Kaiser Foundation Hospital and Rehab Center

“DIRECTOR OF RESPIRATORY SERVICES CFR(s): 482.57(a)(1) There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. This Standard is not met as evidenced by: 42291 Based on interviews and record review, the facility failed to ensure there was a documented full-time or part-time director of Respiratory Care Services who is a Doctor of Medicine (DOM) or Osteopathy (DO). This failure resulted in the Respiratory Care Services not having a DOM or DO with the knowledge and experience to supervise and administer the Respiratory Care Services Department. Findings: During an interview with the Manager Respiratory Therapy (MRT) on 9/4/25 at 9:00 a.m., MRT indicated that he reported to the Nursing Director (ND 2), a Registered Nurse. The MRT further indicated that there was no Medical Director for the Respiratory Care Services. During an interview with ND 2 and MRT on 9/4/25 at 9:25 a.m., ND 2 indicated, MRT reported directly to ND 2 and ND 2 reported to the Chief Nurse Executive (CNE). ND 2 acknowledged that there was no Medical Director for the Respiratory Care Services. During a concurrent interview and record review with the Quality and Safety Oversight Specialist (QSOS) on 9/4/25 at 11:30 a.m., the facility’s Organizational Charts titled “[Facility Name] Administrative Leadership Team for the Hospital and the Medical Group” was reviewed. The QSOS acknowledged there was no Medical Director responsible for the Respiratory Care Services on the Organizational Charts. During a review of the facility’s policy and procedure (P&P) titled, “Respiratory Care Services Plan for the provision of Care,” approval date 2/25, the P&P indicated, “The inpatient Respiratory Care Department provides respiratory care services to inpatients and managers and operates the Blood Gas Laboratory [analyzes a sample of blood to see how well the lungs are working] (in conjunction with the clinical lab) ... The Respiratory Care Department operates under the standards of the community and individual licensed requirements of the Respiratory Care Practice Act, State of California ... The Respiratory Care Manager in conjunction with the [Facility Name] Site Supervisor has accountability and responsibility to assure that the program is in place ...” The Policy did not indicate whether a DOM or DO was required to oversee the Respiratory Care Department.”

“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: 31424 Based on observations, staff interviews, clinical record and document reviews, and review of the hospital’s policies and procedures, Hospital 1’s noncompliance with the requirements under EMTALA occurred as a result of Hospital 1’s failure to follow its policy and procedure for patient discharge from the Emergency Department (ED) when Patient 100 was discharged home to an environment that was unsafe and interventions were not in place to address his physical and psychosocial needs. [Cross-Reference 2409] Findings: During a concurrent interview and emergency medical record review on 6/11/24 at 9:10 a.m., Assistant Nurse Manager G stated Patient 100 arrived in the ED on 1/26/2024 at 11:48 a.m. She stated he was triaged (prioritization of injured/sick patients based on their need for emergency treatment) at an ESI (Emergency Severity Index) level of 3 (urgent). (Orientation Tool: Alert and Oriented (A&O) x1, x2, x3, x4 - stands for orientation to person (x1), place (x2), time (x3), and situation (x4). A patient who is oriented x1 means they are only oriented to themselves (confused about place/time/situation). A patient oriented x2 is oriented to themselves and where they are, but confused about time/situation, etc. This tool is commonly used to describe the mental status of patients in healthcare settings and serves as an evaluation tool for understanding a patient’s cognitive abilities and identifying potential concerns.) A review of Patient 100’s ED Provider Notes, dated, “1/26/2024 5:48 PM,” indicated, “History of Present Illness: [Patient 100] was a 77-year-old male with a prior stroke, vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain [mayoclinic.org], diabetes and hypertension ... they (family) have been unable to fully clean or turn him. He is incontinent of urine and stool, so he has essentially been sitting in incontinence for several days ... patient’s wife is disabled (does not walk) and [son] himself is also disabled and is too weak to turn his father ... his current situation at home is very unsafe ... Patient’s son arrived ... States ... the patient cannot come back home under any circumstances. ‘The doors will be locked.’ ...” Review of Patient 100’s medical record indicated a social worker (SW T) submitted an Abuse Report (regarding Patient’s 100 home living situation) to (local county) Adult Protective Services (APS) on 1/26/24 at 3:50 p.m., that indicated Patient 100 “...Has multiple caregivers quit because patient is verbally abusive ... patient’s son states ... they (family) have been unable to fully clean or turn him... They have been unable to find a caregiver to assist... current situation at home is very unsafe...” Review of a Physical Therapy (PT) evaluation, dated 1/30/2024 (three days prior to discharge home), indicated Patient 100 was not fully cognitively intact at the time of the assessment and, “...Patient currently unaware where he is located...” (i.e., not oriented to place). The evaluation indicated Patient 100, “Requires 24-hour assistance...” with toileting, mobility, and ADL’s (Activities of Daily