisor of Labor and Delivery), Patient 2’s L&D record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled, “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” was reviewed. SLD confirmed there was no documentation of triage, a Maternal-Fetal Index (MFTI, scoring tool used to determine urgency of a pregnant patient’s condition), vitals signs, maternal or perinatal assessments, fetal monitoring, or a physician medical screening exam (MSE, a doctor’s exam required to determine if an emergency condition exists). SLD further confirmed there was no physician order documented for transfer of Patient 2 back to the ED from L&D and no nurse-to-nurse hand-off between the L&D staff and the ED staff prior to the transfer of Patient 2 back to the ED. During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2’s ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby’s heart rate (fetal heart tones, or FHTs- the baby’s heartbeat heard with a handheld Doppler [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available. During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2’s non-stress test (NST, test of baby’s heart rate with movement or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with the interim Supervisor of Labor and Delivery (SLD, a supervising nurse temporarily overseeing the childbirth unit), Patient 2’s ED record, dated 8/17/2025 through 8/21/2025, were reviewed. SLD confirmed there was no documentation that fetal heart tones (unborn babies heartbeat measured with a handheld Doppler device [a medical imaging device that uses high-frequency sound waves to create images]) were checked after Patient 2’s return to the ED from L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA), the Governing Body’s minutes (the official written record of a meeting held by a governing body) from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept.,” dated 4/26/2023, the P&P indicated, “Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE),” and that documentation be included in the record ... “The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ...” During a concurrent interview and record review with the Administration Manager (MA) on 8/22/2025 at 5:30 p.m. the Governing Body’s minutes from July 2025 to March 2025 were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB has the responsibility for providing oversight on overall quality of care and patient safety. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department,” dated 12/15/2024, the P&P indicated, “ (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient’s presenting complaint and condition. Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ...” During a review of the facility’s policy and procedure (P&P) titled, “Hand-Off/SBAR Communication, Patient,” dated 5/22/2024, the P&P indicated, “To provide accurate information about patient’s care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are “handed off’ from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit. During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board by-laws indicated, “The Governing Board is responsible for compliance with The Joint Commission (“TJC”) standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital’s goals, policies and programs ...” During a review of the facility’s “Quality Assessment/Performance Improvement Plan (QAPI) 2025,” dated 6/25/2025, the plan indicated, “The (Name of the facility) Governing Board: 1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization. 2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained 3. Acts strategically to ensure the delivery of high-quality care and services. 4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. 3. During a record review of Patient 2’s medical record titled, “ED (Emergency Department, hospital unit for urgent and life-threatening care) physician Hand Off Note,” dated 8/17/2025, indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The ED physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer of Patient 2 to L&D (Labor and Delivery, department that provides care for pregnant individuals during labor, childbirth, and the immediate after birth). During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2’s electronic medical record, was reviewed. RN 14 confirmed that Patient 2’s L&D electronic record did not contain an obstetric provider medical screening exam (MSE, a doctor’s exam to determine if an emergency condition exists), no physician’s order to transfer Patient 2 back to the Emergency Department (ED-hospital unit for urgent and life-threatening care), and no nurse-to-nurse hand-off (verbal communication of patient information when responsibilities is transferred) between the L&D nurse and the ED nurse prior to Patient 2’s transfer back to the ED. During the same interview on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2’s L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the interim supervisor of Labor and Delivery (SLD), Patient 2’s Labor and Delivery Emergency Room (a hospital unit that handles urgent obstetric or pregnancy-related medical issues) record titled, “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., was reviewed. SLD confirmed that there was no documentation of triage (initial assessment to determine urgency of care), a Maternal-Fetal Triage Index (MFTI, tool used to score urgency for pregnant patients), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby’s health], fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2’s transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses). During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2’s NST, was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During a concurrent interview and record on 8/22/2025 with RN 13, Patient 2’s “ED Physician Hand-Off Note.” dated 8/21/2025, was reviewed. The record indicated transfer to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed that Patient 2 was discharged without obstetric clearance (the medical evaluation of a pregnant patient to determine if their condition is an obstetric emergency and if it is safe for them to receive non-obstetric care) and the note did not reflect evaluation of fetal status (the process of assessing a fetus’s health). During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA),the Governing Body’s minutes (the official written record of a meeting held by a governing body), from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety. During a review of the facility’s “Medical Staff General rules and Regulations (are a set of detailed operational standards, policies, and professional conduct guidelines for hospital medical staff),” dated 10/31/2020, the documents indicated, “Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician ... Patients shall be discharged only on a written order of the attending or alternate physician ...Medical Screening Exam (MSE): Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner, Registered Nurses functioning under Standardized Procedures) are authorized to perform the MSE ...” During a review of the facility’s policy and procedure (P&P) titled, “Hand-Off/SBAR Communication, Patient,” dated 5/22/2024, the P&P indicated, “To provide accurate information about patient’s care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are “handed off’ from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit. During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board by-laws indicated, “ The Governing Board is responsible for compliance with The Joint Commission (“TJC”) standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital’s goals, policies and programs ...” During a review of the facility’s “Quality Assessment/Performance Improvement Plan (QAPI) 2025,” dated 6/25/2025, the plan indicated, “The (Name of the facility) Governing Board: 1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization. 2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained 3. Acts strategically to ensure the delivery of high-quality care and services. 4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.”

“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: 50516 Based on observation, interview and record review, the facility failed to: 1.a. Ensure one of 30 sampled patients (Patient 26) was assessed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk and ensure appropriate interventions were implemented, in accordance with the facility’s policy regarding patients at risk for elopement. This deficient practice had the potential to place Patient 26 and other patients at risk of harm such as accidents or injury from being hit by a car, falling and breaking bones, and/or death. 1.b. Ensure one of one sampled set of Emergency Exit double doors (Door #1), had a working alarm to notify staff of when the door was opened, which could impact 30 of 30 sampled patients, in accordance with the facility’s policy regarding environmental rounds. This deficient practice had the potential to place patients in harm when a functioning security system to alarm staff is not available and consequently may increase the risk patient elopement. 2. Ensure staff followed their “Sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) Utilization Policy,” for one of 30 sampled patients (Patient 12), when staff was assigned to be a sitter for Patient 12 and at the same time was assigned to assist other patients thus unable to maintain a “line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)” of Patient 12. This deficient practice had the potential for Patient 12 to injure self and/or others due to hospital staff not being able to maintain constant observation to ensure a safe environment. On 8/22/2025 at 4:15 p.m., the survey team called an immediate Jeopardy (a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Manager Quality Risk Management (MQRM), Vice President of Quality Risk Management (VPQRM), and the Emergency Department Registered Nurse (RN). The facility failed to ensure the following for the Emergency Department (ED): -There was a working Emergency Exit door alarm near patient rooms 8, 9, and 10. -Security or Engineering were accountable for maintaining the security system in the Emergency Department (ED) -Risk assessment for elopement and interventions were implemented to prevent Patient 26 from leaving the ED. These deficient practices had the potential to place Patient 26 and current patients at risk of elopement to suffer from harm and/or death. During a review of Patient 26’s “ED Note,” dated 6/17/2025, the record indicated Patient 26 was brought to the facility’s ED after being found wandering outside her apartment confused, incontinent (lost bladder control) of urine, and with a high alcohol level. The record further indicated Patient 26 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility’s ED through a set of double doors with no alarm, was brought back into the ED and placed on right and left soft wrist restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), removed herself (Patient 26) from the restraints and eloped again. Patient 26 was brought back to the ED and was ultimately discharged after becoming sober (think and function without impairment). This incident prompted the survey team to investigate the ED door alarms. A set of emergency exit ED door alarms was found to not be working. Upon interviews with security and engineering, security stated that a log of when the doors were checked, was not kept, and both departments (security and engineering) stated it was the other department’s (referring to either the security or engineering department) responsibility to check the ED doors. On 8/22/2025 at 9:25 p.m., the IJ was removed in the presence of the CFO, CNO, VPQRM, and MQRM, after the facility submitted an acceptable IJ Removal Plan (IJRP, interventions to correct the deficient practice). The elements of the IJRP were verified and confirmed through observations, interviews, and record review. The acceptable IJRP regarding the emergency exit doors included the following: The Security Department shift supervisor would round and check all ED doors alarms daily and keep a log containing the officer’s name, date, time, and disposition; door alarm log audits would be reported to Environment of Care (EOC) Committee monthly; alarm doors not working would be escalated to the Engineering Department immediately for repair; repairs would be tracked via work orders and reported to the monthly EOC.” The ED door alarm was immediately fixed by the Engineering Dept to ensure the door alarmed, when opened. The acceptable IJRP regarding Elopement risk included an “Elopement Risk Assessment,” which was created and implemented on 8/22/2025 for all patients in the Emergency Department and would be conducted during Triage; current and subsequent staff received training on the assessment form which included low, moderate, and high-risk interventions to implement. Findings: 1.a. During a concurrent interview and record review on 8/21/2025 at 3:10 p.m. with Registered Nurse (RN) 2, Patient 26’s “ED (Emergency Department, a hospital unit for urgent and life- threatening care) Note,” dated 6/17/2025, was reviewed. The record indicated Patient 26 was brought to the facility’s ED for “Evaluation of confusion ...She (Patient 26) was found to be confused and incontinent (involuntary loss) of urine.” The record indicated Patient 26 denied a past medical history. The record also indicated at 4:25 p.m. (on 6/17/2025), “Patient (Patient 26) was found to have left her (Patient 26) room, exited the main ER (Emergency Department) and was on her way out of the building when she (Patient 26) was caught be security and brought to the emergency department. Patient is intoxicated (drunk, impaired function) and not clinically sober (can function) for discharge ...” The record further indicated at 4:45 p.m. (on 6/17/2025), “Patient (26) was found to have escaped her restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and was again attempting to leave the emergency department. She (Patient 26) was returned to her bed by security. Restraints were then placed again on her upper extremities. Patient remains intoxicated ...” During a concurrent interview and record review on 8/21/2025 at 3:10 p.m. with RN 2, Patient 26’s “Flowsheet Inquiry Report,” dated 6/17/2025, was reviewed. The record indicated the following nursing notes about Patient 26’s elopement attempts: -On 6/17/2025 at 4:20 p.m., the record indicated “Pt (Patient 26) attempted to elope and left out of an emergency exit that did not sound. Pt was being incoherent (incomprehensible or unclear speech) and intoxicated towards staff and attempting to walk into traffic ...” -On 6/17/2025 at 4:44 p.m., the record indicated “At approx. (approximately) 1620 (4:20 p.m.), pt (Patient 26) walked from ER bed 8 to bathroom with a steady gait ...RN was seated outside of bed 11 and saw pt walk out through the double doors. Double doors did not alarm. Pt found outside of ER on sidewalk, escorted back to ER bed 8 and placed on 2 pt (point) restraints (restraints applied to both wrists) for safety.” -On 6/17/2025 at 4:50 p.m., the record indicated that at “4:45 p.m., pt (Patient 26) again attempted to elope, removed herself from restraints and attempted to exit the building. She was safely received by security, RNs and ED tech in entrance to ED and compliant to come back to ED while she sobers up. Restraints reapplied...” During the same concurrent interview and record review on 8/21/2025 at 3:10 p.m. with RN 2, Patient 26’s “Physician Order Restraints,” dated 6/17/2025, was reviewed. The record indicated Patient 26 had two orders, the first ordered at 4:25 p.m. and the second at 4:45 p.m., for soft wrist right and left restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for being impulsive (acting without forethought), trying to get out of bed, and unsteady. During an interview on 8/22/2025 at 9:25 a.m. with Registered Nurse (RN) 7 , RN 7 stated the ED emergency exits were in the front and the back of the unit (the ED unit). RN 7 stated she heard the door alarms triggered before and had no experience with them being broken. RN 7 stated for patients trying to elope (the act of leaving a facility unsupervised and without prior authorization), interventions would be asking where the patient was going and assess (evaluate) the patient’s orientation. RN 7 stated there was no assessment completed for elopement but would still document a note. During a concurrent interview and record review on 8/22/205 at 10:03 a.m. with Registered Nurse (RN) 2, RN 2 stated there was no standard elopement assessment tool being completed by staff in the ED and staff would just write narrative notes about an event. RN 2 confirmed Patient 26 did not have an order for a sitter (a trained hospital staff member who provides constant, one-on-one supervision to a patient who is at high risk of falling, wandering, causing self-harm, or harming others) because the patient (Patient 26) was just really drunk and not aggressive, and the restraints were for personal safety, and would not necessarily warrant a sitter. RN 2 stated Patient 26 had the appropriate intervention, and a sitter was not needed because Patient 26 was not exhibiting behavioral issues such as trying to throw themselves out of bed. During a review of the facility’s policy and procedure (P&P) titled, “Sitter Utilization,” dated 12/1/2021, the P&P indicated, “A physician’s order is not needed for a sitter ...The following are patient presentations/conditions/behaviors that indicate a higher level of observation (constant or one-to-one) may be necessary to protect the patient ...A patient that actively attempts elopement or verbalizes desire for elopement.” 1.b. During a concurrent observation and interview on 8/22/2025 at 9:41 a.m. with the Director of Security (DS), Chief Nursing Officer (CNO), and the Vice President Quality Risk Management (VPQRM), the survey team observed a set of Emergency Exit double doors alarms that was not working, The Emergency Exit double door (Door #1) led out to an open area of the hospital and to the street. This set of Emergency Exit doors was near Patient rooms 8, 9, and 10. DS stated he (DS) could not recall when the alarm was changed. DS stated rounding (method to check environmental safety conditions/concerns) was done once a week by engineering or security. DS stated a log was not kept that indicated findings. DS stated he (DS) would call engineering to fix the non-working alarm. DS stated it might be the whole system that’s broken and not just the battery for the Emergency Exit doors. During an interview on 8/22/2025 at 11:22 a.m. with Security Officer (SO) 1, SO 1 stated the responsibility to check the doors in the Emergency Department (ED), was by engineering. SO 1 stated he (SO 1) assisted the Engineering department by using a key to turn off the alarm. SO 1 stated if the alarms were not working, the engineering department would be notified right away. SO 1 stated if the door alarms were not working, a patient could get into an accident. SO 1 confirmed the set of emergency exit doors near Patient room 10, led to the street. During an interview on 8/22/2025 at 11:43 a.m. with the Facilities Supervisor (FS), FS stated security was responsible for checking the integrity of the doors. FS stated he (FS) had not recently received any service tickets for the ED doors, except for today (8/22/2025). FS stated the batteries were replaced for the door alarm on 8/22/2025. FS also stated there was a monthly safety round and different areas were picked monthly. During an interview on 8/22/2025 at 2:38 p.m. with Registered Nurse (RN) 2, RN 2 stated he (RN 2) was not aware that the ED door alarm near patient room 10, was not working. RN 2 stated he (RN 2) was aware of an incident when a patient (Patient 26) went through a set of doors in the ED, where the alarm did not go off, and did not know if repairs were made at that time. During an interview on 8/22/2025 at 3:18 p.m. with the Chief Nursing Officer (CNO), CNO stated there was an alarm installed on the doors (Door #1) that was observed earlier, to prevent it from being left open. CNO was not aware that the door was not working until the observation with the survey team on 8/22/2025. CNO confirmed that the door alarm not working created a safety risk to patients on a hold or elopement risk. During a review of the facility’s “Repair Report,” dated 6/1/2025-8/22/2025, the record indicated there was no service request for the ED doors (Door #1) on 6/17/2025 (when an ED patient eloped using Door #1 and the alarm did not sound). During a review of the facility’s “Safety Surveillance Rounds,” dated 1/7/2025, the record indicated for the ED, the “Security Exit Alarm,” was checked. The next check for ED security exit alarm was completed six months later on 7/1/2025. During a review of the facility’s policy and procedure (P&P) titled, “Environmental Rounds,” dated 10/23/2024, the P&P indicated, “If conditions or hazards are identified during Environmental Rounds that pose immediate threat to life, health or safety, the situation must be immediately and appropriately addressed and reported to the Safety Officer.” 2. During a review of Patient 12’s “Face Sheet (a concise summary document containing key information about a person or entity, often used in healthcare),” dated 8/21/2025, the Face Sheet indicated Patient 12 was admitted to the facility unit on 7/25/2025 at 10:36 p.m. During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/25/2025, the “H&P” indicated the following: Patient 12 was reportedly assisted by an Uber (transportation network) driver when Patient 12 was not talking and was in a confused state. During a review of Patient 12’s “Progress Notes ,” dated 8/19/2025, the Progress Notes indicated the following: Patient 12 with “history of altered mental status (a change in a person’s level of consciousness [a person’s degree of wakefulness, alertness, and awareness of their surroundings], alertness, and cognitive function [the brain’s ability to process information]) and remains confused.” During an interview on 8/19/2025 at 11:21 a.m. with Charge Nurse (CN 11), CN 11 stated the following: Confirmed there was another patient who was also confused and in the same room with Patient 12. Patient 12 was confused and was assigned a sitter (CNA 2) on that day (8/19/2025). CNA 2 was also assisting the other patient who was in the same room as Patient 12. During a concurrent observation and interview on 8/19/2025 at 11:24 a.m. with Nurse Manager (NM 2) in Patient 12’s room, CNA 2 went to assist the other patient in the shared room with Patient 12, and did not maintain “line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)” of Patient 12. NM 2 stated the following: Confirmed CNA 2 was the sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) for Patient 12 and was also assigned to assist with the other patient in the same room shared with Patient 12. During an interview on 8/19/2025 at 11:46 a.m. with Registered Nurse (RN 11), RN 11 stated the following: Patient 12 was not assigned to RN 11 but knew that Patient 12 had a sitter due to being confused. RN 11 was assigned to the other patient (in the same room with patient 12) who was also very confused sometimes. CNA 2 was the main sitter for Patient 12 and watched both patients. During an interview on 8/20/2025 at 2:22 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated the following: Confirmed on 8/19/2025 was assigned to Patient 12 as a sitter and also helping sometimes to assist the other patient in the same room. Patient 12 needed a sitter for safety concerns due to confusion. CNA 2 stated the other patient in the room was also confused on and off so that is why CNA 2 assisted the other patient. CNA 2 said “It is hard to watch both patients at the same time, I should focus on the patient who has an order for sitter. I can not see Patient 12 when I am assisting the other patient in the same room. Both patients are confused and can fall out of bed. For safety reasons there should be only one sitter for one patient. I do not decide or make the decision for sitter assignments.” During an interview on 8/20/2025 at 2:52 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated the following: Confirmed assigned to Patient 12 as a sitter today (8/20/2025) and assigned to assist with the other patient in the room. Confirmed both patients were still confused. CNA 2 said Patient 12 was confused, restless, and always wanted to get out of bed when awake. CNA 2 further stated “Not really safe to be watching both patients. Don’t know if patient (Patient 12) is on Constant observations to maintain [‘line of sight.’]” During an interview on 8/20/2025 at 3:23 p.m. with Registered Nurse (RN 3), RN 3 stated the following: Confirmed there was a sitter assigned to Patient 12 today (8/20/2025) for constant observation and line of sight. Patient 12 was confused and had a sitter for the past couple of days. RN 3 said the CNA who was assigned to be a sitter for Patient 12 was also watching the other confused patient in the same room. CNA 2 was helping watch both patients. RN 3 stated the set-up with the use of the sitter was a safety concern for patients. There was no line of sight for Patient 12 when CNA 2 helping the other patient. The confused patient (Patient 12) can fall from the bed. During an interview on 8/20/2025 at 3:44 p.m. with Nurse Manager (NM 2), NM 2 stated the following: Confirmed Patient 12 had a sitter assigned for safety and was on a constant observation. NM 2 confirmed that with staff not following the sitter policy regarding constant observation and line of sight was a concern for Patient 12 when the assigned sitter for Patient 12 was busy assisting the other patient in the room. NM 2 further stated the current practice was a safety concern because confused patients can fall out of bed. NM 2 stated “Will educate staff on following sitter policy.” During a review of the facility’s policy and procedure (P&P) titled, “Sitter Utilization Policy,” dated December 2021, the “P&P” indicated “Purpose: To protect patients who exhibits behaviors consistent with altered mental status, and could contribute to risk of injury or decreased efficacy of clinical care. Policy: Two methods of observation are employed by a sitter to enhance the safety of patients. These methods of observation include: Constant observation and One-to-One Observation. Constant observation consists of staff member assigned to one or more patients where the staff member can directly observe the patient’s activities at all times. This is also known as “line of sight,” whereby the patient(s) is always within the staff’s direct field of vision. Continuous direct visual observation will continue even when patients shower, change clothes, or use the bathroom. All attempts will be made to maintain the patient’s privacy as much as possible; however, the safety of the patient must be the main concern.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that a registered nurse (RN, a licensed healthcare professional who has completed advanced training in nursing and passed a state licensing exam) supervised and evaluated nursing care for one (1) of 30 sampled patients (Patient 2). Specifically, the triage assessment (initial check to decide how urgent a patient’s condition is) did not reflect the results of the C-SSRS (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), in accordance with the facility’s policy regarding suicide (thoughts of ending one’s own life) prevention. This deficient practice had the potential to miss the opportunity to identify important risk factors and may delay the implementation of treatment and safety plans, which may result in harm for Patient 2. Findings: During a review of Patient 2’s ED (Emergency Department, a hospital unit for urgent or life-threatening care) record titled, “History and Present illness,” documented by ED physician (MD, a medical doctor) 1, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation (thoughts of ending one’s own life). During a concurrent interview and record review on 8/21/2025 at 10:16 a.m. with RN 14, Patient 2’s ED record titled, “Emergency Department Triage (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) Report,” dated 8/16/2025, was reviewed. The record indicated there were multiple cuts on Patient 2’s wrists. However, the triage assessment indicated “Suicidal Risk: No.” RN 14 stated the triage suicidal risk assessment did not include the results from the C-SSRS tool (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), which indicated the following responses: -“Have you wished you were dead or wished you could go to sleep and not wake up?” Patient 2’s answer: “Yes.” -“Have you actually had any thoughts of killing yourself?” Patient 2’s answer: “Yes.” -RN 14 stated the triage assessment should have reflected these results and should have indicated “Yes” for suicidal ideation. During an interview on 8/19/2025 at 11:34 a.m. with the Nurse Manager of ED (NM, a nurse in charge of supervising nurses and operations in the department) 1 , NM1 stated the expectation was for all patients presenting with suicidal ideation to have the Columbia (C-SSRS) tool completed at triage and the results documented in the record. This would allow the patient’s suicide risk to be properly evaluated and interventions (such as psychiatric consults [a meeting with a psychiatrist- a medical practitioner specializing in the diagnosis and treatment of mental illness], sitter assignment [one-to-one staff assigned to observe a patient at all times], or increased observation [closer monitoring by staff]), could be initiated. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Prevention,” dated 9/23/2020, the P&P indicated, “To identify individuals at risk for suicide and to decrease the risk of suicidal death. To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients ... The patient will be screened for suicide risk at the point of entry, or at any time during the course of hospitalization if their psychiatric condition changes or if suicidal ideation is expressed ... The Emergency Department (ED) Triage Registered Nurse (RN) determines suicide risk initially by completing the Columbia-Suicide Severity Rating Scale (C-SSRS) ...must be documented.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to develop an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 1) to address Patient 1’s high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for delayed recognition and intervention of fall risks, which could result in additional falls and physical injury (such as broken bones [fractures] or head trauma [brain injury from a blow or impact]). It also had the potential to affect all patients admitted with fall risks who do not receive individualized care planning. Findings: During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/12/2025, the “H&P” indicated, Patient 1 was 92 years old, with known history of dementia (a group of symptoms affecting memory, thinking and social abilities). The H&P further indicated Patient 1 had been recently discharged after an admission for generalized weakness (a feeling of muscle fatigue or lack of strength that affects multiple muscle groups) with worsening confusion. At readmission, Patient 1 was described as “severely agitated (extremely emotional upset and restless)” and “combative (eager to fight or resist),” requiring admission for further evaluation. During a concurrent interview and record review on 8/19/2025 with the Emergency Department (ED, hospital unit for urgent and life-threatening care) Nurse Manager (NM, a supervising nurse responsible for managing unit staff and care planning) 1, Patient 1’s medical record (MR, the official chart of a patient’s care) document titled, “Daily Assessment Inquiry,” dated from 7/12/2025 through 7/17/2025, was reviewed. The MR indicated that Patient 1 was assigned a fall risk score using the Morse Falls Scale (a standardized tool that predicts the likelihood of patient falling; scores of 0-24 = no risk, 25-50 = low risk, and 51 or greater = high risk for falls). Patient 1’ scores were as follows: - On 7/12/2025: 100 (high fall risk) -On 7/13/2025: 70 (high fall risk) -On 7/14/2025: 115 (high fall risk) -On 7/15/2025: 110 (high fall risk) -On 7/16/2025: 110 (high fall risk) During the same interview and record review on 8/19/2025 with NM1, Patient 1’s “Care Plan,” initiated on 7/12/2025, was reviewed. The care plan did not include any interventions or goals addressing Patient 1’s high risk for falls. NM 1 confirmed that there was no documented care plan addressing Patient 1’s high risk of fall, despite Patient 1’s prior fall history and consistently high fall risk scores. NM 1 stated there should have been a care plan initiated for fall risk under these circumstances. During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care Documentation, Interdisciplinary,” dated 9/1/2022, the P&P indicated the following: Purpose: To provide guidelines in completing the Interdisciplinary care plan to ensure that each patient has a completed care plan period ...The Interdisciplinary plan of care should include: A. The RN initiates the Interdisciplinary plan of care after completion of the initial assessment. The plan of care is initiated within 12 hours of patient’s admission ...B. The Interdisciplinary plan of care will be updated every shift and as patient condition indicates. During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Management, Mobility and Ambulation” dated 5/26/2025, the P&P indicated the following: Assessment and Reassessment. 1. The patient’s fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient falls. 2. Evidence-based fall risk interventions will be implemented based upon an age-appropriate fall risk assessment tool.”

“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: 42976 Based on observation, interview, and record review the facility failed to ensure staff followed their “Central Line: Insertion, Maintenance, and Care Policy” for one of 30 sampled patients (Patient 11), when staff incorrectly placed a CHG Foam disc patch (a hydrophilic foam disc dressing impregnated with Chlorhexidine Gluconate [CHG] used to prevent bloodstream infection) for Patient 11 with a PICC line (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period). This deficient practice had the potential for Patient 11’s PICC line to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper placement of CHG foam disc. Findings: During a review of Patient 11’s “Face Sheet (a concise summary document containing key information about a person or entity, often used in healthcare),” dated 8/13/2025, the Face Sheet indicated Patient 11 was admitted to the facility unit on 7/18/2025 at 4:35 p.m. During review of Patient 11’s “History and Physical (H&P),” dated July 2025, the “H&P” indicated the following: Patient 11 with a history nonhealing right foot infection and right foot underlying osteomyelitis (infection of the bone tissue). During a concurrent observation and interview on 8/19/2025 at 11:29 a.m. with Nurse Manager (NM 2) in Patient 11’s room, Patient 11’s PICC (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) line to the right upper arm was observed with a CHG foam disc incorrectly placed underneath the transparent dressing at the PICC insertion site. The CHG foam disc placed underneath the transparent dressing did not allow the catheter to rest within the slit of the disc. NM 2 stated the following: Confirmed CHG foam disc was improperly placed and would educate staff on proper placement of CHG foam disc. During an interview on 8/19/2025 at 11:46 a.m. with Registered Nurse (RN 11), RN 11 stated the following: Confirmed assigned to Patient 11 for the day (8/19/2025). RN 11 stated “did not do the last dressing change for patient (Patient 11) and it was done by some one else.” RN 11 said “will change patient’s (Patient 11) PICC line dressing because the CHG foam disc is improperly placed. Improper placement of the CHG foam disc could be a risk for infection.” During an interview on 8/21/2025 at 3:31 p.m. with Registered Nurse (RN 13), RN 13 stated the following: RN 13 was a PICC line nurse and confirmed RN 13 placed PICC line for Patient 11. RN 13 said it was important to properly place the CHG foam disc underneath the transparent dressing making sure the PICC line catheter was resting within the slit of the CHG foam disc. RN 13 further said, If not properly placed, it could lead to the possibility of staff who changes the PICC line dressing to pull out the PICC by accident and a risk for infection can happen too. During a review of the facility’s policy and procedure (P&P) titled, “Central Line: Insertion, Maintenance, and Care Policy,” dated April 2024, the “P&P” indicated “Purpose: To serve as guidelines concerning the safe initiation and care of central lines (central venous catheters [CVCs] or central venous access devices [CVADs]). Types of central lines include non-tunneled catheters (short-term catheters), peripherally inserted central catheter (PICCs), tunneled catheters (long-term catheters) and implanted ports (Port-A¿Cath and Power Ports). Policy: E. Always use Chlorhexidine gluconate (CHG) impregnated sponge on all central lines, unless contraindicated (i.e. allergy). Ensure proper application of CHG impregnated sponge at the insertion site, white foam side next to skin. Do not lay CHG impregnated sponge on top of catheter hub. B. Dressing Change: F. Apply CHG impregnated sponge following manufacturer’s instructions.” During a review of the facility’s manufacturer’s instructions titled, “Aegis CHG-Impregnated Foam Disc” the manufacturer’s instructions indicated “Aegis is a hydrophilic foam disc dressing impregnated with chlorhexidine gluconate (CHG) that supports clinical best practices and professional guidelines for reducing CLABSI (Central Line Associated Blood Stream Infection) and CRBSl (Catheter Related Blood Stream Infection). It absorbs exudate and inhibits or kills microorganisms on the dressing’s surface. How to apply: Step 3 Ensure the Aegis disc makes 360° contact with the skin around the catheter. Additionally, the catheter should rest upon the slit portion of the disc.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure medical records were accurately written or documented for one (1) of 30 sampled patients (Patient 2), in accordance with the facility’s policy regarding suicide (thoughts of ending one’s own life) prevention. Specifically, the triage assessment (an initial assessment to decide how urgent a patient’s condition is) indicated “No suicidal risk,” which did not reflect the results of the Columbia Suicide Severity Rating Scale (C-SSRS, a standard tool used be healthcare staff to evaluate suicidal thoughts and behaviors), which showed the patient answered “Yes” to having thoughts of dying and “Yes” to having thoughts of killing herself.” This deficient practice had the potential to result in patients with suicidal ideation (thoughts of ending one’s own life) not being properly identified or monitored, leading to delayed or missed safety interventions. This could result in patients harming themselves or others. Findings: During a review of Patient 2’s ED (Emergency Department, a hospital unit for urgent and life-threatening care) record titled, “History and Present illness,” documented by ED physician (MD, a medical doctor) 1, dated 8/16/2025, the record indicated Patient 2 presented to the Emergency Department with suicidal ideation (thoughts of ending one’s own life). During a concurrent interview and record review 8/21/2025 at 10:16 a.m. with RN 14, Patient 2’s ED record titled, “Emergency Department Triage (initial check to decide how urgent a patient’s condition is) Report,” dated 8/16/2025, was reviewed. The triage assessment indicated “Suicidal Risk: No.” RN 14 stated that the assessment should have reflected the results of the C-SSRS, which indicated: -“Have you wished you were dead or wished you could go to sleep and not wake up?” Patient 2’s answer: “Yes.” -“Have you actually had any thoughts of killing yourself?” Patient 2’s answer: “Yes.” -RN 14 confirmed that the documentation in the triage assessment was inaccurate and inconsistent with the C-SSRS results. During an interview on 8/19/2025 at 11:34 a.m. with the Nurse Manager of ED (NM, a nurse in charge of supervising nurses and operations in the department)1, NM1 stated the expectation was for all patients presenting with suicidal ideation to have the Columbia (C-SSRS) tool completed at triage, and the results documented in the record accurately. This ensured the patient’s suicide risk level was clearly identified and interventions (such as psychiatric consults [a meeting with a psychiatrist- a medical practitioner specializing in the diagnosis and treatment of mental illness], sitter assignment [one-to-one staff assigned to observe a patient at all times], or increased observation [closer monitoring by staff]), could be initiated. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Prevention,” dated 9/23/2020, the P&P indicated, “To identify individuals at risk for suicide and to decrease the risk of suicidal death. To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients ... The patient will be screened for suicide risk at the point of entry, or at any time during the course of hospitalization if their psychiatric condition changes or if suicidal ideation is expressed ... The Emergency Department (ED) Triage Registered Nurse (RN) determines suicide risk initially by completing the Columbia-Suicide Severity Rating Scale (C-SSRS) ...must be documented ...””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that medical record entries were properly documented, in accordance with facility’s “Correction of Errors/Omission in Medical Records” policy and procedure, for five (5) of 30 sampled patients (Patient 1, Patient 3, Patient 4, Patient 7, and Patient 10). This was evidenced by the sitter documentation (sitter Observation Form, a monitoring tool used when staff provide continuous one-to-one observation of a patient) for Patient 1, and restraint documentation (Restraint Flowsheet, record used to monitor the safe application, release, and care of patients in restraints [any manual method, physical or mechanical device, material, or equipment used to restrict a patient’s freedom of movement]) for Patients 3, 4. 7, and 10. This deficient practice had the potential to cause miscommunication among healthcare providers and place patients at risk for medical treatment error (mistakes in care such as missed interventions, delays, or incorrect treatments). Findings: 1. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/12/2025, the “H&P” indicated, Patient 1 was 92 years old, with known history of dementia (a group of symptoms affecting memory, thinking and social abilities). The H&P further indicated Patient 1 had been recently discharged after an admission for generalized weakness (a feeling of muscle fatigue or lack of strength that affects multiple muscle groups) with worsening confusion (change in a person’s ability to think, focus, and be aware of their surroundings). At readmission, Patient 1 was described as “severely agitated (extremely emotional upset and restless)” and “combative (eager to fight or resist),” requiring admission for further evaluation. During a concurrent interview and record review on 8/19/2025 at 2:00 p.m. with the Emergency Department (ED, hospital unit for urgent and life-threatening care) Nurse Manager (NM, a supervising nurse responsible for managing unit staff and care planning)1, Patient 1’s “Sitter Observation Form,” dated 7/12/2025, was reviewed. The form contained two different time entries for the same 15-minute observation period, with scribbling-out errors and overwritten initials. NM 1 confirmed this was not an appropriate documentation. During a review of the facility’s policy and procedure (P&P) titled, “ Correction of Errors/ Omission in Medical Records,” dated 6/22/2022, the P&P required staff to correct errors by drawing a single line through the error, labeling it as “errors,” and including the date, time, and staff authentication. Scribbling or obliterating entries was not permitted. 2. During a review of Patient 3’s medical record (MR) document titled, “ED Physician Hand Off Note (a real-time, written document that summarizes patient information and the care plan for another physician or healthcare team),” dated 7/12/2025, the note indicated Patient 3 was verbally aggressive and placed in restraints. During a record review of Patient 3’s “Restraint Flowsheet,” dated 6/8/2025, the staff were instructed to document restraint release every 2 hours using a key: check mark (?) = done, star (*) =see notes, R = Refused. At 8:00 a.m., staff wrote “NA” instead of using the required key. During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that documentation should follow the key, and that “NA” was not appropriate to use. During a review of the facility’s policy and procedure (P&P) titled, “ Correction of Errors/ Omission in Medical Records” dated 6/22/2022, the P&P indicated, “Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry.” 3. During a review of Patient 4’s “History and Physical (H&P),” dated 5/31/2025, the “H&P” indicated Patient 4 was admitted for shortness of breath (difficulty breathing) and hypoxia (low oxygen in the blood). On arrival, oxygen saturation (percentage of oxygen in the blood) dropped below 80s. Patient 4 became altered (confused) and unresponsive (not reacting) and went into cardiopulmonary arrest (heart and breathing stopped). The patient was resuscitated (reviving using emergency life-saving measures), and admitted to the ICU (Intensive Care Unit, hospital unit for critical ill patients). During a concurrent interview and record review on 8/22/2025 at 1:40 p.m. with RN 2, Patient 4’s “Restraint Flowsheet,” dated 5/30/2025, was reviewed. The Flowsheet contained entries marked “NA” at 12:30 a.m. and at 1:30 a.m. instead of using the facility-approved key (check mark (?) = done, star (*) =see notes, R = Refused). RN 2 confirmed this did not follow policy. During a review of the facility’s policy and procedure (P&P) titled, “ Correction of Errors/ Omission in Medical Records” dated 6/22/2022, the P&P indicated, “Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry.” 4. During a review of Patient 7’s “H&P,” dated 5/17/2025, the record indicated Patient 7 had shortness of breath, lived in a boarding care home (a group living environment providing daily care), and had mental impairment (reduced ability to think, reason, or remember). Patient 7 was in respiratory distress (severe difficulty breathing that threatens life) and referred to ED. During record review of patient 7’s “Restraint Flowsheet,” dated 5/16/2025, the Flowsheet indicated restraint releases at 8:00 p.m., 10:00 p.m., and 12:00 a.m. were marked “NA” instead of using the required documentation key (check mark (?) = done, star (*) =see notes, R = Refused). During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that documentation should follow the key, and that “NA” was not appropriate to use. During a review of the facility’s policy and procedure (P&P) titled, “ Correction of Errors/ Omission in Medical Records,” dated 6/22/2022, the P&P indicated, “Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry.” 5. During a review of Patient 10’s “H&P,” dated 5/15/2025, the record indicated Patient 10 was found unresponsive, responded to Narcan (a medication that rapidly reverse opioid [a class of drug used to reduce moderate to severe pain] overdose), and was admitted to the ED with glucose (blood sugar) greater than 900. Patient 10 required chemical (medications used to control dangerous behavior) and physical restraints. During record review of Patient 10’s “Restraint Flowsheet,” dated 5/15/2025 - 5/16/2025, entries at 2:00 p.m., and 4:00 p.m., contained straight line and scribbles in areas where staff should have documented checks for food, fluids, and range of motion (ROM, gentle exercises that move a patient’s joints). Instead of using the required documentation key , the entries were unclear. During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that not using the key (check mark (?) = done, star (*) =see notes, R = Refused) and scribbles were not acceptable documentation. During a review of the facility’s policy and procedure (P&P) titled, “ Correction of Errors / Omission in Medical Records” dated 6/22/2022, the P&P indicated, “Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry ...Draw a single line through the discovered error (do NOT scribble over it, erase it; tear the incorrect portion off, “X” it out, or otherwise obliterate the incorrect entry). Do not use White Out. Write the word ERROR either in the margin or at the end of the line containing the incorrect entry, followed by the time, date, and proper authentication of the individual making the correction. Note the correct information in close proximity to the original entry, if possible. Where the correction requires more space than is available near the original entry, record the correct information in a new entry in the medical record or in an addendum to the medical record. The correct information must be separately authenticated, timed, and dated.””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the hospital failed to ensure that one (1) of 30 sampled patient’s (Patient 2), medical record contained the results of consultative evaluations and appropriate findings by clinical staff. Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term), considered a high-risk because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal stimulant drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). This deficient practice resulted in the discharge of Patient 2 to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without documentation of obstetric (pregnancy-related) consultation findings or confirmation of the baby’s well-being. This deficient practice also had the potential risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). Findings: During a record review of Patient 2’s medical record titled, “ED (Emergency Department, hospital unit for urgent and life-threatening care) physician Hand Off Note,” dated 8/17/2025, indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The ED physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer of Patient 2 to L&D (Labor and Delivery, department that provides care for pregnant individuals during labor, childbirth, and the immediate after birth). During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2’s electronic medical record, was reviewed. RN 14 confirmed that Patient 2’s L&D electronic record did not contain an obstetric provider medical screening exam (MSE, a doctor’s exam to determine if an emergency condition exists), no physician’s order to transfer Patient 2 back to the Emergency Department (ED-hospital unit for urgent and life-threatening care), and no nurse-to-nurse hand-off (verbal communication of patient information when responsibilities is transferred) between the L&D nurse and the ED nurse prior to Patient 2’s transfer back to the ED. During the same interview on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2’s L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the interim supervisor of Labor and Delivery (SLD), Patient 2’s Labor and Delivery Emergency Room (a hospital unit that handles urgent obstetric or pregnancy-related medical issues) record titled, “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., was reviewed. SLD confirmed that there was no documentation of triage (initial assessment to determine urgency of care), a Maternal-Fetal Triage Index (MFTI, tool used to score urgency for pregnant patients), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby’s health], fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2’s transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses). During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2’s NST, was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During a concurrent interview and record review on 8/22/2025 with RN 13, Patient 2’s “ED Physician Hand Off Note,” date 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby’s well-being. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department,” dated 12/15/2024, the P&P indicated, “In no event shall the provision of emergency services and care be based upon, or affected by, the person’s race, ethnicity, religion, national origin, citizenship, age, gender identity or expression, sexual orientation, pre-existing medical condition, physical or mental disability, insurance status, economic status, or the ability to pay for medical services. (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient’s presenting complaint and condition. Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. The patient’s physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage /Charge RN Responsibilities: Perform an assessment by identifying the patient’s immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. mercury and proteinuria greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation admitted through Emergency Department requiring perinatal screening examination ...” During a review of the facility’s “Medical Staff General rules and Regulations (are a set of detailed operational standards, policies, and professional conduct guidelines for hospital medical staff),” dated 10/31/2020, the documents indicated, “Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician ... Patients shall be discharged only on a written order of the attending or alternate physician ... A medical record will be created and maintained for each patient receiving services from (Name of the facility) for the purpose of: Providing continuing care for the patient at HPMC and at other health care facilities and health care providers ...Serving as a method of communication between health care providers serving the patient. Providing a historical record of tests, treatments, and interventions for the patient. Medical Screening Exam (MSE): Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner, Registered Nurses functioning under Standardized Procedures) are authorized to perform the MSE ...” During a review of the facility’s policy and procedure (P&P) titled, “Hand-Off/SBAR Communication, Patient,” dated 5/22/2024, the P&P indicated, “To provide accurate information about patient’s care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are “handed off’ from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure one (1) of 30 sampled patients (Patient 2), who presented to the Emergency Department (ED-hospital unit for urgent and life-threatening care) and Labor & Delivery (L&D-hospital unit for pregnancy and childbirth emergencies), received required assessments and physician examinations in accordance with the facility’s policy and procedures, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department.” Patient 2, was 32 weeks pregnant (about 8 months long, not yet full term), considered high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). In L&D, Patient 2 did not receive triage (an initial check to decide urgency of care), a Maternal-Fetal Triage Index (MFTI, scoring tool used to determine urgency of a pregnant patient’s condition), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby’s health], fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2’s transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses). When Patient 2 returned to the ED, staff did not check her (Patient 2) unborn baby’s heart rate (fetal heart tones). Patient 2 later discharged to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without confirmation of Patient 2’s own condition or the well-being of her (Patient 2) unborn baby. This deficient practice had the risk of serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (The baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). On 8/22/2025 at 4:09 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), VP Quality Risk Management (VPQRM), Manager of Quality Risk Management (MQRM), and the Charge Nurse Emergency Department (RN 2). The facility failed to protect the health and safety of a pregnant patient (Patient 2). Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term) and was considered a high-risk pregnancy (a pregnancy with conditions that increase the chance of serious complications for the mother or baby) because she had an active urinary tract infection (bladder or kidney infection), no prenatal care (regular pregnancy check-ups), and a positive drug screen for cocaine (a powerful and stimulant drug that can harm the pregnancy) and methamphetamine (stimulant drugs that can harm the pregnancy). During a record review of Patient 2’s emergency department (ED) medical record titled, “History and Present Illness,” dated 8/16/2025, the record indicated Patient 2 walked into the ED and reported suicidal ideation (thoughts of harming herself) and abdominal discomfort (nonspecific stomach pain). The record indicated an ultrasound (imaging technique that uses high-frequency sound waves to generate images) confirmed that Patient 2 was 32 weeks pregnant (about 8 months, not yet full term). During a record review of Patient 2’s medical record titled, “ED physician Hand Off Note,” dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer to Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review with Registered Nurse (RN 14) on 8/21/2025 at 10:40 a.m., Patient 2’ L&D electronic medical record, was reviewed. RN14 confirmed that there was no documented evidence that the obstetrician reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim Supervisor of Labor and Delivery (SLD), Patient 2’s L&D Emergency Room record, dated from 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” was reviewed. SLD confirmed the following: - No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented. - No vital signs were documented, including temperature (body heat measurement, used to detect infection), heart rate (pulse, beats in one minute), blood pressure (force of blood against vessel walls), respiration rate (breaths per minute), oxygen saturation (percentage of oxygen in the blood), and pain assessment (patient’s self-report pain rating). - No focused maternal or perinatal assessment (evaluation of the health of mother and baby) was documented. - No obstetric provider medical screening exam (MSE, a physician examination to determine emergency conditions in pregnancy), was documented. - No provider orders were issued to transfer Patient 2 back to the ED. - No hand-off report (report patient care information, authority, and responsibility from one healthcare provider to another during a shift change or patient transfer) from the L&D Registered Nurse (RN) 1 to the ED nurse, was documented. During a concurrent interview and record review with SLD on 8/21/2025 at 12:55 p.m., Patient 2’s ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby’s heart rate (fetal heart tones, or FHTs- the baby’s heartbeat heard with a handheld Doppler, [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available. During a concurrent interview and record review on 8/22/2025 with RN 14, Patient 2’s “ED Physician Hand Off Note,” dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric (branch of medicine that deals with mental health issues) rehabilitation facility. RN 14 confirmed Patient 2 had been transferred. During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2’s NST, was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 stated when there is no fetal monitoring, vital signs, triage assessments, or physician medical screening exams (initial evaluation provided to determine if a patient has an emergency medical condition) completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death. On 8/22/2025 at 9:24 p.m. the IJ was removed in the presence of the CFO, CNO, VPQRM, and MQRM, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan included: Creation of an algorithm (a step-by-step instruction designed to solve a problem or accomplish a task) for “Triage of Pregnant Patients in the Emergency Department,” to help ensure patients presenting to the Emergency Department (ED) and L&D received appropriate treatment. A tool, “ED to L&D Intake Form,” was created to identify high-risk pregnant patients presenting to the ED and to ensure all pregnant patients 20+ weeks of gestation receive a complete assessment, vital signs, and medical screening examinations in the ED. ED and L&D current staff were educated on the “Triage of Pregnant Patients in the Emergency Department” and the “ED to L&D Intake Form.” All subsequent staff would be educated by the department leader (director, manager, supervisor, charge RN) or designee prior to shift. The “ED to L&D Intake Form” would be used as a handoff tool when transferring pregnant patients 20+ weeks of gestation from ED to L&D. The “Triage of Pregnant Patients in the Emergency Department,” outlined that patients who were 20+ weeks of gestation would be sent to L&D for fetal heart rate monitoring. Once the patient is in L&D, an MFTI and MSE would be conducted in triage. L&D staff would place “discharge to ED” order in CPOE (the account number will not carry over to ED- a new account number for ED is needed) and document discharge destination in Centricity to ensure that there is a physician order if/when sending patient back to the ED. Thirty random monthly audits would be conducted to ensure: All patients presenting to L&D receive an MFTI and MSE. The expectation is 100% compliance; all non-compliance will be coached and/or lead to disciplinary action. All patients discharged to the ED would have a doctor’s order. Findings: During a concurrent observation and interview with Certified Nurse Assistant (CNA, a healthcare professional who provides direct, hands-on care to patients under the supervision of a license nurse) 4 on 8/19/2025 at 11:10 a.m. in the Emergency Department (ED, hospital unit for urgent and life-threatening care), Patient 2 was repositioning herself back and forth in a recliner chair, eventually settling into a fetal position (a position in which someone lies in a curved shape with legs and arms bent and close to the body) in a recliner chair. CNA 4 stated that Patient 2 was pregnant and under one-to-one observation (a practice where a designated healthcare professional stays in continuous, close proximity to a patient to ensure their safety) for suicidal ideation (thoughts of self-harm or ending one’s life). CNA 4 stated they (referring to healthcare staff) had been assigned to observe Patient 2. During a review of Patient 2’s ED record titled, “History and Present illness, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation and abdominal discomfort (general stomach pain without a clear cause). The record also indicated an ultrasound (a scan that uses sound waves to see inside the body) confirmed Patient 2 was 32 weeks and 5 days pregnant. During a record review of Patient 2’s record titled, “ED physician Hand Off Note,” dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2’ L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/21/2025 at 12:08 p.m., with Interim SLD, Patient 2’s record “Triage (an initial check to decide urgency of care),” dated 8/17/2025, was reviewed. The record indicated Patient 2 was scratching, and kicking, and the Non-Stress Test (NST, is a noninvasive prenatal test that monitors the baby’s heart rate in response to its own movements and contractions) monitor had to be physically held in place for 20 minutes, but the nurse was unable to hold the Toco transducer (Toco, the device used during an NST and other fetal monitoring to measure the timing and duration of uterine contractions detecting changes in abdominal wall tension). SLD confirmed that an NST was attempted; however, the reading was not completed. During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the SLD, Patient 2’s L&D Emergency Room record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” was reviewed. SLD confirmed the following: - No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented. - No vital signs (temperature, blood pressure, heart rate, respiration rate, oxygen saturation, or pain score). - No maternal or perinatal assessment - No physical medical screening exam -No provider orders to transfer Patient 2 back to the ED. - No nurse-to-nurse hand-off report from the L&D nurse to the ED nurse During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2’s ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff checked fetal heart tones (the baby’s heartbeat measured with a handheld Doppler device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available. During a concurrent interview and record review with on 8/22/2025 with RN 13 , Patient 2’s “ED Physician Hand Off Note,” dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby’s well-being. During a concurrent interview and record review on 8/22/2025 at 10:00 a.m. with RN 15, Patient 2’s NST, was reviewed. RN 15 stated the reading was not clear as there were many missed spaces (gaps of no reading). RN 15 stated “from this reading, we cannot say for certain whether the patient is having contractions or not.” RN 15 also stated “with this reading, there should be a repeat test done as the test is inconclusive.” During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2’s NST, was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 confirmed that when there was no fetal monitoring, vital signs, triage assessments, or physician medical screening exams completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department,” dated 12/15/2024, the P&P indicated, “(Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient’s presenting complaint and condition. Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. The patient’s physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage /Charge RN Responsibilities: Perform an assessment by identifying the patient’s immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. Mercury) and proteinuria greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation admitted through Emergency Department requiring perinatal screening examination.” During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept.,” dated 4/26/2023, the P&P indicated, “Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient’s health or fetus’ (estimated gestational age >20 weeks) health in serious jeopardy... Identify patient’s immediate needs as follows; does the patient have any of the following: Pregnancy > 20 weeks gestation with or without pregnancy-related complaint ... Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE). The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department.” During a review of the facility’s policy and procedure (P&P) titled, “Antepartum Testing.,” dated 10/27/2021, the P&P indicated, “To provide guidelines for the noninvasive determination of fetal well-being by observing the response of fetal heart rate to fetal movement or Nonstress Test (NST) ... The nurse will notify the physician of all abnormal test results and obtain follow-up orders, documenting actions and results.””

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure proper integrated communication between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery (L&D, hospital unit for pregnancy and childbirth emergencies) for one (1) of 30 sampled patients (Patient 2), 32 weeks pregnant (about 8 months long, not yet full term), considered a high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy). Specifically, the facility failed to: -Ensure L&D staff documented and communicated results of obstetric evaluations (such as triage [an initial check to decide urgency of care], vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating]), maternal or perinatal assessment (assessment of mother and baby’s health), fetal monitoring (non-stress test [NST, test of baby’s heart rate with movement] or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor’s exam to find emergency conditions). -Ensure L&D staff obtained and communicated physician orders before transferring Patient 2 back to the ED. -Ensure L&D staff provided nurse-to-nurse hand off (direct communication of patient status and care needs) when sending Patient 2 back to the ED. -Ensure ED staff received and acted on L&D findings by checking fetal heart tones after Patient 2 returned from L&D. -Ensure continuity of care so that maternal and fetal well-being was assessed and communicated before Patient 2 was discharged to a psychiatric facility (a healthcare institution that specializes in the diagnosis, treatment, and care of individuals with mental health disorders). These deficient practices placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby’s heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). Findings: During a record review of Patient 2’s medical record titled, “ED physician Hand Off Note,” dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note also indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women’s reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies). During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim SLD (Supervisor of Labor and Delivery), Patient 2’s L&D record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled, “OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency),” was reviewed. SLD confirmed there was no documentation of triage, a Maternal-Fetal Index (MFTI, scoring tool used to determine urgency of a pregnant patient’s condition), vitals signs, maternal or perinatal assessments, fetal monitoring, or a physician medical screening exam (MSE, a doctor’s exam required to determine if an emergency condition exists). SLD further confirmed there was no physician order documented for transfer of Patient 2 back to the ED and no nurse-to-nurse hand-off between the L&D staff and the ED staff prior to the transfer of Patient 2 back to the ED. During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2’s ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby’s heart rate (fetal heart tones, or FHTs- the baby’s heartbeat heard with a handheld Doppler [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available. During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2’s non-stress test (NST, test of baby’s heart rate with movement or fetal heart tones [baby’s heartbeat measured with a handheld Doppler device-small imaging monitor]), was reviewed. CN 2 confirmed the NST was “inconclusive” and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained. During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2’s Labor and Delivery electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby’s heart rate in response to its own movements). During a concurrent interview and record review on 8/22/2025 with RN 13 , Patient 2’s “ED Physician Hand Off Note,” dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby’s well-being. During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept.,” dated 4/26/2023, the P&P indicated, “Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE),” and that documentation be included in the record ... “The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ...” During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Labor and Delivery Department,” dated 12/15/2024, the P&P indicated, “ (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient’s presenting complaint and condition. Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ...” During a review of the facility’s policy and procedure (P&P) titled, “Hand-Off/SBAR Communication, Patient,” dated 5/22/2024, the P&P indicated, “To provide accurate information about patient’s care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are “handed off’ from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff used the less restrictive restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) intervention for one of nine sampled patients (Patient 5), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 5 was placed on 4-point (bilateral [both] wrists and bilateral ankles) restraints to prevent Patient 5 from getting out of bed in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 5/21/2025. This deficient practice resulted in restraint overuse for Patient 5. Findings: During a review of Patient 5’s “Emergency Department Notes (ED note, assessment notes completed by ED physician),” dated 5/21/2025, the ED note indicated, Patient 5 presented to ED with acute (new onset) head injury and acute psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality). During a review of Patient 5’s “Physician Order Restraints,” dated 5/21/2025, the “Physician Order Restraints,” indicated, non-violent or non-self-destructive restraint with soft bilateral (both) wrists and ankles (4-point restraint), was started on 5/21/2025 at 11:45 a.m. with indication for restraint: “observed trying to climb out of bed when instructed not to do so, and unsteady, will not ask for assistance.” During a concurrent interview and record review on 6/3/2025 at 10:28 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 5’s “Clinical Assessment - Note (nursing note),” dated 5/21/2025, was reviewed. The nursing note indicated, “at 11:46 a.m. patient (Patient 5) wandering and stepping into patient rooms, requires constant redirection from Registered Nurse (RN), Certified Nursing Assistant (CNA) and security staff. Patient (Patient 1) unsteady, will not ask for assistance. Physician (MD 53) at bedside with security staff, CNA and RN. Received verbal order for non-behavioral restraints.” During the same interview on 6/3/2025 at 10:28 a.m. with the Nurse Manager of Emergency Department (NM 1), NM 1 stated the following: 4-point restraints were considered as behavioral/violent restraint use because it was restricting the patient’s (Patient 5) all four extremities. For patient attempting to wander and getting out of bed, a lesser restrictive measure such as bilateral soft wrists restraints should be used first. NM 1 also stated there was no documented attempt of using other less restrictive restraints method prior to the 4-point restraint use for Patient 5. During an interview on 6/3/2025 at 10:39 a.m. with the Director (DIR 1) of Emergency Department, DIR 1 stated the following: there was some confusion regarding 4-point restraints, but it was clarified. 4-point restraints should only be used for patients with violent behavior. For non-behavioral/non-violent restraints, nurse could only use up to 3-point restraints (restraining up to three of four extremities). During an interview on 6/2/2025 at 10:51 a.m. with the ED Registered Nurse (RN 1), RN 1 stated a 4-point restraint would be considered as violent/behavioral restraints. Nurses should never use 4-point restraints as non-violent/behavioral restraints. Nurses should try to use 2-point (restraining up to two extremities) or 3-point restraints before using a 4-point restraint. Nurses should try the least restrictive method first. During a review of the facility’s policy and procedure (P&P) titled, “Non-Violent Behavior,” dated 11/2024, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 2. All patients have the right to be free from any form of abuse and neglect. All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ... 3. Restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure staff assessed, evaluated, and documented a patient’s behavior to justify the continued use of restraints, when renewing a behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of nine sampled patients (Patient 4), in accordance with facility’s policy and procedure regarding restraints use, when the physician restraint renewal order and the nursing assessment did not indicate what was Patient 4’s behavior, which was indicative of immediate danger to self or others that warrants the use of restraints. This deficient practice resulted in unnecessary restraints use on Patient 4 from 10 p.m. to 2:30 a.m. (total 4.5 hours) on 4/27/2025 and violated Patient 4’s rights to be free from restraints. Findings: During a review of Patient 4’s “Emergency Department Notes (ED note, assessment notes completed by ED physician),” dated 4/27/2025, the ED note indicated, Patient 4 presented to ED with suicidal (feeling of ending his/her own life) and homicidal (feeling of killing others) ideations. The ED note also indicated Patient 4 was medically cleared (a healthcare professional has assessed a person’s health and determined they are fit to participate in a specific activity) and pending psychiatric (specializes in mental health) evaluation. During a review of Patient 4’s “Physician Order Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body),” dated 4/27/2025, the “Physician Order Restraints,” indicated, behavioral restraints with soft bilateral (both) wrists and ankles (4-point restraint) was started on 4/27/2025 at 8:30 p.m. with indication for restraint (must identify the specific behavior requiring restraints such as harming self, hitting, throwing objects): injury to self - hostile threatening self; injury to others - threatening staff, to be violent, pacing, walking towards staff. The “Physician Order Restraints” indicated, time limit for written order was four [4] hours. During a concurrent interview and record review on 6/3/2025 at 9:36 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4’s “Restraint Flowsheet,” dated 4/27/2025, was reviewed. The “Restraint Flowsheet” indicated, 4-point restraints started on 4/27/2025 at 8:30 p.m. and removed on 4/28/2025 at 2:30 a.m. NM 1 stated Patient 4 was on 4-point restraints for 6 hours. During a concurrent interview and record review on 6/3/2025 at 9:47 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4’s “Restraint Flowsheet,” dated 4/27/2025, was reviewed. The “Restraint Flowsheet” indicated, Patient 4 was sleeping at 10 p.m., at 12 a.m. and at 2 a.m. per documented assessment. NM 1 stated there was no indication for continuation for restraints. Nurse should have assessed and evaluated the patient and discontinued the restraints as Patient 4 was sleeping. During a concurrent interview and record review on 6/3/2025 at 9:56 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4’s “Suicide Prevention Monitor Observation Flowsheet (sitter flowsheet, documentation of patient’s behavior and location during 1:1 monitoring [the continuous, direct observation of a patient by a designated staff member]),” dated 4/27/2025, was reviewed. The sitter flowsheet indicated Patient 4’s behavior as follows: -At 8:30 p.m.: awake and disruptive; at 9 p.m.: awake and calm; at 9:45 p.m.: awake and sitting quietly; at 10 p.m.: patient (Patient 4) was sleeping. The sitter flowsheet also indicated Patient 4 remained sleeping from 10 p.m. to 2:30 a.m. the next day. NM 1 stated there was no necessity to continue restraints for Patient 4 because Patient 4 was calm and sleeping. NM 1 said the Nurse did not discontinue Patient 4’s restraints at the earliest time possible. NM 1 further stated, this (referring to the continued use of restraints even though Patient 4 was calm and sleeping) was a patient’s rights violation. During a concurrent interview and record review on 6/3/2025 at 5:10 p.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4’s “CPOE (Computerized Provider Order Entry) Order Report (physician order, orders entered by physician electronically),” dated 4/27/2025, was reviewed. The physician order indicated physician (MD 55) ordered bilateral (both) wrists and ankle restraints on 4/27/2025 at 10:41 p.m. The physician order did not indicate any reason for restraints. NM 1 stated the restraint renewal order did not have any indication for continuation of restraints. NM 1 also stated restraints was unnecessary because Patient 4 had been sleeping since 10 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 2. All patients have the right to be free from any form of abuse and neglect. All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints are discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36206 Based on interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) was met, as evidenced by: 1. The facility’s Governing Body/Governing Board failed to ensure that recommendations of the medical staff were considered before making medical staff reappointments when, the Governing Body/Governing Board granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without considering recommendations from the medical staff for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment. This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without considering recommendations by the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. (Refer to A-0046) 2. The facility’s Governing Body/Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that the process articulated in the medical staff bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations), rules, or regulations which included criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners, was followed, when the Governing Body granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without verifying that the physicians met the criteria for reappointment based on individual character, competence, training, experience and judgment for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment. This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without examination of their credentials by the Medical Staff Credentials Committee as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. (Refer to A-0050) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36206 Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility’s nursing staff failed to ensure that interpreter information was documented, when and if the interpreter was used to translate information regarding advance directives acknowledgement form (a form confirming that a healthcare provider has received and understands an individual’s advance directive [outlines their wishes regarding future medical treatment]), for one of 30 sampled patients (Patient 12), whose preferred written and spoken language was Korean, in accordance with the facility’s policy and procedure regarding interpreter services (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction). This deficient practice had the potential to result in Patient 12 misunderstanding the information regarding advance directives, which could compromise Patient 12’s ability to make informed decisions (means patients understand their health condition, treatment options, risks, benefits, and alternatives, allowing them to make choices aligned with their values and preferences) about their healthcare. (Refer to A-0129) 2. The facility failed to ensure its nursing staff escalated an alleged physical abuse (including hitting, slapping, pinching, and kicking) to the house supervisor, for one of 30 sampled patients (Patient 6), in accordance with the facility’s policy and procedure regarding abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Patient 6 reported to Registered Nurse (RN 5) that Certified Nursing Assistant (CNA 5) punched Patient 6 in the face. This deficient practice resulted in CNA 5 not being removed from the facility immediately and putting Patient 6 and other patients at risk for further abuse. (Refer to A-0145) 3. The facility failed to ensure its nursing staff developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided), for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints. This deficient practice had the potential to result in lack of monitoring regarding restraints use and the potential for inappropriate or prolonged restraints use, which may result in complications such as skin breakdown (damage to the skin and underlying tissue), psychological distress, etc. (Refer to A-0166) 4. The facility failed to ensure a physicians’ order for restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) included the indication for restraints for one of 30 sampled patients (Patients 23), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential for patients to be restrained unnecessarily and may lead to lack of monitoring to determine if the restraints are still necessary in order to reduce or eliminate the need for restraints due to potential complications such as skin injury, circulation (blood flow) problems, psychological distress, etc. (Refer to A-0168) 5. The facility failed to ensure staff assessed and evaluated a patient’s behavior when renewing a behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3’s behavior, which was indicative of immediate danger to self or others to warrant the use of restraints. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0171) 6. The facility failed to ensure its nursing staff discontinued restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use at the earliest possible time for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints from 8:40 p.m. to 4:40 a.m. (total right [8] hours) despite Patient 3 documented as being calm and sleeping most of the time from 9:15 p.m. to 4:45 a.m. (7.5 hours) during the restraint episode. This deficient practice resulted in unnecessary restraint use on Patient 3 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0174) 7. The facility failed to ensure its nursing staff assessed and monitored one of 30 sampled patients (Patient 3), upon initiation of behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in accordance with the facility’s policy regarding restraints use, when nursing assessment started twenty (20) minutes after initiation of 4-point behavioral restraints (bilateral [both] wrists and bilateral ankles). There was no assessment completed/documented upon initiation of restraints at 8:40 p.m. on 4/14/2025. This deficient practice resulted in nursing staff not assessing and monitoring Patient 3 during the first 20 minutes during the restraint episode and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and circulation (blood flow) problem. (Refer to A-0175) 8. The facility failed to ensure its physician performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of a 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in lack of evaluation of Patient 3’s response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as skin tear, dehydration, psychological distress, etc. (Refer to A-0178) 9. The facility failed to ensure its physician documented a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of a 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in lack of evaluation of Patient 3’s response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complication such as skin tear, dehydration, psychological distress, etc. (Refer to A-0184) 10. The facility failed to ensure there was a documentation of patient’s specific behavior for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3’s behavior which was indicative of Patient 3 posing immediate danger to self or others that warrants the use of restraints. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture). (Refer to A-0185) 11. The facility failed to ensure nursing staff documented the reason for placing on restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely), one of 30 sampled patients (Patient 23), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential for the patients to be restrained unnecessarily, which may result in complications such as skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), circulation (blood flow) problem, psychological distress, etc. (Refer to A-0187) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Staff was met, as evidenced by: 1. The facility failed to ensure its Medical Staff reviewed the credentials (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and made recommendations to the Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations) The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed. This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under care of these reappointed practitioners. (Refer to A-0341) 2. The facility failed to ensure its Medical Executive Committee was held accountable for applying the criteria for privileging and appointment of eligible candidates and to make their recommendations, before the Governing Body makes a final decision to reappoint a practitioner to the medical staff when, its Medical Staff did not review the credentials (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and did not make recommendations to the Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations). The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed. This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to the patients under care of these reappointed practitioners. (Refer to A-0347) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that one of 30 sampled patients (Patient 12), who was admitted to the facility after sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), when Patient 12 fell out of the bed and fractured a right 7th rib (broken rib), had their (Patient 12) reported pain level of 7 out of 10 (7/10- moderate pain) and 5 out of 10 (5/10-moderate pain) addressed, when Patient 12 was not provided an intervention (any action taken to alleviate or manage pain) for pain relief, in accordance with the facility’s policy regarding pain management. This deficient practice resulted in Patient 12’s pain not being managed and had the potential for Patient 12 to be in significant discomfort and prolonged suffering, leading to increased risk of complications associated with unmanaged pain, such as respiratory issues due to shallow breathing or avoidance of moving. (Refer to A-0395) 2. The facility failed to ensure the pain level was assessed prior to and after administering a pain medication for two of 30 sampled patients (Patients 21 and 22), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for ineffective pain relief, which may result in functional limitations (Example: reduced Mobility, etc.), prolonged discomfort, prolonged hospital stay, anxiety, etc. (Refer to A-0395) 3. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 22) to address Patient 22’s high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for the lack implementation of fall precautions (a multi-faceted approach to minimize the risk of falls, encompassing universal interventions for all patients, as well as individualized strategies based on specific risk factors. These precautions include ensuring a safe environment, assisting with mobility, and educating patients and their families) for Patient 22, which could result in a fall and possible serious injury or harm such fracture (broken bones), etc. (Refer to A-0396) 4. The facility failed to ensure that one of 30 sampled patients (Patient 12), had their (Patient 12) pain assessment (the systemic evaluation of a patient’s pain experience, including intensity, location, quality, and acceptable level of pain) performed/assessed every four hours along with vital signs (VS, measurements of essential bodily functions including hear rate, blood pressure, respiratory rate, and temperature), in accordance with the facility’s policy and procedure regarding pain assessment and management. This deficient practice had the potential for Patient 12’s pain to be inadequately managed, leading to Patient 12’s prolonged discomfort and suffering, and a negative impact on the patient’s overall recovery (delayed healing process). (Refer to A-0398) 5. The facility failed to ensure one of 30 sampled patients (Patient 21), who complained of moderate pain (4 - 7 rate out of 10 on the pain scale), was treated with a pain medication ordered to treat moderate pain, in accordance with the facility’s policy regarding pain management. Instead, Patient 21 was treated with a pain medication (Tylenol, an over-the-counter pain medication), which was ordered to treat mild pain and not moderate pain. This deficient practice resulted in inadequate pain relief for Patient 21, which also has the potential to result in prolonged discomfort, psychological distress, etc. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 36206 Based on interview and record review the facility failed to ensure the Condition of Participation for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 14), contained pertinent information when: 1.a. The administration site for 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions [behavior, mood, thoughts, and perception]), for one of 30 sampled patients (Patient 14), was not documented, in accordance with the facility’s policy regarding documentation of medication administration. This deficient practice had the potential to compromise Patient 14’s safety due to lack of communication among healthcare providers and lack of monitoring for the potential adverse events and complications at the injection site (Example: infection, nerve damage, allergic reactions, etc.). (Refer to A-0449) 1.b. There was no correctly filled out behavioral restraint (interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others) physician order(s) and restraint assessment documentation containing all the necessary elements (justification for restraint use, type of restraints, duration of restraint, monitoring requirements, and alternatives considered), for one of 30 sampled patients (Patient 14), in accordance with the facility’s policy and procedure regarding behavioral restraints assessment and documentation. This deficient practice had the potential to result in Patient 14’s increased risk of harm due to inappropriate continuation of restraints, exposing the patient (Patient 14) to physical and psychological harm. Additionally, without proper assessment and documentation, changes in Patient 14’s condition may go unnoticed, increasing the risk of complications such as injury (example: skin breakdown- damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture`), emotional distress and/or death. (Refer to A-0449) 2. The facility failed to ensure there was documentation of a patient’s specific behavior for one of 30 sampled patients (Patient 3), when the physician restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) renewal order and the nursing assessment, did not indicate what was Patient 3’s behavior that would indicate that Patient 3 was posing immediate danger to self or others, in accordance with the facility’s policy regarding restraints use and documentation. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours on 4/15/2025) and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0450) 3. The facility failed to ensure two of 30 sampled patients’ (Patient 12, and Patient 17) medical records contained appropriate documentation of assessments and findings when: 3.a. For Patient 12, pain assessment was not recorded in Patient 12’s medical record, along with vital signs (VS, measurements of the body’s most basic functions), obtained and documented every 4 hours, in accordance with the facility’s policy regarding pain assessment and documentation. This deficient practice compromised Patient 12’s medical record integrity by undermining the completeness and accuracy of the documentation, essential for effective patient care and pain management. In addition, this deficient practice had the potential for Patient 12’s pain to be unrecognized, leading to inadequate pain management and delayed interventions that could prevent complications related to unmanaged pain. (Refer to A-0467) 3.b. For Patient 17, the medical record contained no nursing documentation of Patient 17 sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) in the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries), during Patient 17’s hospital stay on 1/22/2025, in accordance with the facility’s policy regarding fall prevention and management. In addition, Patient 17 sustained an open left ankle fracture (a type of bone fracture [broken] where the bone breaks through the skin, exposing the fracture site to the outside environment). This deficient practice had the potential to result in Patient 17’s condition and injury to be overlooked by providers, potentially leading to complications arising from the fall and fracture, such as infection and impaired healing, adversely affecting Patient 17’s health and care. (Refer A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 36206 Based on interview and record review, the Governing Body/Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that recommendations of the medical staff were considered before making medical staff reappointments when, the Governing Body/Governing Board granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without considering recommendations from the medical staff for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment. This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without considering recommendations by the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. Findings: During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility’s Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals’ most recent reappointment to the Medical Staff and their requested clinical privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) had been approved by the Governing Board for sixty (60) days. Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges extended for another 60 days. MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days. During an interview on 4/17/2025 at 1:37 p.m. with the Chief of Medical Staff (COS), the COS stated that the Medical Staff Committee’s (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) duties included making recommendations to the Governing Body/Governing Board for physicians seeking initial appointments and re-appointments to the medical staff. The Medical Executive Committee did not meet in January, February, and March of 2025 due to questionable election results for Medical Staff Committee members which occurred at the end of 2024. The COS also stated that the Governing Body/Governing Board has now re-appointed medical staff for sixty (60) day extensions without the recommendations of the Medical Staff. During an interview on 4/18/2025 at 9:36 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: The credentialing process of appointing and re-appointment starts with a physician submitting an application and other required documents to the Medical Staff Office (handles the appointments of physicians). The Credentialing Committee reviews the application, and forwards the application to the Medical Staff Committee, who then makes recommendations to grant or deny privileges. The Medical Staff Committee then sends the recommendations to the Governing Board for approval. The CEO stated the MEC did not meet in January, February, and March of 2025, and therefore, no recommendations were made for appointments or re-appointments. The Governing Board reached out to the MEC, but there was no response. Due to this unprecedented situation, the Governing Board wanted to ensure there was no lapse in the re-appointment of privileges and care of the patients, therefore, the Governing Board reviewed the credentialing files and decided to grant 2-month reappointments, in leu of 2-year reappointments. Some physicians were granted a second (2nd) 2-month reappointment, thereby, bypassing some steps in the usual credentialing process. During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which was due to expire on 5/31/2025. During a review of the facility’s “Medical Staff Executive Committee,” meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned), the minutes indicated there were no meeting minutes documented for the month of January 2025. During a review of the facility’s “Medical Staff Executive Committee,” meeting minutes, dated 2/19/2025, the minutes indicated the Committee “chose not to recognize the Credentials Report, and did not review the report ...” During a review of the facility’s “Governing Board,” meeting minutes, dated 1/22/2025, the meeting minutes indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The meeting minutes also indicated the medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations) ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board. During a review of the facility’s “Governing Board,” meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: The following items were voted on and approved off-cycle and require ratification: Resolution providing 60-day approval of physician’s credentials. Approval was required due to lack of MEC meeting in January 2025. During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board ... During a review of the Medical Staff Bylaws, last amended and approved by the Governing Board in October 2020, indicated under Section 7.3-3 “Reappointment Procedure:” a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or a Committee thereof, shall review the application for the reappointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care, and if available, relevant practitioner-specific data compared to aggregate data and performance measurement data, including morbidity and mortality data. The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard to clinical privileges. When recommendation is for reduction in clinical privileges, the reason for such recommendation shall be stated and documented. b) The extent of his participation in patient care, admission of patients, and consultation shall also be considered. c) Prior to the meeting of the Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for reappointment of a member and shall also consider: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings, timely completion of records, his ethics and conduct, his cooperation with medical center personnel, his relation with other practitioners, and his general attitude towards patients, the medical center, and the public. [ ...] d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented. Section 14.2-1 b) of the Bylaws lists the Medical Executive Committee Authority and Duties, which include: 9) To review the credentials of the applicants through Credentials Committee reports and make recommendations for Staff membership, assignments to Departments, and delineation of clinical privileges; 10) To review periodically all information available, (normally by means of Credentials and Department reports), regarding the performance and clinical competence of staff members and other practitioners with clinical privileges and as a result of such reviews to make recommendations for reappointments and renewal or changes in clinical privileges.”