Living, a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). The evaluation indicated Patient 100 was unable to transfer (sit to stand, bed to chair, chair to bed) because he was, “unable due to left lower extremity (leg) pain and weakness” and was unable to be assessed for Gait (walking) as he was unable to bear weight (support his body weight during activities like standing/walking). A review of Patient 100’s seven-day ED stay, from 1/26/24 to 2/2/24, indicated staff and providers documented his mentation fluctuated between oriented and confused: On 1/26/24 at 5:48 p.m., Physician V documented, “ ...does not appear to understand the ramifications of his words and actions on his overall care.” On 1/26/24 at 7:22 p.m., a Registered Nurse (RN) documented, “... asking for wire cutters so he could cut his wires off and escape. Attempted to reorient patient without success ...” On 1/27/24 at 5:17 a.m., an RN documented, “Pt states he is a manager at Safeway and drives to work every day.” On 1/29/24 at 12:04 p.m., a provider documented, “Patient currently unaware where he is located...” and, On 1/31/24 at 10:16 a.m., the wound nurse documented, “Patient is awake, but not able to make needs known effectively at this time... Unable to follow simple commands...” Review of Patient 100’s medical record indicated his mental status on 2/2/24, the day of his discharge: At 12:56 p.m., Physician B documented, “Addendum: Hold patient additional light (sic) since there appears to be a waxing and waning mental status pattern...” At 3:25 p.m. (the afternoon of discharge), CM D further documented, “...Canceled (ambulance) request. Patient’s mental status (was) waxing and waning therefore HBS (Hospitalist, physician) has suspended discharge and will watch again overnight.” During an interview on 6/12/24 at 10:35 a.m., when asked about her discharge work with Patient 100, CM D stated Patient 100’s mental status, “was being questioned,” and many times he was alert and oriented but she thought he was overestimating his ability to care for himself. Review of a letter from Napa County Adult Protective Services, dated 2/2/2024 at 5:22 p.m., indicated APS SW (APS Social Worker) wrote to Hospital 1 about Patient 100’s impending discharge. The letter indicated, “This letter is in response to notification that your facility intends to discharge a patient back to his home. Please be advised that APS believes discharging this patient does not comply with California Health & Safety Code... and/or Medicare regulations... The services needed to ensure a safe discharge have not been put in place. APS is therefore requesting that the discharge of (Patient 100) be postponed until such time that the necessary services are in place... In the case of (Patient 100), the services necessary to meet his continuing health care needs include a caregiver or other in-home support agency that can assist (Patient 100) with meals, medications, incontinent care, and all other activities of daily life... APS is opposed to discharging (Patient 100) until such time the ‘appropriate arrangements for posthospital care’ are available. Discharging in the absence of necessary services is not an acceptable discharge plan...” During an interview on 6/12/24 at 2:46 p.m., Social Worker F (SW F) stated she became involved in Patient 100’s discharge at approximately 5 p.m., that evening (2/2/24) and she was aware of the APS letter. Review of SW F’s medical record documentation of that evening’s events indicated she documented the incident on 2/3/24 at 6:51 p.m. (the following day). SW F documented, “(Hospital 1) received a fax from Napa County APS at 5:22PM indicating they do not feel that we have created a safe discharge for the patient and would advise against sending him home. Social worker called and spoke with... management (Director C) who state (sic) that (Hospital 1) has fulfilled its role of creating a safe discharge plan...” Further review of Patient 100’s medical records on the evening of his discharge indicated at 7:30 p.m., an RN documented, “... Pt is currently alert and oriented to person and place...,” and at 8:21 p.m. (immediately prior to ambulance transfer back home), an RN documented, “... Pt is currently alert to person only... He states it is 2034 (the year) ... Pt is also requesting for a phone so that he can call out sick from his job as the manager of Safeway...” Review of Patient 100’s ambulance trip sheet, dated 2/2/24 (discharge from Hospital 1 to home) indicated the EMT’s (Emergency Medical Technicians) documented the Transfer of Care form (authorization for treatment and transport) was signed by Hospital 1’s ED nurse (prior to departure) due to Patient 100’s, “...confusion.” The EMT’s documented Patient 100 required ambulance transportation, “...due to confused mental state, and being bedridden,” and indicated they arrived at Patient 100’s home at approximately 8:51 p.m. The EMT’s documented that enroute to the home, “Pt (patient) exhibited confusion during transport, continuously thought EMT was a grocery store employee and discussed being at Albertson’s instead of the Hospital.” Continued review of the 2/2/34, ambulance trip sheet indicated once at the home, the EMT’s met the new caregiver. The EMT’s documented, “...Lockbox (with house key) to house was empty, caretaker attempted contacting family with no success. Caretaker contacted Social Worker (at Hospital 1) who contacted a locksmith. Waited with the patient in ambulance to keep warm... Napa PD (Police Department) arrived for unknown reason... Locksmith was able to open door, 2 police