“MEDICAL STAFF - SELECTION CRITERIA CFR(s): 482.12(a)(6) [The governing body must] ensure that criteria for selection are individual character, competence, training, experience, and judgement. This Standard is not met as evidenced by: 36206 Based on interview and record review, the Governing Body/Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that the process articulated in the medical staff bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations), rules, or regulations which included criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners, was followed, when the Governing Body granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without verifying that the physicians met the criteria for reappointment based on individual character, competence, training, experience and judgment for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment. This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without examination of their credentials by the Medical Staff Credentials Committee as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. Findings: During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility’s Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals’ most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members are normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days. During concurrent interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the MEC (Medical Executive Committee, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board/Governing Body (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointments, but at present the Medical Staff did not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings have not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year, but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board/Governing Body, the President and the President-Elect of the MEC, but the President refused, and therefore the Board (Governing Board/Governing Body) granted a temporary 60-day reappointment to candidates in order to maintain continued patient care. During an interview on 4/18/2025 at 9:36 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: The credentialing process (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of appointing and re-appointment starts with a physician submitting an application and other required documents to the Medical Staff Office (handles the appointments of physicians). The Credentialing Committee reviews the application, and forwards the application to the Medical Staff Committee, who then makes recommendations to grant or deny privileges. The Medical Staff Committee then sends the recommendations to the Governing Board/Governing Body for approval. The CEO stated that the MEC did not meet in January, February, and March of 2025, and therefore, no recommendations were made for appointments or re-appointments. The Governing Board reached out to the MEC, but there was no response. Due to this unprecedented situation of no Credentialing Committee or Medical Executive Committee, the Governing Board wanted to ensure there was no lapse in the re-appointment of privileges and care of the patients, therefore, the Governing Board reviewed the credentialing files and decided to grant 2-month reappointments, in leu of 2-year reappointments. Some physicians were granted a second (2nd) 2-month reappointment, thereby, bypassing some steps in the usual credentialing process. During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which is due to expire on 5/31/2025. During a review of the facility’s “Governing Board,” meeting minutes, dated 1/22/2025, the meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned) indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations) ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board. During a review of the facility’s “Governing Board,” meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: There is a concern to the validation of the Credentials Report, as it may not have been approved by the Medical Executive Committee (MEC) .... there is no Credentialing Committee in existence. During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board... Article VII, Medical Staff Appointments: Section 1. Governing Board Authority. The Governing Board shall have authority and responsibility for all appointments and reappointments of the Medical Staff members and assignment of clinical privileges in accordance with these Bylaws and the Medical Staff Bylaws ... During a review of the facility’s “Medical Staff Bylaws,” dated 10/31/2020, the Medical Staff Bylaws indicated the following: 7.3-1, Reappointment Process ... In no case shall reappraisal and reappointment be greater than two (2) years from the previous reappraisal and reappointment .... 7.3-3 Reappointment Procedure. a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or Committee thereof, shall review the application for appointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care ... The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard for clinical privileges .... c) Prior to the meeting of Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for the reappointment of a member ...The Credentials Committee shall also consider the: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings ...his ethics and conduct ...his general attitude towards patients, the medical center, and the public ...The Credentials Committee shall also consider the applicant’s physical and mental health; the recommendation of the Department Chairman concerning the findings of monitoring and evaluation activities; and his fulfillment of continuing medical education requirements ... The Credentials Committee shall transmit its recommendation, in writing, to the Medical Executive Committee ... During a review of the facility’s policy and procedure (P&P) titled, “Reappointment Application Process for Medical Staff,” dated 12/1/2021, the P&P indicated the following: The Medical Staff Services Department will adhere to the processes detailed in this policy when processing applications for providers seeking reappointment to the Medical or Allied Health Professional Staff of the Hospital ...6. Shortened, Conditional Reappointment. -6.1. Medical Staff Bylaw 7.3-7 states: “Whenever any of the of the procedure authorized by these Bylaws shall have been initiated against any member of the Medical Staff who otherwise would have been a candidate for reappointment pursuant to these Bylaws, reappointment made shall be conditional in nature and the practitioner’s right to continued Medical Staff membership shall be contingent upon the outcome of the procedures authored within these Bylaws. -6.2. To support this process, the Medical Executive Committee, upon the recommendation of the Credentials Committee, may approve a shortened, conditional reappointment (less than two years), in situations where the reapplicant has demonstrated patient safety concerns related to clinical competency, professional behavior, and/or well-being. -6.2.1. In cases where a shortened, conditional reappointment is recommended, the reason, and the specific actions needed in order to qualify for reappointment after the shortened period, must be clearly articulated...”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility’s nursing staff failed to ensure that interpreter information was documented, when and if the interpreter was used to translate information regarding advance directives acknowledgement form (a form confirming that a healthcare provider has received and understands an individual’s advance directive [outlines their wishes regarding future medical treatment]), for one of 30 sampled patients (Patient 12), whose preferred written and spoken language was Korean, in accordance with the facility’s policy and procedure regarding interpreter services (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction). This deficient practice had the potential to result in Patient 12 misunderstanding the information regarding advance directives, which could compromise Patient 12’s ability to make informed decisions (means patients understand their health condition, treatment options, risks, benefits, and alternatives, allowing them to make choices aligned with their values and preferences) about their (Patient 12) healthcare. Findings: During a review of Patient 12’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility on 4/12/2025 with right chest wall pain, after falling off the bed. The H&P further indicated that Patient 12 had past medical history (PMH, a patient’s previous medical conditions, surgeries, hospitalizations, and treatments) of dementia (a condition characterized by progressive or persistent loss of intellectual functioning), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high leading to high blood pressure readings), and history of stroke (occurs when blood flow to a part of the brain is interrupted or reduced, causing damage to brain tissue). During an observation on 4/15/2025 at 3:22 p.m., with Patient 12, in Patient 12’s room, Patient 12 was observed lying down in bed, with a family member at bedside. Patient 12 did not speak English, and a translator was utilized to conduct an interview. Patient 12 verified that their preferred language (written and spoken) was Korean. During a concurrent interview and record review on 4/18/2025, at 11:02 a.m. with Nurse Manager (NM 1), Patient 12’s “Face sheet (a document the provides essential patient demographic information, including the details such as the patient’s name, date of birth, medical record number, preferred language and contact information), was reviewed. NM 1 stated that according to Patient 12’s face sheet, Patient 12’s documented primary spoken and written language was Korean. During a concurrent interview and record review on 4/18/2025 at 11:02 a.m. with Nurse Manager (NM 1), Patient 12’s electronic medical record (EMR, digital version of paper chart) titled, “Advance Directive acknowledgment form (a form confirming that a healthcare provider has received and understands an individual’s advance directive [a legal document that allows an individual to state in advance their wishes regarding future medical care shall they become incapacitated (means a person lacks the ability to make informed decisions or to manage their own affairs due to a physical or mental condition. This could be temporary or permanent, and the condition may affect their ability to perform daily tasks or make medical decision) to make medical decisions...]),” dated 4/12/2025, was reviewed.The form indicated that it was in Korean language and was dated 4/12/2025. NM 1 stated that for advance directive forms, nurses should use the interpreter (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction) as per facility’s policy if the patient’s preferred language was not English. NM 1 also said,” No interpreter use was documented on this form. I don’t speak Korean, so I don’t know what is said here, but I don’t see the interpreter identification (ID) documented. We have an English version of the form; should it be in the chart? I am not sure, but perhaps we should include a copy of the English version of the form to mirror the document. Per our policy, the patient signs in their own language, and we do have forms in the Korean language.” During a review of the facility’s policy and procedure (P&P) titled, “Interpreter Service,” dated 8/24/2024, the P&P indicated that, “Staff shall document in the patient’s electronic health record the name of the interpreter and the interpreter identification (ID) number ... If the patient feels strongly that a family member or friend can interpret, staff shall make a notation in the patient’s record that an offer of an interpreter was made and declined and enter the name of the person serving as interpreter at the patient’s request.” During a review of the facility’s policy and procedure (P&P) titled, “PATIENTS RIGHTS AND RESPONSIBILITIES,” dated 3/2023, the P&P indicated that patients have the right to considerate and respectful care and the right to respect for their cultural ... preferences... They have the right to effective communication...”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff escalated an alleged physical abuse (including hitting, slapping, pinching, and kicking) to the house supervisor, for one of 30 sampled patients (Patient 6), in accordance with the facility’s policy and procedure regarding abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Patient 6 reported to Registered Nurse (RN 5) that Certified Nursing Assistant (CNA 5) punched Patient 6 in the face. This deficient practice resulted in CNA 5 not being removed from the facility immediately and putting Patient 6 and other patients at risk for further abuse. Findings: During a review of Patient 6’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/19/2025, the H&P indicated, Patient 6 was admitted to the facility with diagnoses including but not limited to acute kidney injury (a sudden and often temporary loss of kidney function), right pleural effusion (excessive fluids accumulates in the area between the lungs and the chest wall), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin [a protein found in red blood cells that carries oxygen from the lungs to the rest of the body] in the blood, resulting in pallor [pale] and weariness) and leukocytosis (high white blood cell count). During an interview on 4/16/2025 at 10:19 a.m. with the Vice President of Quality and Risk Management (VPQRM), VPQRM stated the following: Patient 6 reported to the patient experience staff (individual whose primary focus is on ensuring a positive experience for patient and their families throughout their interactions with the facility) during morning round on 2/26/2025 that a Certified Nursing Assistant (CNA 5) punched him (Patient 6) in the face last night. The patient experience staff escalated to the department director (DIR 2) and triggered internal investigation. During the same interview on 4/16/2025 at 10:19 a.m. with the Vice President of Quality and Risk Management (VPQRM), VPQRM stated CNA 5 was placed on suspension during the facility’s investigation of the alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish). During an interview on 4/16/2025 at 11:08 a.m. with the Director (DIR 2) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), DIR 2 stated the following: on 2/26/2025 at around 10 a.m. the patient experience staff informed him (DIR 2) about Patient 6’s alleged abuse. He (DIR 2) interviewed Patient 6’s primary nurse (RN 5) from night shift (6:45 p.m. to 6:45 a.m. shift) and found out Patient 6 had reported to RN 5 that CNA 5 punched him (Patient 6) on 2/26/2025 early morning around 5 or 6 a.m. RN 5 reported the alleged abuse to the charge nurse (CN 2). However, CN 2 did not escalate to the house supervisor on duty. During the same interview on 4/16/2025 at 11:08 a.m. with the Director (DIR 2) of Medical-Surgical, DIR 2 stated RN 5 and CN 2 should have escalated to the house supervisor, so proper action could be taken including removing the alleged staff (CNA 5) from the facility immediately, for patient safety while conducting investigation. During a concurrent interview and record review on 4/18/2025 at 3:47 p.m. with the Human Resources Manager (HRM), CNA 5’s timecard record, dated 2/25/2025, was reviewed. The timecard record indicated, CNA 5 clocked in at 6:44 p.m. on 2/25/2025 and clocked out at 7:28 a.m. on 2/26/2025. HRM stated CNA 5 had completed the whole shift. HRM also stated CNA 5 should have been sent home immediately after the alleged abuse was reported in order to protect the patient and others. During a review of the facility’s policy and procedure (P&P) titled, “Abuse: Prevention, Identification, Investigation, and Protection,” dated 6/2021, the P&P indicated, “In accordance with [the facility’s] covenant of promoting and ensuring patients’ rights, [the facility] is committed to take those steps within its control to prevent and protect patient from abuse and to investigate any suspected or actual incidence of abuse to patients ... The patient/resident shall be protected from further abusive behavior by the immediate removal of the offending party from patient care areas and immediately suspension of any staff member who threatens of willfully harms a patient ... This may include the immediate removal of any employee or staff member purportedly involved in the abuse/neglect and placing the individual(s) on investigatory suspension for the duration of the ensuing review. When an allegation of abuse is reported, the appropriate department or unit leader and/or administration shall be immediately notified.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints. This deficient practice had the potential to result in lack of monitoring regarding restraints use and the potential for inappropriate or prolonged restraints use, which may result in complications such as skin breakdown (damage to the skin and underlying tissue), psychological distress, etc. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) was started on 4/14/2025 at 8:40 p.m. with indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 2:37 p.m. with the ED Clinical Educator (CE), Patient 3’s “Outpatient Care Plan (a document that outlines an individual’s assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided),” dated 4/14/2025, was reviewed. The “Outpatient Care Plan” indicated, “primary problem was suicide (hurting self) self-restraint with interventions including environmental management, violence prevention, suicide prevention and potential physical restraint.” CE stated the following: the facility’s electronic health record (EHR) had limited option of care plan for nursing staff to choose from. There was no care plan developed for Patient 3 after behavioral restraints was started. Nurse should have developed a restraint related care plan for Patient 3 to set goals and interventions in order to evaluate Patient 3’s progress and determine when restraints could be safely removed and to avoid prolonged restraint use. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 11. The use of restraint is ... in accordance with a written modification to the patient’s plan of care ... Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... plan of care/ treatment - include criteria for discontinuation when applicable.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure a physicians’ order for restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) included the indication for restraints for one of 30 sampled patients (Patients 23), in accordance with the facility’s policy regarding restraints. This deficient practice had the potential for patients to be restrained unnecessarily and may lead to lack of monitoring to determine if the restraints are still necessary in order to reduce or eliminate the need for restraints due to potential complications such as skin injury, circulation (blood flow) problems, psychological distress, etc. Findings: During a concurrent interview and record review on 4/16/2025 at 11:45 a.m. with the Nurse Manager (NM) 1, Patient 23’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/7/2025, and the physician orders, were reviewed. NM 1 stated Patient 23 was admitted to the facility on 4/6/2025 for altered mental status (a change in a person’s usual level of mental function, encompassing changes in awareness, thinking, and behavior) and confusion. Patient 23 was diagnosed with hepatic encephalopathy (brain dysfunction due to liver dysfunction, when the liver is no longer able to remove toxins from the blood). Patient 23 was placed on soft restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) to both wrists on 4/7/2025 and on 4/11/2025. NM 1 reviewed the physician’s orders for the restraints and verified that the indication for the restraint was not documented in the physician’s order. NM 1 stated that the physician order should indicate the reason for the use of restraints. During a review of Patient 23’s physician’s order dated 4/7/2025 at 5:15 a.m., the physician’s order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM 1) during an interview on 4/16/2025. During a review of Patient 23’s physician’s order dated 4/7/2025 at 5:15 a.m., the physician’s order indicated the following. Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM 1) during an interview on 4/16/2025. During a review of Patient 23’s physician’s order dated 4/11/2025 at 12:37 a.m., the physician’s order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of Patient 23’s physician’s order dated 4/11/2025 at 12:37 a.m., the physician’s order indicated the following. Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of the facility’s “Medical Staff Rules and Regulations,” dated 10/31/2020, the Rules and Regulations indicated the following: Restraints. The Physician Order Restraints form must include ... Indication for restraints based on assessment ...”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure staff assessed and evaluated a patient’s behavior when renewing a behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use, when the physician restraint renewal order and the nursing assessment did not indicate what was Patient 3’s behavior, which was indicative of immediate danger to self or others that warrants the use of restraints. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) was started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3’s “Restraint Flowsheet,” dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3’s behavior as follows: -At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless (4/14/2025) -At 11 p.m.: calm (4/14/2025) -At 1 a.m.: awake and alert (4/15/2025) -At 2 a.m.: awake and alert (4/15/2025) -At 4 a.m.: awake and alert (4/15/2025) During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025. During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patient every fifteen (15) minutes while on behavioral restraints and document what patient’s behavior warrants continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible. During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3’s “Physician Order Restraints,” dated 4/14/2025 and 4/15/2025, were reviewed. The “Physician Order Restraints” indicated the following: -On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” -On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff discontinued restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use at the earliest possible time for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints from 8:40 p.m. to 4:40 a.m. (total right [8] hours) despite Patient 3 documented as being calm and sleeping most of the time from 9:15 p.m. to 4:45 a.m. (7.5 hours) during the restraint episode. This deficient practice resulted in unnecessary restraint use on Patient 3 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and emotional distress. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint), was started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During an interview on 4/15/2025 at 2:24 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated a sitter (staff stay close to patient to perform constant observation) was required for patients on 5150-hold to provide constant observation. CNA 1 also stated a sitter would document the patient’s behavior every 15 minutes on the “Suicide (thoughts of taking one’s own life) Prevention Monitor Observation Flowsheet.” During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3’s “Restraint Flowsheet,” dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3’s behavior as follows: -At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless (4/14/2025) -At 11 p.m.: calm (4/14/2025) -At 1 a.m.: awake and alert (4/15/2025) -At 2 a.m.: awake and alert (4/15/2025) -At 4 a.m.: awake and alert (4/15/2025) During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. During a concurrent interview and record review on 4/18/2025 at 12:02 p.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3’s “Suicide Prevention Monitor Observation Flowsheet (sitter flowsheet),” dated 4/14/2025, was reviewed. The sitter flowsheet indicated Patient 3’s behavior as follows: -9 p.m. behavior: awake and agitated (4/14/2025) -9:15 p.m. to 9:45 p.m. behavior: awake and calm (4/14/2025) -10 p.m. to 11:45 p.m. behavior: sleeping (4/14/2025) -12 a.m. to 1 a.m. behavior: awake and calm (4/15/2025) -1:15 a.m. to 4:45 a.m. behavior: sleeping (4/15/2025) During the same interview on 4/18/2025 at 12:02 p.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated that based on sitter flowsheet, Patient 3 was asleep most of the time while on restraints. During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document what patient’s behavior warrants continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Assessment/Monitoring/ Care - Violent or Self-Destructive Restraints ... 2. Readiness of discontinuation of restraint - restraints are discontinued when the patient meet behavior criteria for their discontinuation - staff assist the patient to meet these criteria ... behavior criteria may include the ability of the patient to contract for safety; the patient is oriented to the environment and/or cessation of verbal threats ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff assessed and monitored one of 30 sampled patients (Patient 3), upon initiation of behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in accordance with the facility’s policy regarding restraints use, when nursing assessment started twenty (20) minutes after initiation of 4-point behavioral restraints (bilateral [both] wrists and bilateral ankles). There was no assessment completed/documented upon initiation of restraints at 8:40 p.m. on 4/14/2025. This deficient practice resulted in nursing staff not assessing and monitoring Patient 3 during the first 20 minutes during the restraint episode and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and circulation (blood flow) problem. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints to ensure patient’s safety. During a concurrent interview and record review on 4/18/2025 at 5:25 p.m. with the Chief Nursing Officer (CNO), Patient 3’s “Restraint Flowsheet,” dated 4/14/2025, was reviewed. The restraint flowsheet indicated first nursing monitoring and assessment started at 9 p.m. on 4/14/2025. The CNO stated the assessment was done late. It should be done at 8:40 p.m. when the 4-point restraint was first initiated. The CNO also said the assessment was not done every fifteen (15) minutes per facility’s policy. The CNO further said it was important to assess and monitor patient while on restraints to ensure patient’s safety. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... Assessment/Monitoring/Care - Violent or Self-Destructive Restraints ... 1. A staff member who is trained and competent assesses the patient at the initiation of restraint and every 15 minutes thereafter to include as appropriate to the type of restraint: a. signs of injury associated with application of restraint b. nutrition and hydration c. circulation and range of motion in the extremities d. vital signs e. hygiene and elimination f. physical and psychological comfort.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its physician performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in lack of evaluation of Patient 3’s response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as skin tear, dehydration, psychological distress, etc. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), Patient 3’s ED notes, dated 4/14/2025, documented by ED Physician (MD 82), was reviewed. The ED notes indicated, “shortly after arrival, patient (Patient 3) elbowed the wall and broke a plastic frame, attempted to get out of the gurney. Patient (Patient 3) was subsequently chemically sedated and restrained with 4-point restraints ... On reassessment, patient is more calm and cooperative. Restraints have been removed.” During the same interview on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), MD 2 stated the following: physician should be the one performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after patient (Patient 3) was placed on behavioral restraints. The purpose of face-to-face assessment was to evaluate patient, assess cardiovascular (condition of heart and blood vessels) status and behavioral status, evaluate patient’s response to restraints and determine the need for continuation of restraints. The face-to-face assessment should be done within an hour after behavioral restraint was initiated and documented in the notes. Based on ED notes by MD 82, it was unclear what time the reassessment was done because there was no time documented. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... Procedure ... Restraints Orders - Violent or Self Destructive ... Initiation of Restraints 1. The patient for whom restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a: a. physician ... 2. The face-to-face is to evaluate: a. the patient’s immediate situation; b. the patient’s reaction to the intervention; c. the patient’s medical and behavioral condition; and e. the need to continue or terminate the restraints; f. the need for social services referral.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its physician documented a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in lack of evaluation of Patient 3’s response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complication such as skin tear, dehydration, psychological distress, etc. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), Patient 3’s ED notes, dated 4/14/2025, documented by ED Physician (MD 82), was reviewed. The ED notes indicated, “shortly after arrival, patient (Patient 3) elbowed the wall and broke a plastic frame, attempted to get out of the gurney. Patient (Patient 3) was subsequently chemically sedated and restrained with 4-point restraints ... On reassessment, patient is more calm and cooperative. Restraints have been removed.” During the same interview on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), MD 2 stated the following: physician should be the one performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after patient (Patient 3) was placed on behavioral restraints. The purpose of face-to-face assessment was to evaluate patient, assess cardiovascular (condition of heart and blood vessels) status and behavioral status, evaluate patient’s response to restraints and determine the need for continuation of restraints. The face-to-face assessment should be done within an hour after behavioral restraint was initiated and documented in the notes. Based on ED notes by MD 82, it was unclear what time the reassessment was done because there was no time documented. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... Procedure ... Restraints Orders - Violent or Self Destructive ... Initiation of Restraints 1. The patient for whom restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a: a. physician ... 2. The face-to-face is to evaluate: a. the patient’s immediate situation; b. the patient’s reaction to the intervention; c. the patient’s medical and behavioral condition; and e. the need to continue or terminate the restraints; f. the need for social services referral... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure there was a documentation of patient’s specific behavior for one of 30 sampled patients (Patient 3), in accordance with the facility’s policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3’s behavior which was indicative of Patient 3 posing immediate danger to self or others that warrants the use of restraints. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and emotional distress. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3’s “Restraint Flowsheet,” dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3’s behavior as follows: -At 9 p.m.: agitated/ Restless (4/14/2025) -At 11 p.m.: calm (4/14/2025) -At 1 a.m.: awake and alert (4/15/2025) -At 2 a.m.: awake and alert (4/15/2025) -At 4 a.m.: awake and alert (4/15/2025) During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025. During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document what patient’s behavior warrants continued use of restraints. When patient was resting and calm, the nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible. During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3’s “Physician Order Restraints,” dated 4/14/2025 and 4/15/2025, were reviewed. The “Physician Order Restraints” indicated the following: -On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” -On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iv) [there must be documentation in the patient’s medical record of the following: ] The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure nursing staff documented the reason for placing on restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely), one of 30 sampled patients (Patient 23), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential for the patients to be restrained unnecessarily, which may result in complications such as skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), circulation (blood flow) problem, psychological distress, etc. Findings: During a concurrent interview and record review on 4/16/2025 at 11:45 a.m. with the Nurse Manager (NM) 1, Patient 23’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/7/2025, and the physician orders, were reviewed. NM 1 stated Patient 23 was admitted to the facility on 4/6/2025 for altered mental status (a change in a person’s usual level of mental function, encompassing changes in awareness, thinking, and behavior) and confusion. Patient 23 was diagnosed with hepatic encephalopathy (brain dysfunction due to liver dysfunction, when the liver is no longer able to remove toxins from the blood). Patient 23 was placed on soft restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) to both wrists on 4/7/2025 at 5 a.m. NM 1 verified the nursing documentation did not indicate the reason for use of the restraints on 4/7/2025 at 5 a.m. and 6 a.m. NM 1 also verified that the behavior that led to Patient 23 being placed on restraints was not documented on 4/7/2025 from 5 a.m. through 12 p.m. During a review of a physician’s order dated 4/7/2025 at 5:15 a.m., the physician’s order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of a physician’s order dated 4/7/2025 at 5:15 a.m., the physician’s order indicated the following: Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of Patient 23’s Flowsheet (a tool for organizing and displaying patient data over time in a structured format) titled, “Daily Assessment Inquiry,” dated 4/7/2025, the Flowsheet indicated the following. At 5 a.m., and 6 a.m., Patient 23 was on soft restraints to the right and left wrist. The indication for the restraints was not documented in the Flowsheet. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Non-Violent Behavior,” dated 8/2024, the P&P indicated the following. Document all patient information in the medical record including but not limited to ...circumstances that led to the use of restraints.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 39890 Based on interview and record review, the facility failed to ensure its Medical Staff reviewed the credentials (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and made recommendations to the Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations) The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed. This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under care of these reappointed practitioners. Findings: During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility’s Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals’ most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to healthcare practitioners, allowing them to perform certain clinical activities and procedures within a healthcare facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days. During an interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board on the reappointments, but at present, the Medical Staff does not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings have not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year (2024), but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board, the President and the President-Elect of the MEC, but the President refused, and therefore the Board granted a temporary 60-day reappointment to candidates in order to maintain continued patient care. During a telephone interview on 4/18/2025 at 9:35 a.m. with the Chief Executive Officer (CEO), who is a member of the Governing Board, the CEO stated that the issues with Medical Staff credentials stemmed from an issue with the Medical Staff election that was held at the end of last year (2024), following which the Chief of Medical Staff (the same individual who also holds the title of President of the Medical Staff and acts as Chairman of the MEC) canceled the MEC meeting and therefore the MEC never met in mid-January (2025) as normally scheduled. The CEO reported the Board requested an emergency meeting of the MEC in January (2025) to review the Medical Staff credentials but received no response from the MEC; hence the Board “had no choice but to be creative.” The CEO stated that the Board (Governing Body) reviewed the credential files and granted a 2-month reappointment extension, adding that the Board sought and received advice from the facility’s legal counsel prior to proceeding with this extension. The CEO further stated that in April (the current month), the Credentials Committee did meet, chaired by an Interim Chair, and the MEC met two days ago (4/16/2025). During a concurrent interview and record review on 4/18/2025 at 3:15 p.m., selected Medical Staff credential files, were reviewed. The CMO reported that in April (2025), the Medical Staff had a “normal” credentialing and reappointment process, with the MEC having met two days ago and the Credentials Committee two weeks ago, the latter comprised of three (3) department chairs and three (3) elected officers who voted one of the MEC members-at-large to serve as the Interim Chair of the Committee for that meeting. The CMO stated that the plan at the moment, while the Medical Staff and the Board work to resolve the current issue of dispute, is to do the same in May for the Medical Staff credentialing and reappointment, with participation of the elected officers, department chairs, and interim chair. As for the future dates beyond May, the CMO was unable to comment on the facility’s plans. During a review of the Medical Staff Bylaws, last amended and approved by the Governing Board in October 2020, indicated under Section 7.3-3 “Reappointment Procedure:” a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or a Committee thereof, shall review the application for the reappointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care, and if available, relevant practitioner-specific data compared to aggregate data and performance measurement data, including morbidity and mortality data. The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard to clinical privileges. When recommendation is for reduction in clinical privileges, the reason for such recommendation shall be stated and documented. b) The extent of his participation in patient care, admission of patients, and consultation shall also be considered. c) Prior to the meeting of the Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for reappointment of a member and shall also consider: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings, timely completion of records, his ethics and conduct, his cooperation with medical center personnel, his relation with other practitioners, and his general attitude towards patients, the medical center, and the public. [ ...] d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented. Section 14.2-1 b) of the Bylaws lists the Medical Executive Committee Authority and Duties, which include: 9) To review the credentials of the applicants through Credentials Committee reports and make recommendations for Staff membership, assignments to Departments, and delineation of clinical privileges; 10) To review periodically all information available, (normally by means of Credentials and Department reports), regarding the performance and clinical competence of staff members and other practitioners with clinical privileges and as a result of such reviews to make recommendations for reappointments and renewal or changes in clinical privileges.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure its Medical Executive Committee was held accountable for applying the criteria for privileging and appointment of eligible candidates and to make their recommendations, before the Governing Body makes a final decision to reappoint a practitioner to the medical staff when, its Medical Staff did not review the credentials (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and did not make recommendations to the Governing Board (They guide the hospital’s direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations). The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed. This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. Findings: During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility’s Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals’ most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to healthcare practitioners, allowing them to perform certain clinical activities and procedures within a healthcare facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days. During an interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates (the process of verifying a healthcare professional’s qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board/Governing Body on the reappointments, but at present, the Medical Staff does not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings had not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year (2024), but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board (Governing Board/Governing Body), the President and the President-Elect of the MEC, but the President refused, and therefore, the Board granted a temporary 60-day reappointment to candidates in order to maintain continued patient care. During a telephone interview on 4/18/2025 at 9:35 a.m. with the Chief Executive Officer (CEO), who is a member of the Governing Board/Governing Body, the CEO stated that the issues with Medical Staff credentials, stemmed from an issue with the Medical Staff election that was held at the end of last year (2024), following which the Chief of Medical Staff (the same individual who also holds the title of President of the Medical Staff and acts as Chairman of the MEC) canceled the MEC meeting and therefore, the MEC never met in mid-January (2025) as normally scheduled. The CEO reported the Board requested an emergency meeting of the MEC in January (2025) to review the Medical Staff credentials but received no response from the MEC; hence the Board “had no choice but to be creative.” The CEO stated that the Board (Governing Body) reviewed the credential files and granted a 2-month reappointment extension, adding that the Board sought and received advice from the facility’s legal counsel prior to proceeding with this extension. The CEO further stated that in April (the current month), the Credentials Committee did meet, chaired by an Interim Chair, and the MEC met two days ago (4/16/2025). During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which is due to expire on 5/31/2025. During a review of the facility’s “Medical Staff Executive Committee,” meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned), the minutes indicated there were no meeting minutes documented for the month of January 2025. During a review of the facility’s “Medical Staff Executive Committee,” meeting minutes, dated 2/19/2025, the minutes indicated the Committee chose not to recognize the Credentials Report, and did not review the report ... During a review of the facility’s “Governing Board,” meeting minutes, dated 1/22/2025, the meeting minutes indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The minutes also indicated that the medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board. During a review of the facility’s “Governing Board,” meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: The following items were voted on and approved off-cycle and require ratification: Resolution providing 60-day approval of physician’s credentials. Approval was required due to lack of MEC meeting in January 2025. During a review of “The Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital’s medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital’s legal and regulatory obligations),” last amended and approved by the Governing Board in October 2020, the Medical Staff Bylaws indicated under Section 7.3-3 “Reappointment Procedure,” the following: d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented. During a review of the facility’s “Governing Board By-Laws,” dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board ...Article VII, Medical Staff Appointments: Section 1. Governing Board Authority. The Governing Board shall have authority and responsibility for all appointments and reappointments of the Medical Staff members and assignment of clinical privileges in accordance with these Bylaws and the Medical Staff Bylaws ...”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure that one of 30 sampled patients (Patient 12), who was admitted to the facility after sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) when Patient 12 fell out of the bed and fractured a right 7th rib (broken rib), had their (Patient 12) reported pain level of 7 out of 10 (7/10- moderate pain) and 5 out of 10 (5/10-moderate pain) addressed, when Patient 12 was not provided an intervention ( any action taken to alleviate or manage pain) for pain relief, in accordance with the facility’s policy regarding pain management. This deficient practice resulted in Patient 12’s pain not being managed and had the potential for Patient 12 to be in significant discomfort and prolonged suffering, leading to increased risk of complications associated with unmanaged pain, such as respiratory issues due to shallow breathing or avoidance of moving. 2. Ensure the pain level was assessed prior to and after administering a pain medication for two of 30 sampled patients (Patients 21 and 22), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for ineffective pain relief, which may result in functional limitations (Example: reduced Mobility, etc.), prolonged discomfort, prolonged hospital stay, anxiety, etc. Findings: 1. During a review of Patient 12’s medical record (MR) titled, “ Triage (the process of rapidly evaluating patients in the emergency settings, to determine the urgency of their condition and prioritize their treatment based on a system of priorities),” dated 4/11/2025 at 9:10 p.m., the MR indicated that Patient 12 presented to the facility’s Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/11/2025 with a complaint of confusion and a fractured (broken) right 7th rib. The MR also indicated that Patient 12 presented with pain level of 7 (0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10). During a review of Patient 12’s “Emergency Department (ED) Summary Report,” dated 4/11/2025 through 4/12/2025, the report indicated that Patient 12 was assessed for the presence of pain at the following times: On 4/11/2025 at 10:22 p.m.-Pain level was 7 (ribs) On 4/11/2025 at 10:51 p.m.-Pain level was 5 (ribs) On 4/12/2025 at 1:22 a.m.-Pain level was 5 (ribs) On 4/12/2025 at 3:30 a.m.-Pain level was 5 (ribs) On 4/12/2025 at 6:10 a.m.-Pain level was 5 (ribs). During a concurrent interview and record review on 4/16/2025 at 11:18 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 12’s medical record titled, “Emergency Department (ED) Summary Report (a concise document that summarizes a patient’s experience in the Emergency Department ),” dated 4/11/2025 through 4/12/2025, was reviewed. The CAS stated that during Patient 12’s admission to the facility’s emergency department (ED), Patient 12 had an order for 1000 milligrams (mg, measuring unit) of Tylenol (a pain-relieving medication for mild to moderate pain) to be given one time, but the medication was not administered. The CAS also stated that Patient 12’s electronic medical record (EMR, digital version of paper chart) contained no nursing note indicating that Patient 12’s pain was addressed and/or Patient 12 refused an intervention for the reported pain levels of 7/10 and 5/10 from 9:10 a.m. on 4/11/2025 through 6:10 a.m. on 4/12/2025. During an interview on 4/18/2025 at 12:40 p.m. with the Emergency Department (ED) Clinical Educator (CE), the CE stated the following regarding pain management in the ED: “If a patient reports being in pain, the pain should be addressed. In the pain assessment flowsheet (a tool used to document a patient’s pain assessment, including location, intensity, quality, and other relevant factors), located under the pain tab (a section in the electronic medical records [EMR] where all pain-related assessments and interventions are recorded) nurses document pain assessment where they ask patients about their acceptable pain level and document the response there. Intervention for pain is also documented under the same pain tab. Every patient has their pain assessed every two hours because pain level and patient’s condition can change. Nursing interventions for pain can consist of providing a warm blanket or ice. Other interventions for pain should include notifying a physician, and this should also be documented under the MD (Medical Doctor) Notification tab, where nurses should record what was discussed with the provider, orders received, the name of the physician notified, and/or reasons why orders were not received.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2023, the P&P indicated the following: “Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain Management: Alleviation of pain or a reduction of pain to a level of comfort that is acceptable. For PRN (as needed) Pain Medication orders without specific pain scale, the following definitions will be utilized: Mild pain - Pain scale 1; Moderate pain - Pain scale of 4-7; Severe pain- Pain scale of 8-10. The experience of pain is highly individual and variable. The subjective level of pain will be assessed... The self-report of pain by the patient should be considered as evidence that pain is a problem to be addressed ... The nurse will utilize the assessment findings to initiate and or collaborate with physician in the appropriate non-invasive and invasive pharmacological modalities.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 3/22/2023, the P&P indicated the following: “Patients have the right to receive appropriate assessment and management of their pain, information about pain, pain relief measures and to participate in pain management decisions...” 2.a. During a concurrent interview and record review on 4/16/2025 at 10:15 a.m. with the Nurse Manager (NM) 1, Patient 21’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, was reviewed. NM 1 stated the following: Patient 21 was admitted to the facility on 4/15/2025 for weakness and headache. Patient 21 was medicated with Tylenol (acetaminophen, an over-the counter pain reliever) 500 milligrams (mg, a unit of measurement) on 4/16/2025 at 8:55 a.m. NM 1 verified that there was no pain assessment prior to or after the administration of Tylenol, which was ordered for a pain level of 1 - 3 (mild pain; [0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10]). NM 1 stated patients should be assessed for pain level prior to administering a pain medication to ensure the patient was medicated with the appropriate medication and should be reassessed an hour later to assess whether or not the pain medication was effective. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, the H&P indicated Patient 21 presented with generalized weakness and headache and was admitted for further treatment. During a review of Patient 21’s physician’s order, dated 4/15/2025, the order indicated to give Tylenol 500 mg by mouth every 4 hours as needed for pain 1 - 3 (mild pain). During a review of Patient 21’s “Medication Administration Record (MAR),” dated 4/16/25025, the MAR indicated Tylenol 500 mg was given at 8:55 a.m. There was no pain assessment documented prior to or after the administration of Tylenol. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 5/2023, the P&P indicated the following ... Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention. 2.b. During a concurrent interview and record review on 4/15/2025 at 11:09 a.m. with the Nurse Manager (NM) 1, Patient 22’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/13/2025, was reviewed. NM 1 stated Patient 22 was admitted on 4/13/2025 with acute hyponatremia (low salt [sodium] in the blood is too low, can cause nausea [urge to vomit], confusion ...), dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and stage 4 endometrial cancer (cancer that has spread beyond the uterus [womb] and other organs). Patient 22 received Ketorolac (a very strong nonsteroidal anti-inflammatory drug that treats moderately severe pain) 20 mg intravenously (IV, in the vein) for a pain level of 7 of 10 on 4/16/2025 at 1:23 a.m. There was no reassessment documented for efficacy. Patient also received Ketorolac 20 mg IV on 4/16/2025 at 9:14 a.m., no pain level was documented before and after the administration of the pain medication. NM 1 stated the pain level should be assessed before administering a pain medication and one hour later assess for efficacy. During a review of Patient 22’s physician’s order, dated 4/16/2025 at 1:14 a.m., the physician’s order indicated to give Ketorolac 20 mg, as needed for pain via intravenous push (in the vein). During a review of Patient 22’s MAR dated 4/16/2025, the MAR indicated the following: -At 1:23 a.m., the pain level was 7/10, to the abdomen, upper quadrant, right internal..., Ketorolac 20 mg was administered via IV. There was no reassessment of the pain documented in the MAR. -At 9:14 a.m., Ketorolac 20 mg was administered via IV. No pain assessment was documented prior to or one hour after administration of the medication. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 5/2023, the P&P indicated the following ... Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 22) to address Patient 22’s high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for the lack implementation of fall precautions (a multi-faceted approach to minimize the risk of falls, encompassing universal interventions for all patients, as well as individualized strategies based on specific risk factors. These precautions include ensuring a safe environment, assisting with mobility, and educating patients and their families) for Patient 22, which could result in a fall and possible serious injury or harm such fracture (broken bones), etc. Findings: During a concurrent interview and record review on 4/15/2025 at 11:09 a.m. with the Nurse Manager (NM) 1, Patient 22’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/13/2025, was reviewed. NM 1 stated Patient 22 was admitted on 4/13/2025 with acute hyponatremia (low salt [sodium] in the blood is too low, can cause nausea [urge to vomit], confusion ...), dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and stage 4 endometrial cancer (cancer that has spread beyond the uterus [womb] and other organs). The initial nursing assessment indicated Patient 22 was at high risk for fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level). NM 1 verified that a care plan for falls was not developed to address Patient 22’s high risk for falls. NM 1 stated the care plan should have been developed within 12 hours of admission, to provide independent nursing care to help the patient (Patient 22) get back to their baseline. During a review of Patient 22’s “Initial Nursing Assessment,” dated 4/13/2025 at 2:15 p.m., the nursing assessment indicated Patient 22 was at high risk of falls with a score of 45. During a review of Patient 22’s “Care Plans,” initiated on 4/13/2025, the Care Plans indicated there was no care plan addressing Patient 22’s high risk for falls. This was verified by NM 1 during an interview on 4/15/2025. During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care Documentation, Interdisciplinary,” dated 8/2022, the P&P indicated the following: Purpose: To provide guidelines in completing the Interdisciplinary care plan to ensure that each patient has a completed care plan period ...The Interdisciplinary plan of care should include: A. The RN initiates the Interdisciplinary plan of care after completion of the initial assessment. The plan of care is initiated within 12 hours of patient’s admission ... B. The Interdisciplinary plan of care will be updated every shift and as patient condition indicates. During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention and Management,” dated 4/24/2024, the P&P indicated the following: Assessment and Reassessment. 1. The patient’s fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient fall. 2. Evidence-based fall risk interventions will be implemented based upon an age-appropriate fall risk assessment tool.”

“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: 46238 Based on interview and record review the facility failed to ensure that one of 30 sampled patients (Patient 12), had their (Patient 12) pain assessment (the systemic evaluation of a patient’s pain experience, including intensity, location, quality, and acceptable level of pain) performed/assessed every four hours along with vital signs (VS, measurements of essential bodily functions including hear rate, blood pressure, respiratory rate, and temperature), in accordance with the facility’s policy and procedure regarding pain assessment and management. This deficient practice had the potential for Patient 12’s pain to be inadequately managed, leading to Patient 12’s prolonged discomfort and suffering, and a negative impact on the patient’s overall recovery (delayed healing process). Findings: During a review of Patient 12’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility on 4/12/2025 with right chest wall pain, after falling off the bed. The H&P further indicated that Patient 12 had past medical history (PMH, a patient’s previous medical conditions, surgeries, hospitalizations, and treatments) of dementia (a condition characterized by progressive or persistent loss of intellectual functioning), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high causing elevated blood pressure), and history of stroke (occurs when blood flow to a part of the brain is interrupted or reduced, causing damage to brain tissue). During further review of Patient 12’s History and Physical (H&P), dated 4/12/2025, the H&P indicated that Patient 12 had multiple rib fractures (refer to three or more broken ribs). During a concurrent interview and record review on 4/6/2025 at 10:18 a.m. a.m. with the Clinical Applications Specialist (CAS), Patient 12’s medical record titled, “Vitals Inquiry (refers to the collection and documentation of patient’s vital signs, [VS, measurements of the body’s basic functions, including body temperature, pulse rate, respiration rate, and blood pressure]),” dated 4/12/2025 (01:22 a.m.) to 4/16/2025 (8:00 a.m.), was reviewed. The record indicated that Patient 12’s VS (body temperature, pulse rate, respiratory rate [breaths per minute], and blood pressure [BP, the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]), were obtained and recorded every four hours. CAS stated that Patient 12’s record had no documentation of a pain assessment being performed and recorded every 4 hours (along with vital signs) in Patient 12’s electronic medical record (EMR). During an interview on 4/16/2025 at 11:11 a.m., with nurse manager (NM 1), NM 1 stated that patients were assessed for the presence or absence of pain every four hours (along with vital signs [VS]), and pain assessment should be recorded, along with vital signs (VS), in the patients’ medical record, in accordance with the facility’s protocol. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2023, the P&P indicated the following: The effective treatment of pain is contingent upon an accurate pain assessment. The features of pain assessment include Assessments of pain are communicated using both verbal report and written documentation ...The nurse and patient will collaboratively establish a desirable “Comfort Zone” utilizing a pain scale ... Assess pain as the 5th vital sign and as needed ... Assess pain each time vital signs are assessed ... Evaluate the efficacy of behavioral, environmental, and pharmacological interventions in a timeframe appropriate to the intervention. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2023, the P&P indicated the following: “Documentation of pain assessment/reassessment is to be documented in the Electronic Medical Record (EMR) under: a. The initial and daily assessments b. Nurse’s notes. c. With vital signs”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 21), who complained of moderate pain (4 - 7 rate out of 10 on the pain scale), was treated with a pain medication ordered to treat moderate pain, in accordance with the facility’s policy regarding pain management. Instead, Patient 21 was treated with a pain medication (Tylenol, an over-the-counter pain medication), which was ordered to treat mild pain and not moderate pain. This deficient practice resulted in inadequate pain relief for Patient 21, which also has the potential to result in prolonged discomfort, psychological distress, etc. Findings: During a concurrent interview and record review on 4/16/2025 at 10:15 a.m. with the Nurse Manager (NM) 1, Patient 21’s Medication Administration Record (MAR), dated 4/15/2025, was reviewed. NM 1 stated the following: Patient 21 was admitted to the facility on 4/15/2025 for weakness and headache. The physician ordered Tylenol 500 mg (milligrams, a unit of measurement) as needed for mild pain (1-3 out of 10 on the pain scale). The Medication Administration Record (MAR), dated 4/15/2025 at 3:48 p.m., indicated Patient 21 received Tylenol (acetaminophen, an over-the-counter pain medication) 500 milligrams (mg) for a pain level of 5 (moderate pain). NM 1 verified there was no pain medication ordered for moderate pain (4-7) and stated the nurse should have called the physician to obtain a pain medication order to treat Patient 21’s moderate pain, instead of treating Patient 21 with a medication (Tylenol) intended to treat mild pain. On 4/15/2025 at 5:36 p.m., the pain was reassessed at 3 (mild pain). NM 1 stated Patient 21 was not appropriately treated for Patient 21’s pain level. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, the H&P indicated Patient 21 presented with generalized weakness and headache and was admitted for further treatment. During a review of Patient 21’s physician’s order, dated 4/15/2025, the order indicated to give Tylenol 500 mg by mouth every 4 hours as needed for pain 1 - 3 (mild pain). During a review of Patient 21’s “MAR (Medication Administration Record),” dated 4/15/25025, the MAR indicated Tylenol 500 mg was given at 3:48 p.m., for a pain level of 5 (moderate pain). At 5:36 p.m., Patient 21’s pain level was reassessed at 3 (mild). During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 5/2023, the P&P indicated the following ... Assessment: The effective treatment of pain is contingent upon an accurate pain assessment. The patient’s report of pain. Pain is an extremely subjective experience therefore: the patient is the best judge of the intensity and relief of pain. Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention. During a review of the facility’s policy and procedure (P&P) titled, “Medication System Pharmacy Responsibilities,” dated 9/28/2022, the P&P indicated each new order should be carefully reviewed for clarity and therapeutic correctness. All unclear orders or unusual dosages should be questioned and brought to the attention of the prescriber.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that the medical record for one of 30 sampled patients (Patient 14), contained pertinent information when: 1. The administration site for 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions [behavior, mood, thoughts, and perception]), for one of 30 sampled patients (Patient 14), was not documented, in accordance with the facility’s policy regarding documentation of medication administration. This deficient practice had the potential to compromise Patient 14’s safety due to lack of communication among healthcare providers and lack of monitoring for the potential adverse events and complications at the injection site (Example: infection, nerve damage, allergic reactions, etc.). 2. There was no correctly filled out behavioral restraint (interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others) physician order(s) and restraint assessment documentation containing all the necessary elements (justification for restraint use, type of restraints, duration of restraint, monitoring requirements, and alternatives considered), for one of 30 sampled patients (Patient 14), in accordance with the facility’s policy and procedure regarding behavioral restraints assessment and documentation. This deficient practice had the potential to result in Patient 14’s increased risk of harm due to inappropriate continuation of restraints, exposing the patient (Patient 14) to physical and psychological harm. Additionally, without proper assessment and documentation, changes in Patient 14’s condition may go unnoticed, increasing the risk of complications such as injury (example: skin breakdown- damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture`), emotional distress and/or death. Findings: 1. During a review of Patient 14’s History of Present Illness (HPI, refers to a detailed narrative of a patient’s current health problem, including when it began, the symptoms experienced, and any changes over time), dated 4/14/2025, the HPI indicated that Patient 14 was admitted to the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/14/2025 due to a complaint of altered mental status (AMS, a significant change in a person’s normal cognitive [thinking, reasoning, remembering] function) and concerns for hallucinations ( an experience involving the apparent perception of something not present). During a review of Patient 14’s Medication Administration Record (MAR), dated 4/16/2025, the MAR indicated that Patient 14 was given 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions) for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) that was ordered to be given intramuscularly (IM, within or into a muscle, specifically referring to the action of administering something (like a medication) into the muscle tissue). During an interview on 4/16/2025 at 11:50 a.m. with Clinical Applications Specialist Nurse (CAS), CAS reviewed Patient 14’s Medication Administration Record (MAR), dated 4/16/2025, for the administration of 5 mg of Haldol (administered on 4/16/2025 at 6:58 a.m.), and verified that the nurse who administered 10 mg of Haldol via intramuscular (IM), did not document the administration site in the MAR in the allocated space. During an interview on 4/18/2025 at 12:56 p.m. with the Clinical Educator Nurse (CE), the CE stated the following regarding the documentation of an injection site when administering intramuscular (IM) medications: “The administration site for IM medications should be documented in the MAR. If a patient develops a reaction such as infection or cellulitis (a bacterial infection of the deeper layers of skin and underlying tissues) at the injection site, we are able to trace back to identify the specific location of the injection (crucial for assessing potential causes of any adverse reactions and ensuring appropriate follow-up care or interventions).” During a review of the facility’s policy and procedure (P&P) titled, “Medication System Nursing Responsibilities and Administration Guidelines,” dated 9/2022, the P&P indicated the following: “Each professional administering a medication to a patient has the responsibility to accurately document... proper administration as prescribed in the patient’s electronic Medication Administration Record (MAR)...” 2. During a review of Patient 14’s History of Present Illness (HPI, refers to a detailed narrative of a patient’s current health problem, including when it began, the symptoms experienced, and any changes over time), dated 4/14/2025, the HPI indicated that Patient 14 was admitted to the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/14/2025 due to a complaint of altered mental status (AMS, a significant change in a person’s normal cognitive function) and concerns for hallucinations (an experience involving the apparent perception of something not present). During a review of Patient 14’s medical record (MR) titled, “5150 Hold (a 72-hour involuntary detention period for mentally distressed individuals in approved facilities),” dated 4/15/2025, the MR indicated that Patient 14 was placed on the involuntary 5150 hold on 4/15/2025 at 1:00 p.m. due to danger to self and gravely disabled (GD, means a condition where a person, as a result of a mental health disorder or a severe substance use disorder, is unable to provide for their basic needs for food, clothing, or shelter, or cannot provide for their personal safety or necessary medical care) and required transfer to a psychiatric facility for further treatment and evaluation. During a review of Patient 14’s medical record (MR), on 4/16/2025 at 11:50 a.m., with the Clinical Applications Specialist Nurse (CAS), Patient 14’s medical record titled, “Physician’s Orders,” dated 4/15/2025 a.m., was reviewed. The MR indicated that Patient 14 had four (4) orders for a Restraint Device: 1. Soft Wrist Right, 2. Soft Wrist Left; 3. Soft Ankle Right and 4. Soft Ankle Left: placed at 1:54 a.m. on 4/15/2025. The order did not indicate whether the restraints were classified as violent or non-violent (which is crucial for determining the appropriate context and guidelines for use: Violent restraints applied when a patient poses an immediate threat to themselves or others due to aggressive behavior, while non-violent restraints are used to prevent patients from inadvertently harming themselves due to medical conditions or lack of capacity to understand risks). Additionally, the order did not contain an explanation of the justification for the use of restraints. The CAS verified that the four orders for a Restraint Device, did not indicate whether the order was meant for violent or non-violent restraints use and did not indicate the justification for the use of 4-point restraints (use of restraints on all four limbs simultaneously). The CAS stated that no other orders for restraints were found in Patient 14’s electronic medical record (EMR) from 4/12/2025 through 4/16/2025. During a concurrent interview and record review on 4/16/2025 at 11:50 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 14’s Electronic Medical Record (EMR) was reviewed to locate the documentation of the 4-point restraint assessment (a comprehensive evaluation to ensure the use of restraints is justified, monitored, and evaluated according to facility’s policy). The CAS stated that no documentation of patient 14’s restraint assessment was found recorded on 4/15/2025 in Patient 14’s EMR. During a concurrent interview and record review on 4/16/2025 at 11:55 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 14’s medical record (MR) titled, “Social Worker Notes,” dated 4/16/2025 at 11:02 a.m., was reviewed. The MR indicated that Patient 14 was placed on four-point restraints and sedated (the process of using medication to induce a state of calmness, relaxation, or drowsiness) due to agitation (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing). During a concurrent interview and record review on 4/18/2025 at 9:19 a.m. with the Nurse Manager (NM 1), Patient 14’s paper charting documentation of the restraint assessment was reviewed, and the assessment indicated the following: -On 4/14/2025, Patient 14 was in 4-point restraints from 9:00 p.m. through 4/15/2025 at 5:00 a.m. due to being aggressive and combative. -On 4/16/2025 Patient 14 was in 4-point restraints at 12:02 p.m. for 1 hour and 15 minutes due to aggressive behavior. Blood pressure was obtained at 12:02 p.m., and Patient 14 was documented to be agitated and combative. During the same interview on 4/18/2025 at 9:19 a.m. with the Nurse Manager (NM) 1, NM 1 stated that according to Patient 14’s assessment record, Patient 14’s restraint assessment documentation was recorded every two hours, and only visual observations were initialed every 15 minutes (min) during the time Patient 14 remained in behavioral restraints (behavioral restraints are interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others). During a concurrent interview and record review on 4/18/2025 at 10:41 a.m. with the Director of the Emergency Department (Dir 1), Patient 14’s Physician’s Restraint Orders (paper format), dated 4/14/2025 through 4/16/2025, were reviewed. The Dir 1 reviewed the orders and confirmed that Patient 14 was placed in behavioral 4-point restraints, that were meant to be applied for up to 4 hours, due to combative and aggressive behavior. The Dir 1 also stated that the criteria for discontinuing restraints was not marked on the physician’s order form for restraints. The Dir 1 stated that Physician’s Restraint Orders were not filled out correctly. The Dir 1 said: “The physician should define the type of restraints to be applied and indicate when the restraints can be discontinued. For violent restraints, assessment of the patient should be done every 15 min, and patient should be one- to-one (1:1, a nurse provides constant supervision and direct care to a single patient) with the nurse. The criteria for discontinuation of the restraints should be specified and documented on the physician’s order. The Dir 1 then reviewed the facility’s policy regarding violent restraint use and stated, “Violent restraint orders can be placed for up to 4 hours, and the criteria for the discontinuation of the order should be specified by the physician. Assessment should be done every 15 minutes, according to the policy.” During an interview on 4/18/2025 at 12:40 p.m. with the Emergency Department (ED) Clinical Educator (CE), the CE stated the following regarding violent and non-violent restraints orders and the required restraints assessments: “Physicians are used to signing the paper order form for placing orders for restraints, but the expectations for the physicians are to place orders for restraints in the patient’s electronic medical record. We only recently had our annual skills fair training on restraints, where we discussed the non-violent versus (vs) violent restraints orders and assessments. The order for violent (behavioral restraints) should be renewed every 4 hours and placed in EMR as well. Part of the assessment for violent restraints is to assess and document justification for restraint use, vital signs (VS), level of consciousness, skin condition and patient’s condition every 15 minutes.” The CE also stated that nurses can and should document restraints assessment in the patients’ the electronic medical records (EMR). During a review of the facility’s policy and procedure (P&P) titled, “Restraints: VIOLENT Behavior,” dated 12/2021, the P&P indicated the following: “3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. ASSESSMENT / MONITORING / CARE - Violent or Self-Destructive Restraints 1. A staff member who is trained and competent assesses the patient at the initiation of restraint and every 15 minutes thereafter to include as appropriate to the type of restraint: a. Sign of injury associated with application of restraint b. Nutrition and hydration c. Circulation and range of motion in the extremities d. Vital signs e. Hygiene and elimination f. Physical and psychological comfort 2. Readiness for discontinuation of restraint - restraints are discontinued when the patient meets behavior criteria for their discontinuation - staff assist the patient to meet these criteria a. Behavior criteria may include the ability of the patient to contract for safety; the patient is oriented to the environment and/or cessation of verbal threats. 3. Monitoring is done through continuous in-person observation by an assigned staff member who is competent and trained (see training section). Documentation: Use available electronic health records {EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to: - Assessments and care provided - Alternative attempted - Circumstances that led to use restraint/seclusion - Physician/family notifications - Monitoring activities - include each 15 min assessment as applicable...””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure there was documentation of a patient’s specific behavior for one of 30 sampled patients (Patient 3), when the physician restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) renewal order and the nursing assessment, did not indicate what was Patient 3’s behavior that would indicate that Patient 3 was posing immediate danger to self or others, in accordance with the facility’s policy regarding restraints use and documentation. This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours on 4/15/2025) and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. Findings: During a review of Patient 3’s “Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician),” dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility’s emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) shortly after arrival to ED. During a review of Patient 3’s “Physician Order Restraints,” dated 4/14/2025, the “Physician Order Restraints” indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) were started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During a review of Patient 3’s “Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff),” dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025. During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3’s “Restraint Flowsheet,” dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3’s behavior as followed: At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless -At 11 p.m.: calm -At 1 a.m.: awake and alert (4/15/2025) -At 2 a.m.: awake and alert (4/15/2025) -At 4 a.m.: awake and alert (4/15/2025) During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025. During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document patient’s behavior that warrant continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible. During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3’s “Physician Order Restraints,” dated 4/14/2025 and 4/15/2025 were reviewed. The “Physician Order Restraints” indicated the following: -On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” -On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically.” During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Violent Behavior,” dated 12/2021, the P&P indicated, “To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients’ rights ... Policy ... 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure two of 30 sampled patients’ (Patient 12, and Patient 17) medical records contained appropriate documentation of assessments and findings when: 1. For Patient 12, pain assessment was not recorded in Patient 12’s medical record, along with vital signs (VS, measurements of the body’s most basic functions), obtained and documented every 4 hours, in accordance with the facility’s policy regarding pain assessment and documentation. This deficient practice compromised Patient 12’s medical record integrity by undermining the completeness and accuracy of the documentation, essential for effective patient care and pain management. In addition, this deficient practice had the potential for Patient 12’s pain to be unrecognized, leading to inadequate pain management and delayed interventions that could prevent complications related to unmanaged pain. 2. For Patient 17, the medical record contained no nursing documentation of Patient 17 sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) in the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries), during Patient 17’s hospital stay on 1/22/2025, in accordance with the facility’s policy regarding fall prevention and management. In addition, Patient 17 sustained an open left ankle fracture (a type of bone fracture [broken] where the bone breaks through the skin, exposing the fracture site to the outside environment). This deficient practice had the potential to result in Patient 17’s condition and injury to be overlooked by providers, potentially leading to complications arising from the fall and fracture, such as infection and impaired healing, adversely affecting Patient 17’s health and care. Findings: 1. During a review of Patient 12’s medical record (MR) titled, “ Triage (the process of rapidly evaluating patients in the emergency settings, to determine the urgency of their condition and prioritize their treatment based on a system of priorities),” dated 4/11/2025 at 9:10 p.m., the MR indicated that Patient 12 presented to the facility’s Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/11/2025 with a complaint of confusion and a fractured (broken) right 7th rib. The MR also indicated that Patient 12 presented with pain level of 7/10 (0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10). During a review of Patient 12’s “Emergency Department (ED) Summary Report,” dated 4/11/2025 through 4/12/2025, the report indicated that Patient 12 was assessed for the presence of pain at the following times (along with vital signs [VS, measurements of the body’s basic functions, including body temperature, pulse rate, respiration rate, and blood pressure]): -On 4/11/2025 at 10:22 p.m.-Pain level was 7/10 (ribs) -On 4/11/2025 at 10:51 p.m.-Pain level was 5/10 (ribs) -On 4/12/2025 at 1:22 a.m.-Pain level was 5/10 (ribs) -On 4/12/2025 at 3:30 a.m.-Pain level was 5/10 (ribs) -On 4/12/2025 at 6:10 a.m.-Pain level was 5/10 (ribs) During a review of Patient 12’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility (inpatient admission- the process of a patient being admitted to a hospital for overnight care and treatment) on 4/12/2025 (at 6:50 a.m.) with a diagnosis of right chest wall pain. The H&P indicated that Patient 12 had multiple rib fractures (refer to three or more broken ribs). During a concurrent interview and record review on 4/16/2025 at 10:18 a.m. a.m. with the Clinical Applications Specialist (CAS), Patient 12’s medical record titled, “Vitals Inquiry (refers to the collection and documentation of a patient’s vital signs [VS]), dated 4/12/2025 (01:22 a.m.) to 4/16/2025 (8:00 a.m.), was reviewed. The record indicated that Patient 12’s VS (body temperature, pulse rate, respiratory rate [breaths per minute], and blood pressure [BP, the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]), were obtained and recorded every four hours. The CAS stated that Patient 12’s record had no documentation of a pain level assessment that was recorded (along with vital signs) every 4 hours from 4/12/2025 to 4/16/2025. During an interview on 4/16/2025 at 11:11 a.m. with nurse manager (NM 1), NM 1 stated that patients were assessed for the presence or absence of pain every four hours (along with vital signs), and pain level assessment should be recorded, along with vital signs (VS), in the patients’ medical record, in accordance with the facility’s protocol. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2023, the P&P indicated the following: The effective treatment of pain is contingent upon an accurate pain assessment. The features of pain assessment include Assessments of pain are communicated using both verbal report and written documentation ...The nurse and patient will collaboratively establish a desirable “Comfort Zone” utilizing a pain scale ... Assess pain as the 5th vital sign and as needed ... Assess pain each time vital signs are assessed ... During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2023, the P&P indicated the following: “Documentation of pain assessment/reassessment is to be documented in the Electronic Medical Record (EMR) under: a. The initial and daily assessments b. Nurse’s notes. c. With vital signs 2. During a review of Patient 17’s Emergency Department (ED) Summary Report (a document that summarizes a patient’s ED visit, including their medical history, the course of treatment, and follow-up plans), dated 1/21/2025 through 1/23/2025, the ED Summary Report indicated that Patient 17 arrived at the Emergency Department on 1/21/2025 at 11:18 p.m. During a review of Patient 17’s History of Present Illness (HPI, a chronological account of a patient’s current medical problem, including the development of symptoms, from the first sign to the present), dated 1/22/2025, the HPI indicated that Patient 17 presented to the Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) with a chief complaint of left ankle pain after Patient 17 tripped and fell (a patient fall is an unplanned descent to the floor with or without injury), twisting the left ankle. The HPI indicated that Patient 17 complained of pain in the left ankle. The HPI also indicated that Patient 17 was alert and oriented x 4 (oriented to place, time, person, and event), speaking in full sentences, and had intact skin and had a left ankle with obvious deformity, tender to palpation (a medical examination technique that involves feeling or touching a specific area of the body to detect abnormalities). During further review of Patient 17’s History of Present Illness (HPI), dated 1/22/2024, the HPI indicated the following: “Initial X-ray of the ankle showed evidence of fracture or dislocation. Second x-ray (use of radiation to create images of the inside of the body) shows worse in the fracture or dislocation, open fracture...I was informed by nursing staff that patient (Patient 17) was found on the floor adjacent to the gurney. Patient [Patient 17] was evaluated on the floor, with a now obvious open fracture of the left ankle...For open fracture, I discussed case emergently with our on-call orthopedic surgeon (who advised to reduce the fracture [a procedure to line up the ends of a broken bone without the need for surgery] and transfer out to trauma center [a hospital unit specialized in treating patients with severe and life-threatening traumatic injuries], for higher level of care [HLC, a more intensive and specialized type of treatment or service than what is typically offered in outpatient settings or primary care]). Procedural sedation manual reduction of the open fracture left ankle was performed.” During review of Patient 17’s Emergency Department (ED) Progress Note (EDPN), dated 1/22/2025, the EDPN indicated that Patient 17 was re-evaluated at bedside and found to have “the medial malleolus (bony prominence located on the inner side of the ankle) appears to be protruding noticeably through the skin (bone is visibly displayed) surface with angulation (foot is angled outward, away from the midline of the body) of the foot laterally” and underwent second manual reduction of the left ankle open fracture. The EDPN also indicated on 1/22/2025 at 4:42 p.m., Patient 17 continued to remain in the facility’s emergency department (ED) pending transfer to a trauma center. During a review of Patient 17’s Emergency Department (ED) Progress Note (EDPN), dated 1/23/2025, the EDON indicated that on 1/23/2025, at 10:00 a.m., Patient 17 signed out against medical advice (AMA, a patient chooses to leave before their doctor has recommended discharge, even though the doctor believes they need further care) due to a delay in transfer...”Patient stated...would like to go to a nearby trauma center with the help of a friend...” During a concurrent interview and record review on 4/18/2025 at 11:51 a.m. with the Nurse Manager (NM 1), Patient 17’s electronic medical record (EMR) was reviewed in an attempt to find late documentation regarding Patient 17’s sustained fall in the Emergency Department on 1/22/2025. The NM 1 stated that Patient 17’s EMR contained no documentation indicating that on 1/22/2025, Patient 17 sustained a fall (that resulted in an open ankle fracture) in the Emergency Department, while admitted for the left ankle dislocation. The NM 1 also verified that there was no nursing note that indicated that Patient 17 fell in the Emergency Department. The NM 1 also verified that aside from the physician’s progress note, dated 1/22/2025, when the physician documented that “nursing staff informed them [the physician] of Patient 17 being found on the ground,” Patient 17’s EMR contained no other record that would indicate that a fall was sustained by Patient 17 during the admission stay in the facility’s ED on 1/22/2025. During an interview on 4/18/2025 at 12:20 p.m. with the Risk Manager (RM), the RM stated that she (RM) remembered the case and stated the following: “I remember this case. This fall incident was reported to risk management through the internal incident reporting channel (a confidential way for employees to raise concerns about potential wrongdoing without fear of retaliation, promoting transparency and accountability within the organization) and at that time, I had been here for a week and a half. I assigned the case to be investigated to the Emergency Department (ED) leadership and the director of the ED signed off on it. This was reported as a witnessed fall, as the patient came in with ankle injury, and needed to go to the bathroom. The patient [Patient 17] refused the bedpan, or something did not work, and the patient was provided with a bedside commode. When the patient got up, she (Patient 17) fell, and the report says that the gurney’s siderail was down. The patient [Patient 17] sustained an open fracture as a result of the fall.” During an interview on 4/18/2025, at 12:40 p.m. with the Clinical Educator (CE), the CE stated the following regarding the content of patient medical records after a fall: “After a fall, the charge nurse and the house supervisor get informed, and nurses fill out an incident report and a fall debriefing tool (designed to systemically analyze the circumstances surrounding the fall to identify contributing factors and areas for improvement in care). Charge nurse then, should conduct a post-fall huddle to discuss the event and gather additional insights. The physician is notified of the fall to assess and re-assess the patient and to evaluate the extent of any injuries. Nurses should document all the objective data, perform their own assessment, and document the findings in the records. Pain assessment and vital signs are a must after a fall. Nurses should also document who was notified regarding the fall, and all documentation should be thorough to facilitate further evaluation in the event of a change in the patient’s condition.” During a review of the facility’s policy and procedure (P&P) titled,” Fall Prevention and Management,” dated 4/2024, the P&P indicated the following: “F. Post Fall Management 1. Assessment a. Immediately perform and document complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries. Identify changes from pre-fall status. d. Monitor patient for any effects of the fall e. Reassess patient as appropriate, including physical and neuro status f. Conduct Post Fall Debrief, and complete Post Fall Debrief Form. Ask the patient what happened, if patient able to self-report. Information may be used to prevent repeat falls 2. Notify a. Notify the Licensed Independent Provider immediately at the time of the fall. Provide the following: i. Change in neurological status and vital signs; ii. Injury or complaint of pain; iii. Anti-coagulation medication; and iv. Obtain order(s) for medical interventions/ diagnostic procedures b. Follow chain of command c. Patient’s representative as appropriate d. Risk Management/Patient Safety Officer- if the patient fall results in one of the following: i. Significant injury involving higher level of care or medical/surgical intervention ii. Confirmed injury by diagnostic test iii. Death 3. Documentation a. Assessment of patient’s condition, patient’s explanation of what happened, name and time the Licensed Independent Provider and family (if appropriate) was notified, and any interventions initiated by the Licensed Independent Provider or nurse. b. Initiate or update the interdisciplinary plan of care (ipoc) c. Re-assessment of patient d. Complete an online event report e. Complete Post Fall Debriefing Form for all falls and send original to Unit Manager/Director f. Manager/Director will review and send to Risk Management/ Patient Safety Officer/ or designee”

“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: 46333 Based on interview and record review, the facility failed to: 1. Ensure one of 21 sampled patients (Patient 1), received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screen exam (MSE, a medical evaluation to determine if an emergency condition exits) upon returning to the emergency department (ED, a hospital area that designed to provide immediate medical care) for a second visit. Patient 1 visited the ED three times within 34 hours and 57 minutes: - First visit: 5/4/2024, at 7:46 p.m.- Discharged home - Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed - Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac or respiratory arrest) was called, but despite resuscitation efforts, Patient 1 did not survive. This deficient practice resulted in the facility’s inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient’s 1 death. (Refer to A-2406) 2. Ensure that one of 21 sampled patients (Patient 9), who was transferred to a trauma center (facility that treats critical injuries threatening life or limbs), had the required: - “Transfer Summary Form (is a document that outlines a patient’s critical medical information when they are being moved from one healthcare facility to another, ensuring the receiving facility has all necessary details about the patient’s diagnosis, current condition, medications, treatment plan, and any relevant allergies to provide seamless and safe continuity of care)” and -The “Patient Transfer Acknowledgement/Medical Transfer Consent (is a document that allows a patient to be transferred to another facility for care. The document ensures that the patient’s care is continuous and appropriate to their needs),” completed, in accordance with the facility’s policy and procedure titled, “Transfer of Patients From Emergency Department.” This deficient practice resulted in a lack of documented medical justification for the transfer, failure to ensure Patient 9 was informed of the risks and benefits, and absence of a required patient or witness signature. Additionally, the receiving physician’s name was not documented, further compromising the appropriateness and coordination of the transfer. By failing to complete the required transfer documentation, the facility violated federal regulations designed to protect patients from being transferred in an unstable condition without proper medical oversight. This deficient practice deprived Patient 9 of their right in making informed medical decision (when a patient has made a choice about their healthcare after fully understanding their medical condition, the potential benefits and risks of different treatment options, and any available alternatives, allowing them to actively participate in the decision-making process with their healthcare provider based on their personal values and priorities), increased the risk of a breakdown in continuity of care, and created the potential for serious harm, including delays in treatment, medical deterioration enroute, and compromised Patient 9’s safety upon arrival at the receiving facility. (Refer to A-2409) Findings: 1. During a review of Patient 1’s “ED Note History of Present Illness (HPMC, a description of the progression of the patient’s present illness from the first sign and symptom to the present),” documented by ED provider (MD)1, dated 5/4/2024 at 8:06 p.m. (first visit), the “HPMC” indicated: - Patient 1 was brought in by paramedics (emergency medical personnel trained to provide care and transport). - Patient 1 initially called police due to disturbance of neighbor but told responders that he “just did not feel right.” - Patient 1 reported using methamphetamine (stimulant that speeds up body’s system that is highly addictive) earlier that day. - ER Course: Patient 1 was given 2 (unknown if this is referring to 2 milligram or 2 dose) Ativan (lorazepam, a sedative used to treat anxiety and agitation). - Patient 1 felt improved with the above therapy ... “Stable for discharge home.” - Patient 1 was discharged at 9:21 p.m. (1 hour and 15 minutes after arrival for the first visit). During a review of Patient 1’s “ED Progress Note,” documented by ED provider (MD- Medical Doctor)1, dated 5/5/2024 at 12:30 a.m. (second visit), the note indicated: -Patient 1 stated he wanted to “go home and go to bed” and felt calmer during the previous discharge. -Shortly after, Patient 1 was found “passed out (a temporary loss of consciousness [state of being awake and aware of one’s surroundings])” outside the hospital and was brought back into the ED. - Upon return, Patient 1 was extremely agitated (restless, unable to stay calm), raising suspicion of another episode of methamphetamine use. - “Patient (Patient 1) was sedated with: Ativan (lorazepam)- a medication that produce a calming effect on the brain, Benadryl (a medication used to treat allergy that have a sedative effects), and Haldol (a medication used to treat agitation and psychosis [a mental health condition characterized by a loss of contact with reality]), and psychiatric (a mental health evaluation to assess behavior and thinking), and patient is now pending sobering.” The medications were administered at 12:53 a.m. MD 1 also ordered labs. During a concurrent interview and record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), Patient 1’s “ED Lab Results,” dated 5/5/2024, were reviewed. The laboratory report indicated abnormal levels (test results that fall outside the normal range for a given test), as follows: - Creatinine (a waste product in the blood that comes from muscle tissue and protein digestion): 5.39 H (high level) Reference range (a set of values that indicates what’s considered normal for a lab test result): 0.70-1.30 mg/dL (milligrams per deciliter is a unit of measurement). - White Blood (a type of blood cell that play a crucial role in the body’s system to protects the body from infections and other diseases) 30.3 H (high level) Reference range: 3.6-10.2 K/uL (kilo per microliter, a unit of measurement). -Estimated glomerular filtration rate (eGFR, measures kidney function): 10.7 - (End Stage kidney disease level, the final stage of chronic kidney disease, where the kidneys are no longer functioning adequately to support the body’s needs, typically indicated by an estimated glomerular filtration rate (eGFR) of less than 15, requiring dialysis or a kidney transplant). Reference range: eGFR<15mL (milliliter, a unit of measurement) indicates end-stage renal failure During the same interview on 2/5/2025 at 11:00 a.m. with the Director of ED (DED), the DED confirmed that the lab results were abnormal but that there was no documented evidence that providers reviewed or discussed these results with Patient 1. During a concurrent interview and record review on 2/5/2025 at 10:00 a.m. with Registered Nurse (RN) 3, Patient 1’s “Vitals Flowsheet (a digital document within a patient’s electronic medical record [EMR] that records and tracks a patient’s vital signs [like temperature, blood pressure, heart rate, and respiratory rate] over time),” dated 5/5/2024, was reviewed. The Vitals Flowsheet indicated that at 2:00 a.m., Patient 1 was tachycardic (a condition where the heart beats abnormally fast), heart rate (HR, the number of times the heart beats per minute) was 112, and at 4:00 a.m., HR was 116. RN 3 confirmed that there was no documented evidence that this was addressed. During a concurrent interview and electronic medical record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED confirmed the following: -Patient 1 did not receive a triage which included assigning ESI level (a number that indicates how urgent a patient’s condition is and how many resources they need), assessment, and vital signs. -Vital signs were only recorded at 2:00 a.m. on 5/5/2024, 90 minutes after arrival (second visit). -There was no documented evidence of a medical screening examination (MSE) from 5/5/2024 at 12:30 a.m., and through discharge on 5/5/2024 at 11:11 a.m. (10 hours and 41 minutes, the duration of the second visit). During the same interview on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED stated this occurred because Patient 1 was not officially discharged from the electronic medical system (a digital system that stores and manages a patient’s medical history). The Director of ED stated Patient 1 should have been discharged from the electronic medical record during the first encounter from 7:46 p.m. to 8:57 p.m. (1st ED visit), and Patient 1 should have been re-triaged upon arrival to the ED on 5/5/2024 at 12:30 a.m. (2nd encounter). During a record review of Patient 1’s “ED Progress Note,” dated 5/5/2024 at 11:07 a.m., documented by MD 3, the ED Progress Note indicated, Patient 1 was discharged home by MD 3 (2nd discharge) at 11:11 a.m. During an interview on 2/6/2025 at 2:00 p.m. with MD 3, MD 3 stated she (MD 3) discharged Patient 1 based on Patient 1’s clinical appearance, noting that Patient 1 “looked better and was improving.” MD 3 verified that she could not recall if she checked the abnormal labs nor was it was documented that she reviewed the abnormal lab results. During a concurrent interview and record review on 2/5/2025 at 11:15 a.m. with the DED, Patient 1’s electronic medical record (EMR), dated from 5/5/2024 at 12:30 a.m. (time of arrival to ED on second visit) through 5/5/2024 at 11:11 a.m. (time of discharge from second visit), was reviewed. DED confirmed that: - There was no documented evidence that lab results were reviewed or discussed with Patient 1 before discharge. -There was no documentation from MD 2 (who assumed care from 1:00 a.m. to 6:00 a.m.). -There was no hand-off report (a structured communication process where one doctor transfers critical information about a patient’s medical status, current treatment plan, and any necessary next steps to another doctor, typically occurring when a patient is transitioning care between different shifts) between MD 1 to MD 2, or MD 2 to MD 3. During an interview with Security guard (SS) 1on 2/5/2025 at 3:15 p.m., SS1 confirmed that on 5/5/2024 at 6:38 p.m., Patient 1 was found lying outside the ED on the grass. SS1 stated SS1 checked on Patient 1. Patient 1 was unconscious (lacking awareness and the capacity for sensory perception as if asleep or dead and was not responding). SS1 stated SS1 informed ER staff nurses, and RN 1 responded within a minute, transporting Patient 1 into the ED on a gurney (third visit, on 5/5/2024 at 6:38 p.m.). During an interview on 2/6/2025 at 11:44 a.m. with the Medical Director of ED (MDED), MDED stated providers rely on the triage to review the Emergency Severity Index (ESI) level to determine patient priority. Triage provides current vital signs and chief complaints (is the primary symptom or concern described by a patient that prompts them to seek medical attention) which the providers use to cross-reference with patient’s reported complaint. MDED also confirmed that abnormal labs result should be reviewed and discussed with the patient prior to discharge. Additionally, MDED stated that a handoff must occur between providers to ensure continuity of care for pending labs, diagnostics, and treatment recommendations. During an interview on 2/6/2025 at 1:00 p.m. with RN 1, RN 1 stated Patient 1 was without a pulse (the number of heart beats per minute). CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) was initiated on 5/5/2024 at 6:38 p.m. Patient 1 was taken into the ED. A Code Blue was called. During a review of Patient 1’s “Code Blue Record (documents the interventions and clinical condition of a patient during a medical emergency),” dated 5/5/2024, the record indicated, CPR was initiated on 5/5/2024 at 6:38 p.m. At 7:16 p.m., Patient 1 required CPR again. CPR was stopped at 7:24 p.m., despite resuscitation efforts, Patient 1 did not survive. During a review of the facility’s Department of Emergency Medicine Rules and Regulations, dated 11/1/2028, the record indicated, “All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists. Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner) are authorized to perform the medical Screening Examination (MSE) initiation, and must determine whether the patient has a medical condition of sufficient severity ...” During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept,” dated 4/26/2023, the P&P indicated, “To establish the following guidelines:o For safe and expedient triage process, when rapidly identifying adult (> 14 years of age) and pediatric patients (S14 years of age) with urgent life-threatening conditions.o For performing Emergency Department (ED) assessments and reassessments, for initial and ongoing care, and/or observation of patients in treatment areas, or of those waiting placement for a treatment area. Triage- is the process of collecting pertinent information about patients who are seeking Emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity designation system according to the type and urgency of the patient’s medical condition. (Emergency Nurses Association (2011) Emergency Nursing Scope and Standards of Practice) ... Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. The patient’s physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Room Screening Registration,” dated 6/23/2023, the P&P indicated, “(name of the facility’s) policy to provide an emergency medical screening examination to any individual who comes to the Emergency Department, or who presents on HPMC property, to determine whether an “emergency medical condition” or active labor exists, regardless of ability to pay. 1.The patient will be entered into Paragon at time of triage, with minimal information a. Patient Name b. Date of Birth c. Complaint 2.The patient will receive initial triage by an RN. 3.Upon completion of the Medical Screening Exam (MSE), the Admitting Representative will update the registration screens with updated demographic and financial information...” 2. During a review of Patient 9’s “ED Note History of Present Illness (HPMC, a description of the progression of the patient’s present illness from the first sign and symptom to the present),” dated 7/28/2024, the “HPMC” indicated, Patient 9 “who denies any past medical history presenting to the emergency department for evaluation after he was hit by a car. Patient (Patient 9) is unable to give any specific details regarding the incident ...multiple abrasions all over body otherwise grossly normal ...Patient (Patient 9) has moderate-to-severe soft tissue swelling to his face with left facial abrasions, trismus (also known as lockjaw, is a condition that makes it hard to open your mouth) and a left chin laceration (cut in the skin). Patient (Patient 9) placed in a C-collar (also known as a cervical collar or neck brace, is a medical device that supports and limits neck movement). Given the concern for intracranial pathology (injury that affects the brain or the structures within the skull) and the mechanism of action, patient (Patient 9) meets criteria for a 911 re-triage to a trauma center. Case was discussed by charge nurse with (name of the receiving facility) who accepts this patient (Patient 9).” During a concurrent interview and electronic medical (EMR, a digital version of a patient’s medical history, including diagnoses, medications, allergies, immunizations, and treatment plans) record review on 2/7/2025 at 11:20 a.m. with the Manager of the Emergency Department (MED), MED confirmed that there was no documented informed consent of Patient 9 or witness acknowledging the medical transfer. Additionally, there was no evidence of a completed physician certification outlining the risks and benefits of the transfer. MED confirmed that Patient 9 was transferred for a higher-level of care (a hospital capable of providing diagnostic, interventional or tertiary care beyond the capacity of the hospital from which a patient originates) to the trauma center (a specialized hospital unit equipped and staffed to treat patients with severe, life-threatening injuries sustained from car accidents, gunshot wounds, etc.). The MED also validated that a transfer form should have been completed to indicate that the risks and benefits of the transfer were discussed with Patient 9. During a concurrent interview and record review on 2/7/2025 at 4:35 p.m. with the Director of the Emergency Department (DED), Patient 9’s EMR was reviewed. The DED confirmed that there was no documented evidence of the name of the physician at the receiving facility who will resume care for Patient 9. During a review of the facility’s “(Name of the facility) Authorization for and Consent to Transfer,” blank transfer form dated 8/2023, the form included the following: Your/the patient’s undersigned physician has recommended that you/the patient be transferred to ____ by ___Your/the patient’s care has been accepted by____ PHYSICIAN CERTIFICATION FOR TRANSFER: the undersigned physician, have examined and evaluated this patient and hereby certify that I have discussed the transfer described in this consent form with this patient (or the patient’s legal representative), Including: 1. Risk and Benefits of transfer were explained to patient; 2. All questions have been answered; 3. Any adverse effects that may reasonably be expected to occur during transfer; 4. Reasonable alternatives and the relevant risks, benefits related to transfer including not receiving care of treatment. PHYSICIAN SUMMARY: Receiving Facility: __________________ Accepting Physician: __________________ Time Contacted; ___________________ On call Physicians Who Failed to Appear ____________ During a concurrent interview and record review on 2/7/2025 at 4:40 p.m. with the Director of the Emergency Department (DED), the facility’s policy and procedure (P&P) titled, “Transfer of Patients from Emergency Department,” dated 5/22/2029, was reviewed. The P&P indicated, “It is the responsibility of the treating physician to ensure that all transfers for immediate care of an individual to another care facility are carried out in accordance with EMTALA Regulations. Once emergency evaluation and treatment have been provided, transfer may be considered if the individual is stabilized or, the individual has requested a transfer or the physician has certified that the transfer is for a higher level of care ... Informed Consent: Patient Transfer Acknowledgement/Medical Transfer Consent: Where the individual or where applicable, the individual’s LRP, both orally and in writing of the recommended transfer and the reasons thereof. If an individual’s physical or mental condition is such that it is not possible to notify the individual, and the individual is unaccompanied, the Hospital shall make reasonable effort to locate an LRP in order to notify that person of the intended transfer. An acknowledgement by the individual or the LRP of such notification and consent to the transfer should be included on the “Patient Transfer Acknowledgement Form/Medical Transfer Consent”... Stable Patients: Informed Request for Transfer for Non-Medical Reasons: Recommended Transfer for Medical Reasons: A Qualified Medical Person recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer. The transfer may then occur if the individual or LRP consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risks and benefits of the transfer on the “Transfer Summary Form.” Discussion With Receiving Facility/Physician: A representative of the receiving facility must have confirmed that: The receiving facility has available space and qualified personnel to treat the individual. The ED RN or ED RN Case Manager will document the time, date, and name of the person they verify this information with from the receiving facility on the nurses’ notes-EHR Clinical Care Station. The name of the accepting physician, room/ bed assignment and telephone number for RN-to-RN report will also be documented in EHR Clinical Care Station b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. c. Where the individual has an emergency medical condition, the receiving physician must agree to accept and treat the individual. The name of the receiving physician will be documented on the transfer record...” The DED confirmed that the name of the physician at the receiving facility should be documented on transfer form.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to post written notice or signage informing 21 of 21 sampled patients of their right to receive a medical screening examination (the initial examination a patient receives when they go the Emergency Department), stabilizing treatment and an appropriate transfer, regardless of their ability to pay, in an area of the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) likely to be noticed by patients in the ED. This deficient practice had the potential for patients, who were waiting in the waiting room, to not be informed of their rights when they visit the ED seeking treatment for a medical condition. Findings: During an observation on 2/4/2025 at 2:10 p.m. in the Emergency Department (ED), the signage informing patients of their right to a medical screening, stabilizing treatment ...regardless of their ability to pay was posted to the far-right side of the ED, in a hallway, where no patients were waiting or passing through. Patients waited in the waiting room, in front of the Registration window, located on the left side of the ED. The signage was not visible to patients waiting in the ED waiting room (Patients/Visitors have to go to the hallway where the signage was posted to be able to read the signage). During a concurrent interview on 2/4/2025 at 2:10 p.m. with the Director of the Emergency Department (DED), DED verified that the signage was posted in a hallway and would “probably not” be noticed by patients entering the ED or waiting in the waiting room, as well as patients brought in by ambulance. The DED stated the signage notifies patients of their right to be medically screened and receive medical treatment. The DED verified there were no other signs posted in the ED. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights, Medical Screening Exam (MSE),” dated 8/24/2023, the P&P indicated the following: Posting Signs. The Hospital will post signs likely to be noticed by all individuals entering the Emergency Department as well as those individuals waiting for examination and treatment, signs in clear and simple terms in multiple languages appropriate to the community ...”

“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: 46333 Based on interview and record review, the facility failed to ensure one of 21 sampled patients (Patient 1), received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screen exam (MSE, a medical evaluation to determine if an emergency condition exits) upon returning to the emergency department (ED, a hospital area that designed to provide immediate medical care) for a second visit. Patient 1 visited the ED three times within 34 hours and 57 minutes: - First visit: 5/4/2024, at 7:46 p.m.- Discharged home - Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed - Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac or respiratory arrest) was called, but despite resuscitation efforts, Patient 1 did not survive. This deficient practice resulted in the facility’s inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient’s 1 death. On 2/7/2025 at 9:51 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s non-compliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Nursing Officer (CNO), Director of Quality and Risk management (DQRM), Manager of Risk Management (MRM), and Chief Information Officer (CIO). The IJ was related to the facility’s failure to ensure that Patient 1, who was brought in by paramedics to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for general malaise received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and a medical screening exam (MSE, a medical evaluation to determine if an emergency condition exits) by a provider for a second visit. Patient 1 visited the ED three times within 34 hours and 57 minutes: - First visit: 5/4/2024, at 7:46 p.m.- Discharged home - Second visit: 5/5/2024, at 12:30 a.m. - Discharged home without a triage or MSE to determine whether an emergency medical condition existed. - Third visit: 5/5/2024, at 6:43 p.m. -Found unresponsive outside the facility On the third visit, Patient 1 was found unresponsive (not reacting or responding to stimulation) on the facility lawn. A Code Blue (a hospital emergency alert for a patient in cardiac [heart stops beating] or respiratory arrest [not breathing]) was called, but despite resuscitation efforts (the medical actions taken to revive someone who has experienced cardiac arrest), Patient 1 did not survive. This deficient practice resulted in the facility’s inability to determine whether an emergency medical condition existed due to the lack of a triage and MSE, leading to Patient 1 being discharged with an unknown health condition/status, which potentially contributed to Patient’s 1 death. On 2/07/2025 at 5:26 p.m. p.m., while onsite, the IJ was removed in the presence of the CEO, COO, CNO, VPQR, MRM, and CIO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan included the following: Emergency Department (ED) Registration Process o A new ED Registration Process and Procedures guide was created by the Admitting Manager as a quick reference for staff, following the Admitting (Patient Access), Registration Process, Patient” policy. Key elements: o Once a patient is discharged, their visit number becomes inactive. o Nurses are responsible for discharge; the system removes the patient from the tracker. Once the patient is removed from the tracker, the encounter is no longer active and can no longer be utilized. o If the patient needs to come back inside the ED and be seen again for treatment, the patient will need to be re-registered per the “Admitting (Patient Access), Registration Process, Patient” policy. Training & Education: oRegistration staff were trained in May 2024 oRe-education on policy and quick reference sheet for our staff on February 6, 2025. oA visual aid was posted in admitting areas. oPerson Responsible: Admitting Director Nursing Assessment/ Re-assessment: o Beginning February 7, 2025 to ensure “Every patient arriving to the ED is a new encounter, requiring triage, intake information, and vital signs must be done again. The provider will then provide MSE for each patient. Person Responsible: Director, ED and ICU (Intensive Care Unit- handles severe, potentially life-threatening cases) o ED Policy Review Attestation Education was implemented for all new ED nurses, registry, and staff, added to the mandatory onboarding, covering: “Hand-Off (the process of transferring responsibility for a patient’s care from one healthcare provider to another)/SBAR Communication (Situation, Background, Assessment, Recommendation- a communication tool that helps people structure information into a consistent format)” “Notification to providers for critical laboratory, and any other critical diagnostic test results, or a change in patient status as appropriate” “Shift change report, for intra-procedural changes, or change of assignment within a shift. “The handoff will be documented and will be retained in the patient’s medical record.” Assessment & Re-assessment in critical patients: o Upon arrival to unit, patient will have chief complaint and vital signs assessed o A registered nurse (RN) completes the initial assessment within 15 minutes of admission and documents findings in the electronic health record (EHR- digital version of paper chart). o Reassessment is completed by RN and documented in EHR every 2 hours for: stability, complexity, predictability, vulnerability, resiliency o Chain of Command o All physicians and staff have the responsibility and authority to immediately intervene to protect the safety of a patient or to prevent a medical error. Person Responsible: Director, ED and ICU; Director, Education Department Discharge Instructions Updates: o Modified to ensure triage, MSE, labs, and diagnostics are reviewed with the patient prior to discharge. o Patient signature required only after all items are completed; a copy of the signed Discharge Instructions will be kept as part of the EHR. Person Responsible: Manager, Informatics systems; Director, ED & ICU o Nurses trained on the new process; patients cannot be discharged until validation is complete. Person Responsible: Director, ED & ICU Physician Education: On May 25, 2024, ED physicians received training on: o Hand-off process: Reviewing all patients, pertinent labs/diagnostics, diagnosis, and disposition. o Use SBAR (Situation, Background, Assessment, Recommendations) - why was this patient here? What studies/interventions have been done? What are they pending and what are your recommendations? o Oncoming physician assesses all signed out patients. o Document assumption of care on signed out patients. Person Responsible: Co-Associate ED Medical Director o New template has been provided along with attestations to ensure they are aware of the new template that must be used for each patient that is signed off. Re-education to all ED physicians regarding the facility’s Department of Emergency Medicine Rules and Regulations, “All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists” was conducted to ensure all new encounters receive a new MSE. Person Responsible: ED Medical Director Audit Process: 20 charts per week will be reviewed to ensure proper handoff documentation. Compliance reports will be submitted weekly to the ED Medical Director, VP of Quality and Risk, and the Chief Medical Officer will be provided weekly to review compliance. Person Responsible: Quality Department Findings: During a review of Patient 1’s “ED Note History of Present Illness (HPMC, a description of the progression of the patient’s present illness from the first sign and symptom to the present),” documented by ED provider (MD)1, dated 5/4/2024 at 8:06 p.m. (first visit), the “HPMC” indicated: - Patient 1 was brought in by paramedics (emergency medical personnel trained to provide care and transport). - Patient 1 initially called police due to disturbance of neighbor but told responders that he “just did not feel right.” - Patient 1 reported using methamphetamine (stimulant that speeds up body’s system that is highly addictive) earlier that day. - ER Course: Patient 1 was given 2 (unknown if this is referring to 2 milligram or 2 dose) Ativan (lorazepam, a sedative used to treat anxiety and agitation). - Patient 1 felt improved with the above therapy ... “Stable for discharge home.” - Patient 1 was discharged at 9:21 p.m. (1 hour and 15 minutes after arrival for the first visit). During a review of Patient 1’s “ED Progress Note,” documented by ED provider (MD)1, dated 5/5/2024 at 12:30 a.m. (second visit), the note indicated: -Patient 1 stated he wanted to “go home and go to bed” and felt calmer during the previous discharge. -Shortly after, Patient 1 was found “passed out (a temporary loss of consciousness [state of being awake and aware of one’s surroundings])” outside the hospital and was brought back into the ED. - Upon return, Patient 1 was extremely agitated (restless, unable to stay calm), raising suspicion of another episode of methamphetamine use. - “Patient (Patient 1) was sedated with: Ativan (lorazepam)- a medication that produce a calming effect on the brain, Benadryl (a medication used to treat allergy that have a sedative effects), and Haldol (a medication used to treat agitation and psychosis [a mental health condition characterized by a loss of contact with reality]), and psychiatric (a mental health evaluation to assess behavior and thinking), and patient is now pending sobering.” The medications were administered at 12:53 a.m. MD 1 also ordered labs (laboratory tests). During a concurrent interview and record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), Patient 1’s “ED Labs Results,” dated 5/5/2024, were reviewed. The laboratory report indicated abnormal levels (test results that fall outside the normal range for a given test), as follows: - Creatinine (a waste product in the blood that comes from muscle tissue and protein digestion): 5.39 H (high level) Reference range (a set of values that indicates what’s considered normal for a lab test result): 0.70-1.30 mg/dL (milligrams per deciliter is a unit of measurement). - White Blood (a type of blood cell that play a crucial role in the body’s system to protects the body from infections and other diseases) 30.3 H (high level) Reference range: 3.6-10.2 K/uL (kilo per microliter, a unit of measurement). -Estimated glomerular filtration rate (eGFR, measures kidney function): 10.7 - (End Stage kidney disease level, the final stage of chronic kidney disease, where the kidneys are no longer functioning adequately to support the body’s needs, typically indicated by an estimated glomerular filtration rate (eGFR) of less than 15, requiring dialysis or a kidney transplant). Reference range: eGFR<15mL (milliliter, a unit of measurement) indicates end-stage renal failure During the same interview on 2/5/2025 at 11:00 a.m. with the Director of ED (DED), the DED confirmed that the lab results were abnormal but that there was no documented evidence that providers reviewed or discussed these results with Patient 1. During a concurrent interview and record review on 2/5/2025 at 10:00 a.m. with Registered Nurse (RN) 3, Patient 1’s “Vitals Flowsheet (a digital document within a patient’s electronic medical record [EMR] that records and tracks a patient’s vital signs [like temperature, blood pressure, heart rate, and respiratory rate] over time),” dated 5/5/2024, was reviewed. The Vitals Flowsheet indicated that at 2:00 a.m., Patient 1 was tachycardic (a condition where the heart beats abnormally fast), heart rate (HR, the number of times the heart beats per minute) was 112, and at 4:00 a.m., HR was 116. RN 3 confirmed that there was no documented evidence that this was addressed. During a concurrent interview and electronic medical record review on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED confirmed the following: -Patient 1 did not receive a triage which included assigning ESI level (a number that indicates how urgent a patient’s condition is and how many resources they need), assessment, and vital signs. -Vital signs were only recorded at 2:00 a.m., 90 minutes after arrival (second visit). -There was no documented evidence of a medical screening examination (MSE) from 5/5/2024 at 12:30 a.m., and through discharge on 5/5/2024 at 11:11 a.m. (10 hours and 41 minutes, the duration of the second visit). During the same interview on 2/5/2025 at 11:00 a.m. with the Director of the Emergency Department (DED), the DED stated this occurred because Patient 1 was not officially discharged from the electronic medical system (a digital system that stores and manages a patient’s medical history). The Director of ED stated Patient 1 should have been discharged from the electronic medical record during the first encounter from 7:46 p.m. to 8:57 p.m. (1st ED visit), and Patient 1 should have been re-triaged upon arrival to the ED on 5/5/2024 at 12:30 a.m. (2nd ED visit). During a record review of Patient 1’s “ED Progress Note,” dated 5/5/2024 at 11:07 a.m., documented by MD 3, the ED Progress Note indicated, Patient 1 was discharged home by MD 3 (2nd discharge) at 11:11 a.m. During an interview with MD 3, MD 3 stated she (MD 3) discharged Patient 1 based on Patient 1’s clinical appearance, noting that Patient 1 “looked better and was improving.” MD 3 verified that she could not recall if she checked the abnormal labs nor was it was documented that she reviewed the abnormal lab results. During a concurrent interview and record review on 2/5/2025 at 11:15 a.m. with the DED, Patient 1’s electronic medical record (EMR), dated from 5/5/2024 at 12:30 a.m. (time of arrival to ED on second visit) through 5/5/2024 at 11:11 a.m. (time of discharge from second visit), DED confirmed that: - There was no documented evidence that lab results were reviewed or discussed with Patient 1 before discharge. -There was no documentation (a physician progress note, a document that records a patient’s condition, care plan, and treatment updates) from MD 2 (who assumed care from 1:00 a.m. to 6:00 a.m.). -There was no hand-off report (a structured communication process where one doctor transfers critical information about a patient’s medical status, current treatment plan, and any necessary next steps to another doctor, typically occurring when a patient is transitioning care between different shifts) between MD 1 to MD 2, or MD 2 to MD 3. During an interview with Security guard (SS) 1on 2/5/2025 at 3:15 p.m., SS1 confirmed that on 5/5/2024 at 6:38 p.m., Patient 1 was found lying outside the ED on the grass. SS1 stated SS1 checked on Patient 1. Patient 1 was unconscious (lacking awareness and the capacity for sensory perception as if asleep or dead and was not responding). SS1 stated SS1 informed ER staff nurses, and RN 1 responded, transporting Patient 1 into the ED on a gurney (third visit). During an interview on 2/6/2025 at 11:44 a.m. with the Medical Director of ED (MDED), MDED stated providers rely on the triage to review the Emergency severity Index (ESI) level to determine patient priority. Triage provides current vital signs and chief complaints (is the primary symptom or concern described by a patient that prompts them to seek medical attention) which the providers use to cross-reference with patient’s reported complaint. MDED also confirmed that abnormal labs result should be reviewed and discussed with the patient prior to discharge. Additionally, MDED stated that a handoff must occur between providers to ensure continuity of care for pending labs, diagnostics, and treatment recommendations. During an interview on 2/6/2025 at 1:00 p.m. with RN 1, RN 1 stated Patient 1 was without a pulse (the number of heart beats per minute). CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) was initiated. Patient 1 was taken into the ED. A Code Blue was called. During a review of Patient 1’s “Code Blue Record (documents the interventions and clinical condition of a patient during a medical emergency),” dated 5/5/2024, the record indicated, CPR was initiated on 5/5/2024 at 6:38 p.m. At 7:16 p.m., Patient 1 required CPR again. CPR was stopped at 7:24 p.m., despite resuscitation efforts, Patient 1 did not survive. During a review of the facility’s Department of Emergency Medicine Rules and Regulations dated 11/1/2028, the record indicated, “All patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capability of the Emergency Services Department to determine whether or not an emergency medical condition exists. Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner) are authorized to perform the medical Screening Examination (MSE) initiation, and must determine whether the patient has a medical condition of sufficient severity ...” During a review of the facility’s policy and procedure (P&P) titled, “Triage, Assessment and Reassessment Standards, Emergency Dept,” dated 4/26/2023, the P&P indicated, “To establish the following guidelines:o For safe and expedient triage process, when rapidly identifying adult (> 14 years of age) and pediatric patients (S14 years of age) with urgent life-threatening conditions.o For performing Emergency Department (ED) assessments and reassessments, for initial and ongoing care, and/or observation of patients in treatment areas, or of those waiting placement for a treatment area. Triage- is the process of collecting pertinent information about patients who are seeking Emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity designation system according to the type and urgency of the patient’s medical condition. (Emergency Nurses Association (2011) Emergency Nursing Scope and Standards of Practice) ... Triage assessments are done to determine the patient’s need for care, the type of care required and the need for further assessment. The patient’s physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Room Screening Registration,” dated 6/23/2023, the P&P indicated, “(name of the facility’s) policy to provide an emergency medical screening examination to any individual who comes to the Emergency Department, or who presents on HPMC property, to determine whether an “emergency medical condition” or active labor exists, regardless of ability to pay. 1.The patient will be entered into Paragon at time of triage, with minimal information a. Patient Name b. Date of Birth c. Complaint 2.The patient will receive initial triage by an RN. 3.Upon completion of the Medical Screening Exam (MSE), the Admitting Representative will update the registration screens with updated demographic and financial information...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that one of 21 sampled patients (Patient 9), who was transferred to a trauma center (facility that treats critical injuries threatening life or limbs), had the required: - “Transfer Summary Form (is a document that outlines a patient’s critical medical information when they are being moved from one healthcare facility to another, ensuring the receiving facility has all necessary details about the patient’s diagnosis, current condition, medications, treatment plan, and any relevant allergies to provide seamless and safe continuity of care)” and -The “Patient Transfer Acknowledgement/Medical Transfer Consent (is a document that allows a patient to be transferred to another facility for care. The document ensures that the patient’s care is continuous and appropriate to their needs),” completed, in accordance with the facility’s policy and procedure titled, “Transfer of Patients From Emergency Department.” This deficient practice resulted in a lack of documented medical justification for the transfer, failure to ensure Patient 9 was informed of the risks and benefits, and absence of a required patient or witness signature. Additionally, the receiving physician’s name was not documented, further compromising the appropriateness and coordination of the transfer. By failing to complete the required transfer documentation, the facility violated federal regulations designed to protect patients from being transferred in an unstable condition without proper medical oversight. This deficient practice deprived Patient 9 of their right in making informed medical decision-making, increased the risk of a breakdown in continuity of care, and created the potential for serious harm, including delays in treatment, medical deterioration enroute, and compromised Patient 9’s safety upon arrival at the receiving facility. Findings: During a review of Patient 9’s “ED Note History of Present Illness (HPMC, a description of the progression of the patient’s present illness from the first sign and symptom to the present),” dated 7/28/2024, the “HPMC” indicated, Patient 9 “who denies any past medical history presenting to the emergency department for evaluation after he was hit by a car. Patient (Patient 9) is unable to give any specific details regarding the incident ...multiple abrasions all over body otherwise grossly normal ...Patient (Patient 9) has moderate-to-severe soft tissue swelling to his face with left facial abrasions, trismus (also known as lockjaw, is a condition that makes it hard to open your mouth) and a left chin laceration (cut in the skin). Patient (Patient 9) placed in a C-collar (also known as a cervical collar or neck brace, is a medical device that supports and limits neck movement). Given the concern for intracranial pathology (injury that affects the brain or the structures within the skull) and the mechanism of action, patient (Patient 9) meets criteria for a 911 re-triage to a trauma center. Case was discussed by charge nurse with (name of the receiving facility) who accepts this patient (Patient 9).” During a concurrent interview and electronic medical (EMR, a digital version of a patient’s medical history, including diagnoses, medications, allergies, immunizations, and treatment plans) record review on 2/7/2025 at 11:20 a.m. with the Manager of the Emergency Department (MED), MED confirmed that there was no documented informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) of Patient 9 or witness acknowledging the medical transfer. Additionally, there was no evidence of a completed physician certification outlining the risks and benefits of the transfer. MED confirmed that Patient 9 was transferred for a higher-level of care (a hospital capable of providing diagnostic, interventional or tertiary care beyond the capacity of the hospital from which a patient originates) to the trauma center (a specialized hospital unit equipped and staffed to treat patients with severe, life-threatening injuries sustained from car accidents, gunshot wounds, etc.). The MED also validated that a transfer form should have been completed to indicate that the risk and benefit of the transfer were discussed with Patient 9. During a concurrent interview and record review on 2/7/2025 at 4:35 p.m. with the Director of the Emergency Department (DED), Patient 9’ EMR was reviewed. The DED confirmed that there was no documented evidence of the name of the physician at the receiving facility that will resume care for Patient 9. During a review of the facility’s “(Name of the facility) Authorization for and Consent to Transfer,” blank transfer form dated 8/2023, the form included the following: Your/the patient’s undersigned physician has recommended that you/the patient be transferred to ____ by ___Your/the patient’s care has been accepted by____ PHYSICIAN CERTIFICATION FOR TRANSFER: the undersigned physician, have examined and evaluated this patient and hereby certify that I have discussed the transfer described in this consent form with this patient (or the patient’s legal representative), Including: 1. Risk and Benefits of transfer were explained to patient; 2. All questions have been answered; 3. Any adverse effects that may reasonably be expected to occur during transfer; 4.Reasonable alternatives and the relevant risks, benefits related to transfer including not receiving care of treatment. PHYSICIAN SUMMARY: Receiving Facility: __________________ Accepting Physician: __________________ Time Contacted; ___________________ On call Physicians Who Failed to Appear ____________ During a concurrent interview and record review on 2/7/2025 at 4:40 p.m. with the Director of the Emergency Department (DED), the facility’s policy and procedure (P&P) titled, “Transfer of Patients from Emergency Department,” dated 5/22/2029, was reviewed. The P&P indicated, “It is the responsibility of the treating physician to ensure that all transfers for immediate care of an individual to another care facility are carried out in accordance with EMTALA Regulations. Once emergency evaluation and treatment have been provided, transfer may be considered if the individual is stabilized or, the individual has requested a transfer or the physician has certified that the transfer is for a higher level of care... Informed Consent: Patient Transfer Acknowledgement/Medical Transfer Consent: Where the individual or where applicable, the individual’s LRP, both orally and in writing of the recommended transfer and the reasons thereof. If an individual’s physical or mental condition is such that it is not possible to notify the individual, and the individual is unaccompanied, the Hospital shall make reasonable effort to locate an LRP in order to notify that person of the intended transfer. An acknowledgement by the individual or the LRP of such notification and consent to the transfer should be included on the “Patient Transfer Acknowledgement Form/Medical Transfer Consent”... Stable Patients: Informed Request for Transfer for Non-Medical Reasons: Recommended Transfer for Medical Reasons: A Qualified Medical Person recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer. The transfer may then occur if the individual or LRP consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risks and benefits of the transfer on the “Transfer Summary Form.” Discussion With Receiving Facility/Physician: A representative of the receiving facility must have confirmed that: The receiving facility has available space and qualified personnel to treat the individual. The ED RN or ED RN Case Manager will document the time, date, and name of the person they verify this information with from the receiving facility on the nurses’ notes-EHR Clinical Care Station. The name of the accepting physician, room/ bed assignment and telephone number for RN-to-RN report will also be documented in EHR Clinical Care Station b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. c. Where the individual has an emergency medical condition, the receiving physician must agree to accept and treat the individual. The name of the receiving physician will be documented on the transfer record...” The DED confirmed that the name of the physician at the receiving facility should be documented on transfer form.”

“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: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to perform nursing assessments (a process where a nurse gathers, sorts and analyzes a patient’s health information), including vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) upon admission, as ordered by the physician and per the facility’s policy regarding assessment and reassessment for one of three sampled patients (Patient 1) who was admitted to the Labor and Delivery unit (L&D, a unit that specializes in childbirth). In addition, the facility failed to report changes in Patient 1’s condition immediately when Pitocin (oxytocin, a medication to induce labor [last stage of pregnancy when muscles of the womb start to push the baby out or childbirth]) was discontinued, and when Patient 1 experienced abnormal fetal heart strip reading and continuous decelerations (abrupt decreases in fetal [unborn baby] heart rate which can indicate umbilical cord compression [when the baby’s weight puts pressure on the cord during pregnancy or labor and can restrict blood flow and oxygen to the baby] and fetal distress [changes in heart rate, movement, etc.]). These deficient practices resulted in Patient 1 delivering a baby (Patient 2) who was not breathing, had no heart rate, was limp, and cyanotic (bluish color indicating lack of oxygen). Patient 2 was taken to the Neonatal Intensive Care Unit (NICU, unit that specializes in providing intensive (critical) medical care to newborns) and transferred to an outside hospital for a higher level of care. Patient 2 passed away at the outside hospital. (Refer to A-0392) 2. The facility failed to assess a patient who presented to the Labor and Delivery Unit (L&D, a unit that specializes in childbirth) in a timely manner (within 10 minutes) for one of three sampled patients (Patient 3). Patient 3 arrived at the L&D unit at 8:37 a.m., on 12/12/2023 and was first evaluated by a nurse at 4:15 p.m., 8 hours after arriving at the L&D unit. This deficient practice had the potential for an emergency medical condition (EMC, example: heart attack, excessive bleeding, etc.) to go unidentified by nursing staff and could delay treatment and result in harm. (Refer to A-0392) 3. The facility failed to ensure Registered Nurse 9 (RN 9) and Registered Nurse 10 (RN 10) were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) of 30 sampled patients (Patient 27). This deficient practice had the potential to result in an inadequate return of blood from the dialysis machine (a machine that removes blood from the body and filters it [referring to the blood] through a dialyzer [an artificial kidney], and then returns the blood to the body) to the patient (Patient 27) causing harm or even death during hemodialysis treatment. (Refer to A-0397) 4. The facility failed to ensure three of three sampled Patients (Patients 8, 11 and 13) received nursing care interventions and assessments per facility policy to promote wound healing, when: a. Patients 8, 11, and 13 were not repositioned/turned every two hours. b. Patient 8 had no admission and biweekly ongoing wound photographs, assessments, and measurements. c. Patient 8 had no daily wound assessment documentation. These deficient practices had the potential to compromise Patient 11’s and Patient 13’s wound healing progression, and resulted in Patient 8’s sacral and right buttock wounds becoming larger in size, with Patient 8’s sacral wound progressing from a Stage III (Full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) to an unstageable (unable to stage, full thickness tissue loss in which the base of the ulcer is covered by slough- yellow, tan, gray, green or brown- and/or eschar- tan, brown or black) pressure ulcer. (Refer to A-0398) 5. The facility failed to ensure two of two Crash Carts (Crash cart 1- adult Crash Cart and Crash Cart 2- neonatal [relating to newborn children] Crash Cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Labor and Delivery Unit (L&D, a floor of the hospital responsible for the provision of medical care for patients arriving to deliver a baby) were checked every shift per facility’s policy to ensure emergency supplies, equipment, and medications were readily available in the event of an emergency. This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Surgical Services was met as evidenced by: 1. The facility failed to ensure to correctly count and document surgical count of sponges (an absorbent pad used during operations and surgical procedures) for one of 30 sampled patients (Patient 16) in accordance with accepted standards of practice and with the facility’s policies and procedures regarding surgical counts (count of items during surgery which is an essential practice to ensure patient safety). This deficient practice resulted in Patient 16 undergoing another procedure to reopen the incision (a surgical cut into the skin) to remove the remaining sponge inside Patient 16’s abdominal cavity and had the potential to compromise Patient 16’s health and wellbeing. (Refer to A-0951) 2. The facility failed to ensure a Physician provided ongoing monitoring and treatment for one of 30 sampled Patients (Patient 1) and ensure Patient 1 received medical care in a safe and effective manner. Patient 1 required emergency Cesarean Section (C-section, surgical delivery of a baby) due to Fetus (unborn baby) bradycardia (slow heart rate; Normal fetal heart rate is between 110-160 beats per minute). This deficient practice had the potential to place all newborn patients at risk for serious injury, harm, or death. (Refer to A-0951) 3. The facility failed to ensure a properly executed informed surgical consent was in the medical record for one of 30 sampled patients (Patient 5), prior to Patient 5’s Cesarean Section (C-section, surgical delivery of a baby), in accordance with the facility’s policy and procedure regarding obtaining an informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). This deficient practice had the potential for the surgical team to perform the wrong procedure on Patient 5 and had the potential for Patient 5 to not be fully informed of the type of surgical procedure/s she (Patient 5) was having. (Refer to A-0955) The cumulative of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment”

“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: 36206 Based on interview and record review the facility failed to have a documented evidence that one of 30 sampled patients (Patient 5) was fully informed of the type of anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) to be used during a surgical procedure. The “Anesthesia Consent (a form in which the patient acknowledges agreement to treatment such as the use of anesthesia that is recommended by the physician),” did not indicate the type of anesthesia to be used and the physician failed to certify that informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) had been obtained and that risks of anesthesia were discussed with Patient 5. This deficient practice had the potential for Patient 5 to not be fully informed of the type of anesthesia used and the risks of the anesthesia. Findings: During a review of Patient 5’s Face Sheet (a document that gives a patient ’ s information at a quick glance), dated 12/10/2023 at 6:02 a.m., the Face Sheet indicated Patient 5 was admitted to obstetric (a branch of medicine specialized in the care of pregnant women and childbirth) service for a scheduled Cesarean Section (C-section, surgical delivery of a baby). During a review of Patient 5’s “Pre-Operative History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/10/2023, the H&P indicated Patient 5 was 39 weeks pregnant (40 weeks is full term), admitted to the Labor & Delivery (L&D, a unit that specializes in childbirth) area for a repeat C-section. During a review of Patient 5’s “Consent for Anesthesia,” dated 12/10/2023 at 6:53 a.m., the consent did not indicate type of anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) to be used. In addition, the consent was not signed by the physician indicating his/her physician certification of informed consent: “I, the undersigned physician, hereby certify that I have discussed the procedure named above with this patient, including the risk and benefits of the procedures, any adverse reactions that may reasonably be expected to occur, any alternative efficacious methods of treatment which may be medically viable and any research or economic interest I may have regarding this treatment. I further certify that the patient was encouraged to ask questions and that all questions were answered. “ During a review of Patient 5’s “Anesthesia Record,” dated 12/10/2023 at 9 a.m., the Anesthesia Record indicated Patient 5 received spinal (injection of a drug into either the fluid of the spinal canal or immediately outside of the canal) anesthesia for a repeat C-section. During a concurrent interview and record review on 12/12/2023 at 11:16 a.m. with Charge Nurse (CN) 3, CN 3 reviewed Patient 5’s “Anesthesia Consent,” dated 12/10/2023, and stated the following: Patient 3 delivered by C-section on 12/10/2023 at 9:27 a.m. The consent did not indicate the type of anesthesia that would be used during the C-section. The consent was not signed by the physician certifying that he/she discussed the type of anesthesia or the risk of anesthesia with Patient 3. CN 3 stated the consent should be complete to ensure patients were informed of the type of anesthesia to be used and that the risks were discussed by the physician. CN 3 stated patients had the right to know the type of anesthesia patients would receive and the risks involved. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent for Procedures and Treatments,” dated 5/27/2020, the P&P indicated the following: The hospital recognizes and respects the patient ’ s right to be involved in the decision-making of all aspects of their care and to be informed of the risk, benefits and alternatives to proposed procedures and treatments to ensure informed decision-making. The hospital complies with all the state and federal regulations. It is the hospital’s policy for its staff to facilitate obtaining voluntary, informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) from patients (or their legally designated representative [LDR] ..., after the physician has discussed the risk, benefits, and alternatives to the procedure with the patient and prior to rendering medical procedures and treatments that involve material risk. Informed consent must be obtained and documented according to policy ...It is the treating physician’s responsibility to obtain the informed consent ...Documentation of Informed Consent: Documentation of the discussion and patient decision is to be noted in the patient ’ s medical record ...Signed Consent Form required for ...Anesthesia. Signatures: Consent form must be signed by the physician who had the informed consent discussion and by the patient or LDR. During a review of the facility’s policy and procedure titled, “Patient Rights and Responsibilities,” dated 3/22/2023, the P&P indicated “the patient has the right to make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as they may need in order to give informed consent or refuse a course of treatment...””

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to document and sign a legible History and Physical (H&P, a formal and complete assessment of the patient and the problem) for one of 30 sampled patients (Patient 20). This deficient practice had the potential to result in lack of clarity in communication between healthcare providers involved in Patient 20’s care, leading to a failure to follow through with evaluation and treatment plans and resulting in patient harm. Findings: During a review of Patient 20’s intraoperative case report (ICR, a summary of a patient’s surgical procedure), dated 12/13/2023, the ICR indicated, on 12/13/2023 Patient 20 underwent intrarenal (within the kidney) surgery with left stent placement (A renal artery stent is a tiny, metal mesh tube that opens the artery in the kidney to allow better blood flow to the kidney). During a review of Patient 20’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/13/2023, the H&P was handwritten and not readable which was verified by the Vice President of Quality and Risk Management (VPQRM). During a concurrent interview and record review on 12/14/2023 at 9:35 a.m. with vice president of quality and risk management (VPQRM), Patient 20’s History and Physical (H&P), dated 12/13/2023, was reviewed. The H&P was handwritten, incomplete, and not legible. The VPQRM stated, the H&P was not readable and presented the facility’s Medical Staff Rules and Regulations (Rules and Regs), dated 10/2020 indicating the H&P must be a durable legible copy that may be used in the patient’s medical records. During a review of the facility’s Department of Surgery Rules and Regulations, dated 06/2022, the Rules and Regulations indicated, a complete physical examination must be performed within 30 days prior to admission, and has to be durable, legible copy as per facility’s policies and procedures. During a review of the facility’s Medical Staff Rules and Regulations, dated 10/2020, the Rules and Regulations indicated, all physician orders must be written clearly, legibly, and completely. The Code of Federal Regulations states that the purpose of a medical history and physical examination is to determine whether there is anything in the patient’s overall condition that would affect the planned course of the patient’s treatment, such as a medication allergy, or a new or existing co-morbid condition (existence of more than one disease in the patient’s body at the same time) that requires additional interventions to reduce risk to the patient.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to: 1. Perform nursing assessments (a process where a nurse gathers, sorts and analyzes a patient’s health information), including vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) upon admission, as ordered by the physician and per the facility’s policy regarding assessment and reassessment, for one of three sampled patients (Patient 1) who was admitted to the Labor and Delivery unit (L&D, a unit that specializes in childbirth). In addition, the facility failed to report changes in Patient 1 ’ s condition immediately when Pitocin (oxytocin, a medication to induce labor) was discontinued, and when Patient 1 experienced abnormal fetal heart strip (heart rhythm) reading and continuous decelerations (abrupt decreases in fetal [unborn baby] heart rate which can indicate umbilical cord compression [when the baby’s weight puts pressure on the cord during pregnancy or labor and can restrict blood flow and oxygen to the baby] and fetal distress [changes in heart rate, movement, etc.]). These deficient practices resulted in Patient 1 delivering a baby (Patient 2) who was not breathing, had no heart rate, was limp, and cyanotic (bluish color indicating lack of oxygen). Patient 2 was taken to the Neonatal Intensive Care Unit (NICU, unit that specializes in providing intensive [critical] medical care to newborns) and transferred to an outside hospital for a higher level of care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which a patient originates). Patient 2 passed away at the outside hospital. 2. Assess a patient who presented to the Labor and Delivery (L&D, a unit that specializes in childbirth) in a timely manner (within 10 minutes) for one of three sampled patients (Patient 3). Patient 3 arrived at the L&D unit at 8:37 a.m., on 12/12/2023, and was first evaluated by a nurse at 4:15 p.m., 8 hours after arriving at the L&D unit. This deficient practice had the potential for an emergency medical condition (EMC, example: heart attack, excessive bleeding, etc.) to go unidentified by nursing staff and could delay treatment and result in patient harm. On 12/14/2023 at 5:50 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), the Vice President of Quality & Risk Management (CPQRM), the Medical Director/Chief Medical Officer (CMO), the Chief Operating Officer (COO), the Chief Executive Officer (CEO), the Chief Information Officer (CIO), and the Manager for Accreditation, Licensing, and Regulatory (MALR). 1. The facility failed to perform nursing assessments (a process where a nurse gathers, sorts and analyzes a patient’s health information), including vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) upon admission, as ordered by the physician and per the facility’s policy regarding assessment and reassessment, for one of three sampled patients (Patient 1) who was admitted to the Labor and Delivery unit (L&D, a unit that specializes in childbirth). In addition, the facility failed to report changes in Patient 1’s condition immediately when Pitocin (oxytocin, a medication to induce labor [a series of continuous and progressive contractions, the tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows], that allows the fetus [unborn baby] to move through the birth canal]) was discontinued, and when there were signs of fetal [unborn baby] distress (when there are changes in heart rate, fetal movement, or signs of oxygen deprivation before or during labor). Patient 1 delivered a baby (Patient 2) who was not breathing, had no heart rate, was limp, and cyanotic (bluish color indicating lack of oxygen). Patient 2 was taken to the Neonatal Intensive Care Unit (NICU, unit that specializes in providing intensive [critical] medical care to newborns) and transferred to an outside hospital for a higher level of care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which a patient originates). Patient 2 passed away at the outside hospital. 2. The facility failed to assess one of three sampled patients (Patient 3), who presented to the Labor and Delivery (L&D) unit, in a timely manner (within 10 minutes). Patient 3 complained of contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor) upon arrival to the L&D unit on 12/12/2023 at 8:37 a.m., Patient 3 waited on the unit without a nursing or medical assessment for eight (8) hours. At 4:30 p.m., Patient 3’s Flow Sheet (contains important data regarding a patient’s condition) indicated variable decelerations (an abrupt decrease in fetal [unborn baby] heart rate which could indicate umbilical cord compression [when the baby’s weight puts pressure on the cord during pregnancy or labor and can restrict blood flow and oxygen to the baby]) were present on the fetal heart monitor (measures the heart rate and rhythm of the fetus [unborn baby]). These deficient practices had the potential for abnormal vital signs and an emergency medical condition (EMC, example: heart attack, excessive bleeding, etc.) to go unidentified and can result in the delay of rendering potential life-saving treatment and had the potential to result in harm. On 12/15/2023 at 7:35 p.m., the survey team informed the facility in the presence of the CEO, CMO, CIO, CNO, VPQRM, and MALR, that the survey team was unable to verify, though observations and interviews, that the IJ Removal Plan (interventions to correct the deficient practices) had been implemented, and therefore, the IJ had not been removed. The facility was informed that the Department would recommend a 23-day termination (preliminary notice issued to the facility indicating that the provider agreement [Medicare and Medical payment agreement] will be terminated in 23 days if the facility does not correct the identified deficiencies) to the Centers for Medicare & Medicaid Services (CMS, a Federal agency that runs Federal healthcare programs) pending the removal of the IJ. The facility needed to submit evidence that the IJ Removal Plan had been implemented by the facility and verified by the survey team. On 12/22/2023, at 10 a.m., the IJ was removed in the presence of the VP for Quality and Risk Management, Manager for Accreditation, Licensing and Regulatory, Chief Nursing Officer, Chief Executive Officer, Chief Information Officer, and in attendance by phone were the Chief Operating Officer and the Chief Medical Officer, after the facility submitted an acceptable IJ removal plan. The elements of the IJ removal plan were verified and confirmed through observation, interviews and record reviews. The acceptable IJ removal plan included the following: 1. Creation and implementation of a new policy titled “Triage (preliminary assessment to determine the urgency of the patient ’ s need and the nature of treatment needed), Assessment and Reassessment Standards Labor & Delivery Department” which went into effect on 12/15/2023 2. Education of all applicable clinical and contracted services staff regarding the new policy on “Triage, Assessment and Reassessment Standards Labor & Delivery Department” 3. Creation and implementation of a new policy “Labor & Delivery Intake Process Workflow (a structured approach to gathering/collecting information from patients),” which went into effect on 12/14/2023. 4. Education of all applicable clinical and contracted services staff regarding the new policy on “Labor & Delivery Intake Process Workflow” 5. Revision of the facility ’ s daily safety briefing to review any safety incidents or operations that have a high potential to negatively impact patient care and safety within the organization 6. Inservice of the Nursing staff regarding “Fetal and Uterine Monitoring (a method of tracking the Fetal Heart Rate along with the occurrence of uterine contractions): Assessment, Interpretation, and Documentation” 7. Monitoring compliance to ensure patients are registered and triaged within 10 minutes of arrival 8. Monitoring compliance to ensure notification to physicians is communicated immediately when there is no improvement after interventions have been implemented Findings: 1. During a review of Patient 1’s Face sheet (a document that gives a patient’s information at a quick glance), dated 6/25/2023, the Face sheet indicated, Patient 1 was admitted to the facility on 6/25/2023 at 2:29 a.m. to the obstetric (a branch of medicine specialized in the care of pregnant women and childbirth) service. During a review of Patient 1’s un-timed “Obstetric Admission History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/25/2023, the Obstetric Admission History & Physical indicated, Patient 1 was thirty-nine (39) weeks pregnant (full-term is 40 weeks) and complained of uterine contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor). “AROM (artificial rupture of membrane, when a healthcare provider intentionally breaks a person’s amniotic sac [a bag of waters that surrounds the fetus [unborn baby]) clear, IUPC (intrauterine pressure catheter placement is device that measures contractions during labor).” Assessment indicated Patient 1 was in labor (last stage of pregnancy when muscles of the womb start to push the baby out or childbirth). The plan was to admit to the Labor and Delivery Unit (L&D, a unit that specializes in childbirth) for delivery. During a review of Patient 1’s “LD (Labor & Delivery) Flowsheet (contains important data regarding a patient ’ s condition),” dated 6/25/2023, the LD Flowsheet indicated the following: At 3:09 a.m., blood pressure (BP) was 131/81 (normal 120/80) and pulse (Heart rate [HR]) was 78 (normal 60 to 100). At 4:01 a.m., Respiratory Rate (RR) was 18 (normal), Temperature was 98.6 (normal) and 5/10 pain to the abdomen, uterine contractions. Membranes intact (amniotic sac not yet ruptured). At 7:40 a.m., Physician (MD 1) examined Patient 1. Membranes ruptured by MD 1. IUPC (intrauterine pressure catheter is a device that measures contractions during labor) inserted. Dilation (when cervix [the lower part of the uterus] opens to allow the baby to move through the birth canal) 2.5 cm (10 is completely dilated)... At 7:43 a.m., BP was 139/90 and HR was 91. At 9:14 a.m., Patient 1 was in labor (a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal). Uterine activity monitored by IUPC (intrauterine pressure catheter placement is a device that measures contractions during labor). Fetal assessment by external ultrasound, fetal heart rate (FHR) 130 (normal 120-160), no decelerations (decrease in fetal heart rate), FHR category 1 (fetus is reactive and HR is reassuring [when FHR is within normal range between 12-160 beats per minute]). Pitocin (oxytocin, a hormone to strengthen labor contractions during childbirth) was started at 9:14 a.m. At 10 a.m., “Pitocin D/C (discontinue) Post Teaching.” At 10:02 a.m., FHR with prolonged deceleration (an abnormal fetal heart rate under 120 usually lasting at least 2 minutes). Patient 1 positioned to left-lateral (side) and semi-fowlers position (sitting). At 10:07 a.m., “Uterine activity normal ...Fetal Assessment: Late and Variable decelerations present. Actions for decelerations; side to side, oxygen applied, Pitocin off; IV (intravenous- through the vein) bolus (administering a medication over a short period of time), Category II (FHR tracing is considered indeterminate [not exactly known] and cannot be considered either reassuring (within normal variation) or non-reassuring (with heart rate pattern abnormalities). At 10:16 a.m., “Fetal decelerations heard, staff called at bedside to help out.” At 10:18 a.m., Patient 1’s HR was 88 and SpO2 (oxygen saturation- measures the amount of oxygen in the blood) was 100 %. At 10:19 a.m., Patient 1’s position, right lateral and semi-fowlers. At 10:20 a.m., Charge Nurse (CN) 2 is at bedside repositioning Patient 1 and helping out. At 10:23 a.m., Patient 1’s HR was 83 and SpO2 was 100 %. At 10:28 a.m., Patient 1’s HR was 70 and SpO2 at 100 %. At 10:33 a.m., Patient 1’s HR was 79 and SpO2 was 100%. At 10:38 a.m., Patient 1’s HR was 99 and SpO2 was 100%. At 10:39 a.m., MD 1 examined Patient 1 ...Dilation 3 cm ...Membranes leak, clear fluid noted. Registered Nurse (RN) 6 at bedside, reviewed strip (recording of the heart rhythm). Patient 1 kept on her right side. At 10:43 a.m., Patient 1’s HR was 72 and SpO2 was 100 %. At 10:48 a.m., Patient 1’s HR was 78 and SpO2 was 100 %. At 10:51 a.m., Patient 1’s BP was 139/80 and HR was 97. At 10:53 a.m., Patient 1’s HR was 78 and SpO2 was 100 %. At 10:58 a.m., Patient 1’s HR was 71 and SpO2 was 100 %. At 11 a.m., Uterine assessment pattern was normal ...Fetal assessment: Late decelerations, actions taken for decelerations; side to side; oxygen applied; Pitocin off; IV bolus. Call/Page placed to provider. MD 1 notified. MD 1 was busy delivering another patient. At 11:03 a.m., Patient 1’s HR was 83 and SpO2 was 100 %. At 11:04 a.m., Provider (MD 1) reviewed strip (FHR), RN 6 at bedside. MD 1 at bedside. Status update; Fetal status, labor status and membrane status. “Informed MD 1 of fetal decelerations, Pitocin discontinued at 10 a.m., FSE (fetal scalp electrode, a wire placed on the scalp of the fetus to monitor their heart rate) ordered. At 11:08 a.m., Patient 1’s HR was 72 and SpO2 was 100 %. At 11:13 a.m., Patient 1’s HR was 76 and SpO2 was 100 %. At 11:18 a.m., Patient 1’s HR was 86 and SpO2 was 100%, Dilation 3 cm ...MD 1 reviewed strip (FHR). RN 6 at bedside. RN 6 reviewed strip. MD 1 at bedside. Vaginal exam done by MD 1. Informed MD 1 of difficulty to monitor FHR, tracing reviewed by RN 6 with MD 1. At 11:19 a.m., FSE (fetal scalp electrode, a wire placed on the scalp of the fetus to monitor their heart rate) applied by MD 1. At 11:20 a.m., RN 6 at bedside; RN 6 reviewed strip; MD 1 at bedside. MD 1 informed Patient 1 “that if there were more fetal decelerations, he will do a Cesarean section (surgical delivery of a baby). Patient 1 and FOB (father of baby) verbalized understanding to teaching (referring to the need to perform CS if there were more fetal decelerations). At 11:21a.m., Patient 1’s BP was 132/87 and HR was 88. At 11:23 a.m., Patient 1’s HR was 96 and SpO2 was 100 %. At 11:28 a.m., Patient 1’s HR was 85 and SpO2 was 100 %. At 11:31 a.m., Patient 1’s HR was 107 and SpO2 was 94 %. At 11:33 a.m., Patient 1’s HR was 98 and SpO2 was 99 %...Epidural (an injection in the back to stop feeling pain) in progress ... At 11:38 a.m., Patient 1’s HR was 87, 95 and SpO2 was 87 and 98 %. At 11:43 a.m., Patient 1’s HR was 95 and SpO2 was 99 %...Epidural catheter placed. At 11:44 a.m., Patient 1’s HR was 114 (elevated, normal is 60 - 100) ... At 11:46 a.m., Patient 1’s BP was 148/94 (elevated, normal is 120/80). At 11:47 a.m., Patient 1’s BP was 140/71 and HR was 102 (elevated). At 11:48 a.m., Patient 1’s HR was 91 and SpO2 was 98 %. At 11:51 a.m., Patient 1’s BP was 129/77 and HR was 103. Dilation was 4 cm ...Foley catheter inserted. At 11:56 a.m., Position; right lateral and semi-fowlers. At 11:57 a.m., Fetal assessments comments indicated Patient 1 repositioned post epidural. At 12:22 p.m., Uterine activity; IUPC, normal ...Fetal Assessment, mode; internal scalp electrode, FHR baseline 130, actions for decelerations (decrease in fetal heart rate); side to side, oxygen applied, IV bolus, sterile vaginal exam. Category II (indeterminate [not exactly known]). Comments: CN 2 and staff at bedside, decelerations in fetal HR noted. At 12:24 p.m., oxygen 10 Liters via face mask ... RN 6 at bedside. CN 2 at bedside helping out, repositioning Patient 1. Staff called at bedside to help out. At 12:25 p.m., “FSE (fetal scalp electrode) seemed to be not working. External applied while FSE was in place. CN 2 helping, repositioning and applying external doppler. At 12:27 p.m., Patient 1’s BP was 125/80, HR was 103 (elevated). Fetal Assessment: mode; internal scalp electrode. FHR baseline: 50. FHR baseline changes: bradycardia (a heart rate less than 110 beats per minute). Prolonged decelerations (decrease in fetal heart rate) present. Category III (non-reassuring fetal heart rate associated with neurological (affects the brain and the nerves found throughout the body) abnormalities). CN 2 and RN 6 at bedside along with the team, such as L&D staff RN and student doctors; resuscitation efforts done to help with fetus out, MD 1 is at bedside. MD 1 walked at bedside, Patient 1 to take to the OR (operating room) stat (immediately) for C/S (Cesarean Section). At 12:29 p.m., MD 1 at bedside, applied FSE. At 12:29 p.m., IUPC removed. RN 6 and MD 1 at bedside. CN 2 and L&D staff and student doctors at bedside helping in moving the bed. During a review of Patient 1’s “Operative Report,” dated 6/26/2023 at 11:57 p.m., the Operative Report indicated the following: Date of surgery: 6/25/2023. Preoperative (before the surgery) Diagnosis: Intrauterine pregnancy (when a fertilized egg implants and starts to develop within the uterus) at term, fetal bradycardia (a heart rate less than 110 beats per minute). Operative procedure: Emergency C-Section. Findings: Description of procedure: ...infant was delivered gently with vacuum ...The infant was handed off to the awaiting NICU team. During a review of Patient 1’s “Neonatal Delivery and Resuscitation (methods used to restart the heart and lungs if they stop working) Record,” dated 6/25/2023, the Neonatal Delivery and Resuscitation Record indicated the following: Patient 1’s baby (Patient 2) was born at 12:47 p.m. Apgar scores (a scoring system from 0 - 10, used to assess newborns at one minute and five minutes of life to determine whether or not the baby needs medical intervention or assistant) at one minute and five minutes the APGAR scores were 0 (indicating no heart rate, no respirations, no tone (contributes to the control and amount of movement), no reflex (involuntary action that the body does in response to something), bluish skin color). At 10 minutes, the score was 1. At 15 minutes Patient 2 had a heart rate. Comments indicated a “crash” C-section (an emergency C-section due to immediate concern for the health of the mother and/or the baby) for a non-reassuring (with heart rate pattern abnormalities) fetal heart rate (FHR), no FHR detected for 25 minutes prior to delivery. Patient 2 was ventilated and intubated (a tube is inserted through the mouth or airway to keep the airway open so air can get through). Patient 2 was taken to NICU. During a concurrent interview and record review on 12/13/2023 at 1:31 p.m., with the Clinical Educator (CED) of the Labor & Delivery Unit and the Quality Coordinator (QC), the CED stated the following: Patient 1 arrived at the L&D unit at 2:29 a.m. Patient 1 was admitted at 4:01 a.m. A full set of vital signs (VS) was not taken upon admission. Patient 1 had a rupture of membranes (ROM, membranes surrounding fetus [unborn baby] are ruptured and result in leakage of amniotic fluid [fluid that surrounds the fetus]) at 7:40 a.m. Pitocin (medication to induce labor) was started at 9:14 a.m., and discontinued it at 10 a.m. The fetal monitoring strip (record of the heart rate and rhythm) indicated there was a prolonged deceleration (slowing down of the fetus’ heart rate below 120 per minute, indicating fetal distress [changes in heart rate, movement, etc.]). The physician was not notified that Pitocin was discontinued or of the fetal decelerations, until an hour later, at 11 a.m. The Quality Coordinator (QC) said, the physician should have been notified right away to evaluate Patient 1 at 10 a.m. The QC also verified that Patient 1’s Temperature was not checked every 2 hours after the ROM, as ordered by the physician. QC said it was important to take the temperature to check for possible infection. The QC also verified that complete VS (BP, HR, RR, pain) were not taken upon admission or every hour, as ordered, only blood pressure and heart rate were checked. The QC stated VS should be taken to help determine Patient 1’s baseline and to check for abnormal vital signs. The QC said that assessments for uterine contractions and fetal heart rate should be performed every 30 minutes, and the QC verified an assessment was not performed at 10:30 a.m., and between 11 a.m., and 12:22 a.m., Per the L&D Flowsheet, the fetal heart rate assessments indicated there were continuous decelerations from 10 a.m. to 12:22 p.m. The QC stated decelerations were a sign of fetal distress. The QC verified that Patient 1 delivered via emergency Cesarean Section (C-section, surgical delivery of a baby) at 12:47 p.m. Patient 1’s baby (Patient 2) was not breathing, had no heart rate, was limp and cyanotic (bluish color indicating lack of oxygen). Patient 2 was intubated, and a heart rate was obtained at 14 minutes of life. Patient 2 was taken to the Neonatal Intensive Care Unit and transferred to an outside hospital for a higher level of care. During a concurrent interview and record review of Patient 2’s medical record with the Manager of the Neonatal Intensive Care Unit (MNICU) on 12/14/2023 at 3:41 p.m., the MNICU stated Patient 2 was admitted to the NICU then transferred to an outside hospital and passed away. During a review of Patient 1’s physician’s order, dated 6/25/2023 at 8:54 a.m., the physician’s order indicated, “BP (blood pressure), P (pulse), R (respiratory rate) every 60 minutes.” During a review of Patient 1’s physician’s order, dated 6/25/2023 at 8:56 a.m., the physician’s order indicated, “Temperature every 2 hours, if ROM (Rupture of Membrane).” During a review of the Facility’s policy and procedure (P&P) titled, “Admission Assessment and Reassessment Labor and Delivery,” dated 10/27/2021, the P&P indicated, “an initial assessment is to be performed by a Registered Nurse (RN) on all patients within two (2) hours of admission. This initial assessment includes maternal vital signs and pain level ...The initial assessment includes ...vital signs.” During a review of the Facility’s policy and procedure (P&P) titled, “Induction or Augmentation of Labor (prompting the uterus to contract [tightening and shortening] during pregnancy before labor begins on its own): Oxytocin (Pitocin),” dated 6/23/2021, the P&P indicated during oxytocin should be discontinued immediately and the OB (Obstetric) provider notified when ...symptoms/conditions where continuation of oxytocin is assessed as detrimental to maternal and or fetal well-being according to the registered nurse’s (RN) judgment/assessment. 2. During an interview on 12/11/2023 at 4:47 p.m., with the Chief Nursing Officer (CNO), the CNO stated there was no current OB (Obstetric, care of pregnant women and their babies) triage (preliminary assessment to determine the urgency of the patient ’ s need and the nature of treatment needed) policy in place. The policy had not been approved yet. During a concurrent observation and interview, on 12/12/2023 at 10:08 a.m., Patient 3 was observed sitting on a chair in the hallway of the Labor and Delivery Unit (L&D, a unit that specializes in childbirth). Patient 3 stated she (Patient 3) arrived at 8:37 a.m., checked in by filling out a form, and has been waiting for approximately an hour and a half. Patient 3 stated she had not been evaluated by a nurse or a doctor, and vital signs (temperature, blood pressure, heart rate, respiratory rate, pain) had not been taken. Patient 3 stated she (Patient 3) was having contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor, a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal). During an interview on 12/12/2023 at 10:54 a.m., with the Chief Nursing Officer (CNO), the CNO stated the following: Patients arrive to the unit (L&D unit), fill out a “Maternity Check-In Form” then sit down until the charge nurse puts the patient in a room. CNO was currently covering for the Charge Nurse (CN 1) who was assisting in the Operating Room (OR). CNO stated there was a total of 6 triage (preliminary assessment to determine the urgency of the patient’s need and the nature of treatment needed) beds on the unit and 4 of the beds were occupied. During an interview on 12/12/2023 at 11:13 a.m., with Charge Nurse (CN) 1, CN 1 stated the following: CN 1 called the CNO to assist in the L&D unit because CN 1 had to help with a procedure in the OR from 8 a.m., to 11 a.m. CN 1 stated Patients including Patient 3, had not been triaged because she (CN1) was out of the unit for 3 hours. CN 1 confirmed patients were not evaluated until the patients were placed in a room. During an interview and review of Patient 3’s “Maternity Check-In Form, on 12/14/2023 at 10:02 a.m., with the Manager of the Neonatal Intensive Care Unit (MNICU), the NMICU verified Patient 3 checked into the L&D unit on 12/12/2023 at 8:37 a.m. for “having contractions/baby hasn’t been active as much.” During a review of Patient 3’s “OB History and Physical (H&P, a formal and complete assessment of the patient and the problem) Note,” dated 12/12/2023 at 5:47 p.m., the OB History and Physical Note indicated the following: Patient 3 was a 21-year-old who was pregnant for the first time. Patient 3 was 39 - 5/7 weeks (40 weeks is full term) pregnant and presented to the L&D unit complaining of uterine contractions. Patient was 5 cm dilated (when cervix [the lower part of the uterus] opens to allow the baby to move through the birth canal), (10 is fully dilated). During the review of Patient 3’s “OB Triage (preliminary assessment to determine the urgency of the patient’s need and the nature of treatment needed),” Flowsheet, dated 12/12/2023 at 4:15 p.m., the OB triage Flowsheet indicated the following: At 4:29 p.m., the vaginal exam indicated Patient 3 was 5.5 cm dilated (range 0 to 10, 10 means fully dilated). At 4:30 p.m., Patient 3 was placed on an external monitor to detect uterine contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor). Patient 3 was having moderate contractions. An external ultrasound monitor was also placed to assess the fetus (unborn baby). Patient 3 had variable decelerations (abrupt decrease in the fetus heart rate, under 110) and at a Category II (indeterminate assessment of FHR tracing). Patient complained of abdominal pain rated at a 7 (ranges 0 to 10, 10 being the worse possible pain), cramping and contractions. During a concurrent interview and review of Patient 3’s Flowsheets, on 12/14/2023 at 10:03 a.m., with the Quality Coordinator (QC), the QC stated the following: Patient 3 was placed on a monitor to check maternal contractions and the fetus’s heart rate at 3:50 p.m. Patient 3 had a limited Maternal assessment on 12/12/2023 at 4:15 p.m. At 4:30 p.m., the Flow sheet indicated variable decelerations (an abrupt decrease in fetal [unborn baby] heart rate which could indicate umbilical cord compression [when the baby’s weight puts pressure on the cord during pregnancy or labor and can restrict blood flow and oxygen to the baby]) were present, which could indicate that umbilical cord was compressed, which could result to decreased oxygenation to the fetus. In addition, QC verified that vital signs (VS, Temperature, blood pressure, pulse, and respiratory rate) were not taken upon admission at 4:30 p.m. First set of vital signs (VS) were taken at 7 p.m. The QC stated VS should be assessed to determine if patient was having a fever, which was a sign of infection and also check for increased blood pressure in pregnant women which could lead to seizures (sudden, uncontrolled burst of electrical activity in the brain that causes changes in behavior, movements, feelings, and level of consciousness [state of awareness of what’s happening around]). The QC verified there was no nursing documentation for Patient 3 from 8:37 a.m., to 4:14 p.m. The QC stated eight (8) hours was a long time for Patient 3 to be evaluated because Patient 3 could have been having an unidentified medical emergency. During a review of the Facility’s policy and procedure (P&P) titled, “Admission Assessment and Reassessment Labor and Delivery,” dated 10/27/2021, the P&P indicated, “an initial assessment is to be performed by a Registered Nurse (RN) on all patients within two (2) hours of admission. This initial assessment includes maternal vital signs and pain level ...The initial assessment includes ...vital signs.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure Registered Nurse 9 (RN 9) and Registered Nurse 10 (RN 10) were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) of 30 sampled patients (Patient 27). This deficient practice had the potential to result in an inadequate return of blood from the dialysis machine (a machine that removes blood from the body, filters it [refers to the blood] through a dialyzer [an artificial kidney], and returns the cleaned blood to the body) to the patient (Patient 27) causing harm or even death during hemodialysis treatment. Findings: During a review of Patient 27’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/12/23, the H&P indicated Patient 27 was admitted to the facility to restart Hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly). During an observation on 12/12/2023 at 3:15 p.m., on the 8th floor of the facility, with the Chief Nursing Officer (CNO), three dialysis machines were observed to have a sign titled “Emergency procedure for incapacitated Acute dialysis teammate” with instructions. During an interview on 12/15/2023 at 4:22 p.m. with the Medical Director of Hemodialysis program (MD 5), MD 5 stated signs were posted in the dialysis machines regarding instructions on how to shut off the Hemodialysis machine safely in case of an emergency. During a concurrent interview and record review on 12/15/2023 at 5:28 p.m. with the Vice President of Quality and Risk Management (VPQRM), Registered Nurse 9 (RN 9), and Registered Nurse 10 (RN 10), both RN 9 and RN 10 stated that they were not provided in-service or training on how to shut off the hemodialysis machine in case of an emergency such as during a power outage or an incapacitated dialysis nurse during dialysis. Likewise, the VPQRM was not able to provide evidence of in-service or training provided to the facility’s staff for emergencies during hemodialysis including safely shutting-off dialysis in case of an emergency.”

“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: 48186 Based on observation, interview, and record review, the facility failed to ensure: 1. Three of three sampled Patients (Patients 8, 11 and 13) received nursing care interventions and assessments per facility policy to promote wound healing, when: a. Patients 8, 11, and 13 were not repositioned/turned every two hours. b. Patient 8 had no admission and biweekly ongoing wound photographs, assessments, and measurements. c. Patient 8 had no daily wound assessment documentation. These deficient practices had the potential to compromise Patient 11’s and Patient 13’s wound healing progression, and resulted in Patient 8’s sacral and right buttock wounds becoming larger in size, with Patient 8’s sacral wound progressing from a Stage III (Full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) to an unstageable (unable to stage, full thickness tissue loss in which the base of the ulcer is covered by slough- yellow, tan, gray, green or brown- and/or eschar- tan, brown or black) pressure ulcer. 2. Two of two Crash Carts (Crash cart 1- adult Crash Cart and Crash Cart 2- neonatal [relating to newborn children] Crash Cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Labor and Delivery Unit (L&D, a floor of the hospital responsible for the provision of medical care for patients arriving to deliver a baby) were checked every shift per facility’s policy to ensure emergency supplies, equipment, and medications were readily available in the event of an emergency. This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death. Findings: 1a. During a review of Patient 8’s Face Sheet (a document that gives a patient ’ s information at a quick glance), dated 10/23/2023, the Face Sheet indicated, Patient 8 was admitted to the facility on 10/23/2023 at 10:13 a.m. with diagnoses of paraparesis (partial paralysis of the lower limbs), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and intractable pain (severe, constant, relentless, and debilitating pain that is not curable by any known means). During a review of Patient 8’s integumentary (skin) admission assessment note, dated 12/23/2023 at 8 p.m., the integumentary admission assessment note indicated, Patient 8’s skin integrity was not intact (break in the skin) with a Stage II (partial-thickness skin loss into but no deeper than the middle layer of the skin) pressure injury to the sacrum/coccyx (tailbone). During a review of Patient 8’s integumentary (skin) admission assessment note, dated 10/23/2023 at 8:00 p.m., the integumentary admission assessment note indicated, Patient 8’s Braden Scale (a tool used to measure the risk of getting a pressure ulcer) was 13 out of 23. A score of less than 18 or less, indicated actions were pressure injury prevention and management plan (PIPP), turn clock signs, repositioned/turned every two hours, floated heels off mattress with foam boots and other off-loading devices (ie. wedges, pillow, heel protectors, etc.), managed moisture with incontinence (lack of voluntary control over urination or defecation) care products and encouraged adequate nutrition/fluid intake. During a concurrent interview and record review on 12/12/2023 at 1:28 p.m. with the Manager of the Intensive Care Unit (MICU), Patient 8’s Daily Living Daily Assessment record was reviewed. The Daily Living Daily Assessment record indicated Patient 8 was not turned and refusal of Patient 8 to be turned was not documented for the following dates: 10/24/2023 at 7:34 a.m. through 10/25/2023 at 8 a.m., 10/27/2023 at 7:30 a.m. through 10/27/2023 at 7:25 p.m., 11/1/2023 at 7 a.m. through 11/2/2023 at 8 a.m., 11/13/2023 at 8 a.m. through 11/13/2023 at 6 p.m., 11/26/2023 at 10 a.m. through 11/26/2023 6 p.m., and 11/28/2023 8 a.m. through 11/29/2023 at 8:00 a.m. The MICU stated Patient 8 should have been turned every 2 hours or the refusal for turning documented. However, the documentation was not done. The MICU further said that not turning patients can add more pressure to the site, making the wound worse or adding new wounds. During a review of Patient 8’s wound, ostomy (bowel or bladder diversion), and continence (issues of bowel and bladder control) nurse assessment record, dated 10/24/2023 at 9:57 a.m., the wound, ostomy, and continence nurse assessment record indicated, Patient 8 had a Stage III (Full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) pressure injury (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) measuring 3.0 centimeter (cm, a unit of measurement- length) x 2.0 cm (width) x 0.2 cm (depth). Wound appearance was moist, erythemic (superficial reddening of the skin, usually in patches, because of injury or irritation causing dilation of the blood capillaries), yellow and red. During a review of Patient 8’s wound photograph and assessment record dated 11/15/2023 at 2:30 a.m., the wound photograph and assessment record indicated, Patient 8 had a right buttock wound, measuring 2.0 cm (centimeter [a unit of measurement], length) x 2.0 cm (width) x 0.1 cm (depth). Patient 8’s right buttock wound appearance was documented as red and pink excoriation (a scratch in the skin) without drainage. During a review of Patient 8’s wound, ostomy, and continence nurse assessment note, dated 11/16/2023, the wound, ostomy, and continence nurse assessment note indicated, Patient 8 had a right buttock excoriation becoming larger. Wound measurements were not documented. Wound appearance was documented as excoriation, wound edges macerated (skin appears wrinkly, soft and wet when exposed for too long with moisture such as from urine), scant drainage, and moist. During a review of Patient 8’s wound, ostomy, and continence nurse assessment, dated 11/30/2023, the wound, ostomy, and continence nurse assessment note indicated, Patient 8 had a sacrum (triangular bone at the bottom of the spinal column) unstageable pressure injury (a full thickness tissue loss in which the actual depth of the ulcer/injury is completely obscured in the wound bed), measuring 7.0 cm (length) x 12.0 cm (width) x UTD (unable to determine; depth). Wound appearance was documented as irregular wound edges, small purulent (pus formation) drainage, mild odor, and wound appearance as moist. During a concurrent interview and record review on 12/12/2023 at 1:28 p.m. with Wound Care Ostomy Nurse (WCON), Patient 8’s admission wound record was reviewed. Patient 8’s admission wound record, documented as “sacrum,” did not include a photograph, assessment, or measurements of the right buttocks wound. WCON stated that Patient 8’s admission wound documentation did not capture the entire right buttock wound, and the buttock wound was cut off in the picture. WCON stated that wound photos were supposed to be taken at admission, transfer, bi-weekly Wednesday and Sunday, and at discharge. WCON confirmed there was no photograph of Patient 8’s right buttock wound on admission. WCON further stated the admission nursing assessment on 10/23/2023, at 8 p.m., indicated a sacral stage II (partial-thickness skin loss into but no deeper than the middle layer of the skin) pressure injury, but this was incorrect and was documented as a stage III at admission by WCON. A concurrent review of the nursing admission skin assessment documentation indicated the primary nurse did not complete an assessment of the right buttock wound. This incomplete assessment was verified by the WCON. Additional review of the wound care ostomy nurse assessment record, dated 10/23/2023 at 11:44 a.m., indicated Patient 8’s right buttock condition was documented as excoriation (a scratch in the skin), moist and erythemic (redness of the skin caused by injury or inflammation). No measurements were documented on the WCON’s right buttock wound documentation for Patient 8. WCON stated there was no initial wound assessment done by the primary nurse, and the WCON documentation was done after 24 hours of Patient 8’s admission. WCON stated she was unable to find any wound photograph documentation of Patient 8’s right buttock until 11/15/2023. During a concurrent interview and record review on 12/12/2023 at 1:28 p.m. with the Manager of Intensive Care Unit (MICU) and the WCON, Patient 8’s wound care documentation record was reviewed. WCON stated they (both the MICU and the WCON) did not see any documentation in Patient 8’s chart for Patient 8’s refusal of wound photographs. WCON also said interventions should have been implemented for Patient 8’s right buttock wound, such as: offloading, turning, and photographs. During an interview on 12/12/2023 at 1:28 p.m., with WCON, the WCON stated that only the wound care nurse and physician can stage a wound. WCON said the assessment policy is to assess and photograph a wound within 24 hours of admission. WCON stated a pressure ulcer/injury can become worse if it is not documented on admission and a photo is not taken. WCON said there should be ongoing wound documentation per facility policy. During an interview on 12/12/2023 at 3:04 p.m. with Registered Nurse 2 (RN 2), RN 2 stated if a patient comes in the facility with a wound, the wound policy is to take wound pictures at admission, complete a wound care consult, and request initial treatment for the wound. RN 2 further said wounds are supposed to be assessed every day and every shift. During a concurrent interview and record review on 12/14/2023 at 3:44 p.m. with the Manager of Medical Surgical (MMS) Unit, Patient 8’s wound care record was reviewed. MMS stated there were no nursing assessments documented in Patient 8 ’ s chart for the right buttocks wound from 10/25/2023 through 11/26/2023. MMS stated that the admission photograph of Patient 8’s right buttocks was not properly labeled and did not include an assessment. MMS stated that multiple wound photographs for Patient 8’s sacrum and right buttocks were missing the assessment which was supposed to include wound’s size, wound color, periwound (tissue surrounding a wound) appearance, and drainage. MMS also said that biweekly wound photos were not taken for Patient 8. During an interview on 12/14/2023 at 3:44 p.m. with the Manager of Medical Surgical (MMS) Unit, MMS stated wound photos are taken biweekly and wounds should be measured at this time. MMS said if a wound was not assessed or documented, nursing staff would not know if wounds were progressing or if it was healing. MMS also said it was part of the admission assessment to identify and describe a wound, and the wound care nurse will appropriately stage the wound. MMS stated that the wound care nurse and doctors can stage wounds. MMS said if wounds were not documented and a picture was not taken, the staff would not be able to identify the appropriate treatment for the wound. MMS stated that lack of treatment can cause infection of the wound and can result in patient harm. During a review of the facility’s policy and procedure (P&P) titled “Wound Care: Assessment and Documentation,” dated 4/22/2022, the P&P indicated: “A. Skin Integrity (skin health): The patient’s skin integrity from head to toe will be assessed upon admission and each shift. Procedure: Wound Assessment: Document description of each wound in the electronic medical record in the “Daily Assessment” under the integumentary (skin) and pressure injury tab to include the following: Location (Specific injury location on body). Size (length x width x depth in cm) Length: Longest head ¿¿- to - toe measurement Width: Longest hip - to - hip measurement Depth: Deepest part of the wound (perpendicular to the skin surface) Undermining (separation of the wound edges from the surrounding health tissue, often creating a pocket under the wound surface)/Tunneling (when a wound extends deeper into the tissue than its surface, creating a channel or tunnel) Document if present Wound/Periwound (tissue surrounding a wound) Appearance... Photographing: Photographs should be included in the medical record to support documentation to determine progress of wound healing and effectiveness of therapy. Photographed open wounds and pressure injuries are to be posted on the Wound Photograph Wound will be photographed: Within 24 hours of admission. ii. Change of condition iii. Upon discovery of a new wound iv. Within 24 hours of discharge Bi-weekly on Wednesday and Sunday. The photo label should include: i. Patient’s date of birth or medical record number ii. Location of wound/lesion iii. Date and time of photograph iv. Measurement device v. Optional body alignment sticker If unable to obtain a photograph, document the reason in the medical record. C. Risk Prevention 2. Positioning and care and documentation: a. The nursing team will position the patient to ensure the skin integrity is maintained in accordance with the patient care plan and document the following interventions in the “Daily Assessment” under ADL’s (Activities of Daily Living) tab: i. Reposition patient as frequently as the patient can tolerate, minimum every 2 hours. ii. Clarify and document any limitations per physician or any patient refusal.” 1b. During a review of Patient 11’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/2/2023, the Face Sheet indicated, Patient 11 was admitted to the facility on 12/2/2023 at 6:44 a.m., with a diagnosis of altered mental status (AMS, a change in mental function that stems from illnesses, disorders and injuries affecting your brain). During a review of Patient 11’s integumentary (skin) admission assessment note, dated 12/2/ 2023 at 10:46 a.m., the integumentary admission assessment note indicated, Patient 11 had a stage I (mildest stage of pressure injury that does not have open wounds) pressure ulcer/injury (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) to the sacrum/coccyx (tailbone), present on admission. During a review of Patient 11’s integumentary admission assessment note, dated 12/2/2023 at 10:46 a.m., the integumentary admission assessment note indicated, Patient 11’s Braden Scale (a tool used to measure the risk of getting a pressure ulcer) was 14 out of 23. A score of less than 18 or less, indicated actions were: pressure injury prevention and management plan (PIPP), turn clock signs, repositioned/turned every two hours, floated heels off mattress with foam boots and other off-loading devices (ie. wedges, pillow, heel protectors, etc.), managed moisture with incontinence (lack of voluntary control over urination or defecation) care products and encouraged adequate nutrition/fluid intake. During a concurrent interview and record review on 12/15/2023 at 10:55 a.m. with the Manager of the Medical Surgical (MMS) Unit, Patient 11’s Daily Living Daily Assessment record was reviewed. The Daily Living Daily Assessment record indicated Patient 11 was not repositioned/turned every two hours per facility policy on turning/repositioning and Patient 11’s refusal for turning was also not documented for the following dates: 12/6/2023 at 7:45 a.m. through 12/6/2023 at 7 p.m., 12/7/2023 at 8 a.m. through 12/7/2023 at 7 p.m., 12/9/2023 at 7:00 p.m. through 12/10/2023 at 8 am., and 12/12/2023 at 7:00 a.m. through 12/13/2023 at 7:08 a.m. This lack of documentation regarding Patient 11’s turning/repositioning was verified by the facility’s MMS. During a review of the facility’s policy and procedure (P&P) titled, “Wound Care: Assessment and Documentation,” dated 4/22/2022, the P&P indicated: “A. Skin Integrity (skin health): The patient’s skin integrity from head to toe will be assessed upon admission and each shift. Procedure: Wound Assessment: Document description of each wound in the electronic medical record in the “Daily Assessment” under the integumentary (skin) and pressure injury tab to include the following: Location (Specific injury location on body). Size (length x width x depth in cm) Length: Longest head ¿¿- to - toe measurement Width: Longest hip - to - hip measurement Depth: Deepest part of the wound (perpendicular to the skin surface) Undermining (separation of the wound edges from the surrounding health tissue, often creating a pocket under the wound surface)/Tunneling (when a wound extends deeper into the tissue than its surface, creating a channel or tunnel) Document if present Wound/Periwound (tissue surrounding a wound) Appearance... Photographing: Photographs should be included in the medical record to support documentation to determine progress of wound healing and effectiveness of therapy. Photographed open wounds and pressure injuries are to be posted on the Wound Photograph Wound will be photographed: Within 24 hours of admission. ii. Change of condition iii. Upon discovery of a new wound iv. Within 24 hours of discharge Bi-weekly on Wednesday and Sunday. The photo label should include: i. Patient’s date of birth or medical record number ii. Location of wound/lesion iii. Date and time of photograph iv. Measurement device v. Optional body alignment sticker If unable to obtain a photograph, document the reason in the medical record. C. Risk Prevention 2. Positioning and care and documentation: a. The nursing team will position the patient to ensure the skin integrity is maintained in accordance with the patient care plan and document the following interventions in the “Daily Assessment” under ADL’s (Activities of Daily Living) tab: i. Reposition patient as frequently as the patient can tolerate, minimum every 2 hours. ii. Clarify and document any limitations per physician or any patient refusal.” 1c. During a review of Patient 13’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/11/2023, the Face Sheet indicated, Patient 13 was admitted to the facility on 12/11/2023 at 9:33 p.m. with a diagnosis of gastrostomy tube (g-tube, a tube surgically placed through the abdomen into the stomach for feeding) placement. During a review of Patient 13’s integumentary (skin) admission assessment note, dated 12/11/2023 at 11:00 p.m., the integumentary admission assessment note indicated, Patient 13 had a stage IV (most severe type of pressure injury. The skin was severely damaged, and the surrounding tissue begins to die) pressure ulcer/injury (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) to the sacrum/coccyx (tailbone). During a review of Patient 13’s integumentary admission assessment note, dated 12/11/2023 at 11 p.m., the integumentary admission assessment note indicated, Patient 13’s Braden Scale (a tool used to measure the risk of getting a pressure ulcer) was 12 out of 23. A Braden score of less than 18 or less, indicated actions were: pressure injury prevention and management plan (PIPP), turn clock signs, repositioned/turned every two hours, floated heels off mattress with foam boots and other off-loading devices (ie. wedges, pillow, heel protectors, etc.), managed moisture with incontinence (lack of voluntary control over urination or defecation) care products and encouraged adequate nutrition/fluid intake, and wound care nurse referral. During a concurrent interview and record review on 12/15/2023 at 9:20 a.m. with the Manager of the Medical Surgical (MMS) unit, Patient 13’s Daily Living Daily Assessment record was reviewed. The Daily Living Daily Assessment record indicated Patient 13 was not repositioned/turned every two hours per facility’s policy regarding turning/repositioning and Patient 13’s refusal for turning/repositioning was also not documented for dates 12/12/2023 at 12 a.m. through 12/15/2023 at 7:05 a.m. This lack of documentation was verified by the MMS. During a review of the facility’s policy and procedure (P&P) titled, “Wound Care: Assessment and Documentation,” dated 4/22/2022, the P&P indicated: “A. Skin Integrity (skin health): The patient ’ s skin integrity from head to toe will be assessed upon admission and each shift. Procedure: Wound Assessment: Document description of each wound in the electronic medical record in the “Daily Assessment” under the integumentary (skin) and pressure injury tab to include the following: Location (Specific injury location on body). Size (length x width x depth in cm) Length: Longest head ¿¿- to - toe measurement Width: Longest hip - to - hip measurement Depth: Deepest part of the wound (perpendicular to the skin surface) Undermining (separation of the wound edges from the surrounding health tissue, often creating a pocket under the wound surface)/Tunneling (when a wound extends deeper into the tissue than its surface, creating a channel or tunnel) Document if present Wound/Periwound (tissue surrounding a wound) Appearance... Photographing: Photographs should be included in the medical record to support documentation to determine progress of wound healing and effectiveness of therapy. Photographed open wounds and pressure injuries are to be posted on the Wound Photograph Wound will be photographed: Within 24 hours of admission. ii. Change of condition iii. Upon discovery of a new wound iv. Within 24 hours of discharge Bi-weekly on Wednesday and Sunday. The photo label should include: i. Patient’s date of birth or medical record number ii. Location of wound/lesion iii. Date and time of photograph iv. Measurement device v. Optional body alignment sticker If unable to obtain a photograph, document the reason in the medical record. C. Risk Prevention 2. Positioning and care and documentation: a. The nursing team will position the patient to ensure the skin integrity is maintained in accordance with the patient care plan and document the following interventions in the “Daily Assessment” under ADL’s (Activities of Daily Living) tab: i. Reposition patient as frequently as the patient can tolerate, minimum every 2 hours. ii. Clarify and document any limitations per physician or any patient refusal.” 2. During a concurrent observation and record review on 12/11/2023 at 3:13 p.m., in the Labor and Delivery Unit (L&D, a unit that specializes in childbirth), Crash Cart (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) 1’s (adult crash cart) log titled “Crash Cart and Defibrillator Checklist,” was reviewed. There was no documentation to indicate that Crash Cart 1 was checked for emergency medications, supplies, and equipment on 9/8/2023, 9/14/2023, 9/16/2023, 9/24/2023, 10/11/2023, 10/14/2023, 11/17/2023, 12/7/2023, and 12/8/2023. During a concurrent interview and record review on 12/11/2023 at 3:35 p.m. with Charge Nurse 1 (CN 1), the Crash Cart 1 ’ s (adult crash cart) log was reviewed. CN 1 stated the Charge Nurse is responsible for checking the crash cart each shift for day shift and night shift. Verified with CN 1 that the Crash Cart 1 was missing Crash Cart checks from the “Crash Cart Checklist” for September 2023, October 2023 and December 2023. Items on the “Crash Cart Checklist” that should have been checked included: cart locked, defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat) checked, code blue (requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest) record/form present, RRT (Rapid Response Team, a team of medical providers that respond when a patient demonstrates signs of imminent clinical deterioration) form present, O2 (oxygen tank, a container with oxygen inside it, used for helping people to breathe) Above 2000 PSI (pounds per square inch, a unit of measurement), and transport defibrillator checked with pads. CN 1 stated she (CN 1) was unaware why the dates and Crash Cart checks were not completed, and also stated she (CN 1) was not working on the missing dates. CN 1 said if the Crash Carts were not checked, items can be missing, and patients can be harmed. During an observation on 12/11/2023 at 3:45 p.m., in the L&D unit, Crash Cart 2’s (neonatal [relating to newborn children] crash cart) log titled “Crash Cart and Defibrillator Checklist” was reviewed. There was no documentation to indicate that Crash Cart 2 was checked for emergency medications, supplies, and equipment on 11/1/2023, 11/2/2023, 11/4/2023, 11/5/2023, 11/8/2023, 11/9/2023, 11/14/2023, 11/15/2023, 11/17/2023, 11/18/2023, 11/22/2023, 11/24/2023, 11/25/2023, 11/26/2023, and 11/30/2023. During a concurrent interview and record review on 12/11/2023 at 3:35 p.m. with the Manager of Neonatal Intensive Care Unit (MNICU), the MNICU verified missing entries for Crash Cart 2 on the “Crash Cart and Defibrillator Checklist,” for the month of November 2023. MNICU stated this (Crash Cart 2) was the only neonatal crash cart in the L&D unit and once it was identified that the crash cart checks were not being completed by L&D, the NICU Charge Nurses took over checking this Crash Cart on 12/5/2023, once in the morning and once at night. MNICU stated that not checking the Crash Cart can lead to the patient getting expired equipment or medications and the patient can have an injury. During a review of the facility’s policy and procedure (P&P) titled, “Crash Cart and Defibrillator Check Procedures,” dated 12/30/2016, the P&P indicated, “ ...The Defibrillator and external area of each Crash Cart will be checked once per shift to ensure that the necessary items are present and in working order. Confirmation of the Crash Cart/Defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat) check will be documented on the Code Blue (indicate a patient requiring resuscitation [to revive] as the result of respiratory or cardiac arrest [when the heart stops beating]) Cart Checklist stored with each cart. Crash Cart Checks: 1. Every department in possession of a crash cart must check the external area of the cart once per shift. 3. The Crash Cart check will include verification that: a. all items are present; b. all items are in working order; c. There are no outdated or expired products; and d. Any missing or outdated items are replaced. 8. The Emergency Crash Cart Check list will be used each shift to document the timely completion of the Crash Cart Check. a. For each item listed on the Emergency Crash Cart checklist. A check-mark will be placed in each column to confirm inspection and is in the row consistent with the date. b. The tag number of the Crash Cart lock will be recorded to confirm that the lock is in place and intact. c. The nurse completing the Crash Cart check will print and sign their name in the appropriate column consistent with the row for date. D. Defibrillator Checks: 1. Defibrillator checks will include: a. An employee will be designated by the charge nurse/lead to check the Defibrillator each and every shift. b. Departments/units with 24-hour care: A visual inspection. Ensure that the defibrillator is plugged into the A/C outlet to include completion of the Crash Cart Checklist for each shift. -0700-1900 shift between 0700-0730, 1900-0700 shift between 1900-1930. -The designated employee will check the assigned defibrillator during the time frames indicated above. d. Manual testing with verification of Code Readiness Log will be performed during the completion of the Crash Cart Checklist ...””

“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: 36206 Based on interview and record review, the facility failed to: 1. Ensure to correctly count and document surgical count of sponges (an absorbent pad used during operations and surgical procedures) for one of 30 sampled patients (Patient 16) in accordance with accepted standards of practice and with the facility’s policies and procedures regarding surgical counts (count of items during surgery which is an essential practice to ensure patient safety). This deficient practice resulted in Patient 16 undergoing another procedure to reopen the incision (a surgical cut into the skin) to remove the remaining sponge inside Patient 16’s abdominal cavity and had the potential to compromise Patient 16’s health and wellbeing. 2. Ensure a Physician provided ongoing monitoring and treatment for one of 30 sampled Patients (Patient 1) and ensure Patient 1 received medical care in a safe and effective manner. Patient 1 required emergency Cesarean Section (C-section, surgical delivery of a baby) due to Fetus (unborn baby) bradycardia (slow heart rate; Normal fetal heart rate is between 110-160 beats per minute). This deficient practice had the potential to place all newborn patients at risk for serious injury, harm, or death. Findings: 1. During a review of Patient 16’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, on 11/20/2023 Patient 16 presented to the facility with contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor [a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal]) after Patient 16’s membranes raptured (a sac that holds the fluid that surround a baby in the womb), but the fetus was in transverse lie (a fetus that’s lying sideways in the uterus [part of the female reproductive system where the baby grows] during labor), and Patient 16 needed a cesarian section (CS, surgical delivery of a baby through a cut [incision] made in the mother’s abdomen and uterus). During a review of Patient 16’s post operative (after surgery) note (PON), dated 11/20/2023, the PON indicated, by the time the surgeon (S2) scrubbed in (elaborate hygiene procedure that surgeons go through right before surgery), the baby was already delivered, and the uterine incision (cutting through a womb) was already closed in one layer by the surgeon (S1) who started the procedure. The PON further indicated, the S2 proceeded to close the second layer of uterine incision, the uterus was returned into the abdomen, and the skin was closed with staples. The PON further indicated, the X-ray (an X-ray is an imaging study that takes pictures of bones and soft tissues) of the abdomen was performed because the instruments and the laparotomy sponges (an absorbent pad used during operations and surgical procedures) were not counted before the procedure due to the emergency nature of the procedure. The PON also indicated, X-ray revealed that there was a laparotomy sponge left inside the abdomen. The PON indicated, the S2 then returned to the operating room and re-opened Patient 16 ’ s incision and removed the sponge. During a review of Patient 16’s intraoperative report (IOR, during surgery report), dated 11/20/2023, the IOR indicated instrument count was performed four times during the procedure, and all four times the count was documented as “Correct.” During an interview on 12/13/2023 at 9:00 a.m. with relief charge nurse (RCN 1), the RCN 1 stated, count of instruments and sponges was done by two people during the procedure and communicated out loud to the rest of the team during the procedure. If the count was not done or was incorrect, due to an urgency of a situation and inability to perform count, this should be documented as “not performed,” as per facility’s policies and procedures and an X-ray should be done before the surgeon proceeds to close the layers of the skin. The RCN 1 further stated, on 11/20/2023, the RCN 1 was present during Patient 16’s crash (rapid) CS (necessary to save the fetus from death or disability) and the RCN 1 stated the team was aware the count of instruments and sponges was not accurate because it (the surgical count) was not done before starting the procedure, and further stated participating surgeons were aware of it (not performing the surgical count). During an interview on 12/13/2023 at 3:34 p.m. with the vice president of quality and risk management (VPQRM), the VPQRM said the facility conducted the internal investigation and the S2 stated, the S2 was not aware of the policy about the need for an X-ray before closing Patient 16’s skin layers during the procedure. During an interview on 12/14/2023 at 2:04 p.m. with surgeon 2 (S2), the S2 stated during the procedure on 11/20/2023, after scrubbing in, the S2 was aware of no count done during the procedure and did not know why the count was not done. The S2 the stated the X-ray was done after closing the skin layers of Patient 16. During an interview on 12/14/2023 at 2:23 p.m. with Chief Nursing Officer (CNO), the CNO stated, the circulator nurse (RN 6) who documented on 11/20/2023, in Patient 16 ’ s intraoperative report, that the count was correct, had to document that count was incorrect and/or not done due to the emergency circumstances of the procedure, but the nurse (RN 6) did not. The CNO stated, the nurse (RN 6) was interviewed, and the nurse recognized that documentation in Patient 16’s chart was wrong, because the count of all instruments and sponges was not done prior to starting the crash CS on Patient 16, but the RN 6 forgot to correct the documentation. During an interview on 12/14/2023 at 2:38 p.m. with surgeon assistant (MD3), the MD 3 stated, the count was always performed before the procedure, and multiple times during the procedure. The MD 3 then stated, in rare instances when the count was not performed, before closing the layers of the skin, the surgeon must ask if the count was correct, and if the count was not performed or incorrect, the Xray needs to be done immediately before closing the skin and the surgery must be stopped until all missing items were located. During a review of the facility’s policy and procedure (P&P) titled, “Surgical Counts,” dated 04/2022, the P&P indicated sponges, sharps (any objects that can prick or cut causing injury to the user), instruments and miscellaneous items shall be accounted for during surgical procedures. The RN and the scrub tech (technician) are responsible for accurately accounting of items used during surgical procedures. The scrub person shall maintain an organized sterile (free from germs) field; maintain awareness of location of soft goods (example: sponges, towels, etc. Used in surgery). The registered nurse shall document and sign the surgery record, the occurrence, accuracy and personnel involved in all counts. Counts not done due to a patient’s emergency shall be documented on the operative record and incident report filled. An Xray shall be taken whenever the physician declines count to be performed. If the count is incorrect, the surgeon is notified, a recount is taken, a search is made for the missing item, and if not found, an Xray should be taken. During a review of the facility’s policy and procedure (P&P) titled, “Surgical Counts,” dated 04/2022, the P&P indicated, “The surgeon and surgical assistant shall maintain awareness of sponges, sharps, and instruments used and shall communicate to the surgical team any item placed into the wound for documentation and tracking purpose. Each sponge must be completely separated, visualized by the circulator RN (responsible for the delivery and documentation of patient care during the intra-operative period [the time period from when the patient is on the operating table to when the operation has finished and the wound is closed]) and scrub tech (technician) and counted audibly. Sponges shall be counted on all procedures.” 2. During a review of Patient 1’s medical record titled, “Obstetric Admission History and physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/25/2023, documented by MD 1, the Obstetric Admission History and Physical indicated, Patient 1 was admitted to the Labor and Delivery (L&D, a unit that specializes in childbirth) for uterine contractions (tightening of uterine muscles [middle and thickest layer of the uterus, which is a part of the female reproductive system where the baby grows] during labor) and pain. Patient 1’s Pelvic exam (used to check the health of the reproductive organs) indicated, Cervical Dilation (when cervix [the lower part of the uterus] opens to allow the baby to move through the birth canal) of 2 to 3 centimeter (cm, range 0 to 10, 10 means fully dilated), and Station -2 (how far into the birth canal the baby’s head is located; scale ranges from a -5 to a +5), Artificial Rupture of Membrane (AROM, when a healthcare provider intentionally breaks a person’s amniotic sac [a bag of waters that surrounds the fetus [unborn baby]) and placement of Intrauterine Pressure Catheter (IUPC) device used to measure uterine contractions. Patient 1’s Fetal Assessment indicated a Fetal Heart Rate (FHR) of 120 (Normal FHR 110 to 160 bpm) and a FHR pattern Category I (Normal baseline FHR of 100 to 160 beats per minute). Patient 1 did not have risk factors documented. Physician Orders included continuous Fetal Heart monitoring. During a Concurrent interview and record review on 12/13/2023 at 1:40 p.m. with the Clinical Educator (CED) of the L&D unit, Patient 1’s LD Flowsheet (contains important data regarding a patient’s condition) and FHR monitor strips (a record of the FHR and contractions) were reviewed. The records indicated, Patient 1 was started on pitocin (medication to increase uterine contractions) at 9:14 a.m. on 6/25/2023, and Pitocin was discontinued at 10 a.m. At 10:02 a.m., Patient 1 had prolonged decelerations (fetal heart rate below baseline for more than two minutes but less than 10 minutes). At 10:07 a.m., fetal assessment in the LD Flowsheet indicated late decelerations (a decrease in fetal heart rate associated with contractions) and variable deceleration (an abrupt decrease in fetal [unborn baby] heart rate which could indicate umbilical cord compression [when the baby’s weight puts pressure on the cord during pregnancy or labor and can restrict blood flow and oxygen to the baby]) and Fetal Heart Pattern was changed from category one (Normal- late or variable decelerations are absent in category one) to category Two (indeterminate [not exactly known]). During a review of a facility document titled, “Fetal and uterine monitoring assessment interpretation and documentation,” dated 4/28/2021, the document indicated “Category one included: baseline FHR 110 to 160 beats per minute, early decelerations are present or absent, late or variable decelerations absent, and predicts normal acid base status (measure of oxygenation of the fetus). Category 2 is indeterminate and includes when not enough evidence is available to classify as category one or category three. Category two requires evaluation surveillance and reevaluation. Category 3 predicts abnormal acid base status and includes absent baseline fetal heart rate and any of the following: recurrent late decelerations, recurrent variable decelerations, Bradycardia.” During a Concurrent interview and record review on 12/13/2023 at 2:15 p.m. with the Clinical Educator (CED) of the L&D Unit, Patient 1’s LD Flowsheet and FHR monitor strips, dated 6/25/2023, were reviewed. The CED stated Patient 1 needed to be on continuous fetal monitoring. CED also said Patient 1 had a rupture of membrane and, therefore, fetal assessment should have been completed every 30 minutes. The CED stated late, variable, and prolonged decelerations indicated fetal distress (changes in heart rate, movement, etc.). Further review of Patient 1’s LD Flowsheet indicated, Patient 1 had Late Decelerations at 11 a.m. Fetal Assessment was conducted. MD 1 was notified, but MD 1 was “delivering another Patient” and ordered Fetal Scalp electrode (FSE, a device attached to fetus’ scalp to monitor FHR). At 11:18 a.m., MD 1 reviewed the FHR tracing, and Placed FSE. At 11:20 a.m., MD 1 informed Patient 1 that if Patient 1 had more fetal decelerations, he (MD 1) will take Patient 1 for Caesarean Section.” The record also indicated Patient 1 had an epidural (an injection in the back to stop feeling pain) placed at 11:33 a.m. The CED reviewed and confirmed there were no Fetal Assessments and documentations of FHR from 11 a.m. to 12:22 p.m. on 6/25/2023. During a review of Patient 1’s LD flowsheet, dated 6/25/2023, the LD Flowsheet indicated that at 12:22 p.m., decelerations in heart rate was noted by staff at bedside, intervention included repositioning. At 12:27 p.m., the LD Flowsheet indicated Patient 1 was Category 3 with “FHR baseline rate of 50, minimum undetectable variability, and prolonged decelerations.” During a review of Patient 1’s “OB (Obstetric, a branch of medicine specialized in the care of pregnant women and childbirth) Cesarean Section Note,” dated 6/25/2023 at 2:34 p.m., the OB Cesarean Section note indicated, a preoperative (before surgery/procedure) diagnosis of intrauterine pregnancy (when a fertilized egg implants and starts to develop within the uterus) at term, fetal bradycardia. Patient 2 (Patient 1’s baby) was delivered at 12:47p.m. During a review of Patient 1’s “Neonatal (relating to newborn children) Delivery and Resuscitation (methods used to restart the heart and lungs if they stop working) Record,” dated 6/25/2023, the Neonatal Delivery and Resuscitation Record indicated, the NICU team attended the delivery of Patient 2 (Patient 1’s baby). Patient 2 was delivered at 12:47 p.m. Patient 2’s APGAR scores (a scoring system from 0 - 10, used to assess newborns at one minute and five minutes of life to determine whether or not the baby needs medical intervention or assistance) were: at one minute was 0, at 5 minutes was zero, at 10 minutes was one, and at 15 minutes was 4. Further review of the Neonatal Delivery and Resuscitation Record indicated Crash C-section (rapid C-section necessary to save the fetus from death or disability) was for “NR FHR (Non reassuring FHR [abnormal fetal heart rate]) and indicated “no fetal heart rate detected for 25 minutes prior to delivery.” The record also indicated that upon delivery, Patient 2 (Patient 1’s baby) “was limp, cyanotic (blue in skin color) and no heart rate. NRP (Neonatal Resuscitation Protocol) was started. Patient 2 was intubated (a tube is inserted through the mouth or airway to keep the airway open so air can get through) and was transported to the Neonatal Intensive Care Unit (NICU, unit that specializes in providing intensive [critical] medical care to newborns).” During a review of Patient 1’s “Delivery Summary,” dated 6/25/2023, the Delivery Summary indicated, the indication for C-section was “non reassuring tracing strip” and Assessment also indicated “extended fetal bradycardia, multiple variable Decels (deceleration).” During an interview on 12/15/2023 at 2:36 p.m. with the Vice President of Quality and Risk Management (VPQRM), the VPQRM said that Patient 1’s and Patient 2’s cases were not reviewed. During a review of the facility’s document titled, Rules and Regulations of OB GYN (obstetrics gynecology, a branch of medicine specialized in the care of pregnant women and childbirth),” dated 7/16/2022 indicated, “the admitting physician shall be primarily responsible for patient care, and the ongoing professional evaluation of the quality of obstetric and gynecology care will be conducted on an ongoing basis by routine collection of information concerning important aspects of care.””

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to ensure a properly executed informed surgical consent was in the medical record for one of 30 sampled patients (Patient 5), prior to Patient 5’s Cesarean Section (C-section, surgical delivery of a baby), in accordance with the facility’s policy and procedure regarding obtaining an informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). This deficient practice had the potential for the surgical team to perform the wrong procedure on Patient 5 and had the potential for Patient 5 to not be fully informed of the type of surgical procedure/s she (Patient 5) was having. Findings: During a review of Patient 5’s Face Sheet (a document that gives a patient ’ s information at a quick glance), dated 12/10/2023 at 6:02 a.m., the Face Sheet indicated Patient 5 was admitted to the obstetric (a branch of medicine specialized in the care of pregnant women and childbirth) service for a scheduled Cesarean Section (C-section, surgical delivery of a baby). During a review of Patient 5’s “Pre-Operative (before surgery) History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/10/2023, the H&P indicated Patient 5 was 39 weeks pregnant (40 weeks is full term), admitted to the Labor & Delivery (L&D, a unit that specializes in childbirth) area for a repeat C-section. During a review of Patient 5’s “Labor and Delivery Consent Form: Authorization for Consent to Surgery or Special Diagnostic or Therapeutic Procedures,” dated 12/20/2023, the consent indicated the following: Patient 5 signed the consent at 6:53 a.m., and the physician signed the consent at 7:30 a.m. Section 3 of the consent was blank and did not indicate whether Patient 5 would have a vaginal delivery with possible episiotomy (a surgical cut made at the opening of the vagina during childbirth), primary (without a previous C-section) C-section, repeat C-section, or other procedure. During a review of Patient 5’s “Anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) Record,” dated 12/10/2023 at 9 a.m., the Anesthesia Record indicated Patient 5 received spinal (injection of a drug into either the fluid of the spinal canal or immediately outside of the canal) anesthesia for a repeat C-section. The procedure (C-section) started at 9:23 a.m., and ended at 10 a.m. During a review of Patient 5’s “Operative Note,” dated 12/20/2023 at 3:15 p.m., the Operative Note indicated the following: Operations Performed: Repeat low transverse (lower part of the uterus) cesarean section plus lysis (cutting bands of scar issue that form after surgery) of pelvic and abdominal adhesions (bands of scar-like tissue that form between two surfaces inside the body and cause them to stick together). During a concurrent interview and record review on 12/12/2023 at 11:16 a.m. with Charge Nurse (CN) 3, CN 3 reviewed Patient 5’s “Labor and Delivery Consent Form,” dated 12/10/2023, and stated the following: Patient 5 delivered by C-section on 12/10/2023 at 9:27 a.m. CN 3 verified that the consent was incomplete. The consent did not indicate whether Patient 5 was having a vaginal delivery or C-section. CN 3 stated the consent should indicate the type of procedure to be performed on Patient 5, so that the patient and staff involved in the procedure would know the type of surgery Patient 5 was having. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent for Procedures and Treatments,” dated 5/27/2020, the P&P indicated the following: “The hospital recognizes and respects the patient ’ s right to be involved in the decision-making of all aspects of their care and to be informed of the risk, benefits and alternatives to proposed procedures and treatments to ensure informed decision-making. The hospital complies with all the state and federal regulations. It is the hospital’s policy for its staff to facilitate obtaining voluntary, informed consent from patients (or their legally designated representative [LDR] ..., after the physician has discussed the risk, benefits, and alternatives to the procedure with the patient and prior to rendering medical procedures and treatments that involve material risk. Informed consent must be obtained and documented according to policy ...Informed consent involves a detailed discussion between the patient (or LDR) and the treating physician that includes: Nature of the proposed care, treatment, and services ...It is the treating physician’s responsibility to obtain the informed consent ...Documentation of Informed Consent: Documentation of the discussion and patient decision is to be noted in the patient’s medical record ...””