officers cleared home premises before we took patient to bedroom, house was empty... “ The EMT’s documented they transferred care of Patient 100 (to the caregiver) at 10:45 p.m. During a telephone interview on 6/13/24 at 8:26 a.m., APS Supervisor (APS S) stated she was on-call the weekend of Patient 100’s discharge on 2/2/24 (Friday). She stated her office was concerned all week (during Patient 100’s seven-day stay) because he had a hard time keeping caregivers, his family could not provide the care he needed, and Patient 100 did not seem to understand the level of care he actually needed. APS S stated on 2/2/24, her department advised Hospital 1 (in the letter) that the pending discharge was unsafe. . APS S stated she spoke to SW F, and told her APS was concerned about Patient 100’s home and care situation. SW F informed her that Patient 100 would be getting four hours of caregiver assistance per day. APS S stated she was still not comfortable with the discharge plans after speaking with SW F and felt Patient 100 was being discharged too early; she stated there was no one (family) at home, and the caregiver may not last. During the same interview on 6/13/24 at 8:26 a.m., APS S stated she received a call on Saturday (2/3/24), from Patient 100’s family who told her they saw (on a doorbell camera) the caregiver leave the home at 1 a.m. APS S stated she called the PD to conduct a welfare check at the home in the morning. The PD reported to her that there was no caregiver present, and Patient 100 did not have access to food nor to a telephone. Review of Patient 100’s ambulance trip sheet, dated 2/3/2024, indicated a Paramedic and an EMT were on-scene at Patient 100’s house at 10:23 a.m. (approximately twelve hours after he was discharged from Hospital 1’s ED the prior night). The Paramedic and EMT documented, “...dispatched ... with pd (Police Department) on scene... pt was found laying (sic) in bed with napa fire assessing pt. no family or caregiver at home. pt A&O 4 (alert and oriented, not confused) ... (patient) stated he came home from the hospital last night via ambulance transfer. pt was released from (Hospital 1) last night. pt family was out of town. pt was left uncared for. pt stated he wasn’t sure where anyone was ‘they abandoned me’ pt did not have anything to eat or drink since leaving the hospital as pt could recall... per PD patient is being taken back to the hospital to get reevaluated and to set up a plan for pt to receive care of the hospital due to not having care for pt at home currently...” During a virtual/video interview on 6/13/24 at 9:27 a.m., Physician B stated he recalled the discharge had been complicated involving complicated family dynamics. Physician B stated Patient 100 had been medically cleared for discharge approximately two days prior to his 2/2/24 discharge but his family could not take care of him. Physician B stated he was aware of Patient 100’s, “waxing and waning,” mentation on 2/2/24, prior to discharge, and stated he was holding him overnight out of abundance of caution. When asked why Patient 100 was then discharged a few hours later, Physician B stated patient discharges were a team activity, not a decision made just by him. During an interview on 6/13/24 at 10:22 a.m., Director C stated she oversaw Patient 100’s discharge plan over his week’s stay in the ED and ensured it was, “moving along.” She stated his plan was to return home with four hours of caregiver assistance. Director C was asked how four hours of daily care would meet Patient 100’s needs when Hospital 1’s PT evaluation indicated he required twenty-four hours of daily care, and she stated it was, “not an ideal plan.” When asked how Hospital 1’s discharge plan was safe, Director C stated it was the, “safest he (Patient 100) would allow.” She stated a Home Health Nurse was scheduled to go to the home three times a week. During an interview on 6/12/24 at 8:35 a.m., Quality Staff W stated the facility did not have a policy specifically addressing ED Boarders (Patients like Patient 100 who stay in the ED for an extended period because they did not meet hospital admission criteria). She stated Hospital 1’s ED policies would cover these patients. Review of ED policy titled, “Patient Flow in the Emergency Department,” subtitled, “ESI Priority III - Urgent” (Approved 11/2021 and reviewed 05/2024), indicated, “Patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. If the patient is not ESI priority 1 or 2, the next decision point asks how many different resources might this patient consume in order for the physician to reach a disposition decision...” The policy identified Resources as, “Labs (blood, urine) ... ECG, Imaging including x-ray, MRI... IV fluids (hydration)... special consultation...” Review of ED policy titled, “Patient Flow in the Emergency Department,” subtitled, “5.0 Procedures” (Approved 11/2021 and reviewed 05/2024), indicated, “5.4 Discharges in the Emergency Department 5.4.1 Once the medical emergency has been determined and stabilized or resolved, the patient is admitted, transferred or discharged ... The physician collaborates with other disciplines ... to determine appropriate discharge needs ... At the time of discharge patient’s physiological and/or psychosocial special needs is taken into consideration ...” 41175”

“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: 31424 Based on observation, interview, and record review, the facility failed to follow its policy for patient discharge from the Emergency Department (ED), when one of 20 sampled patients (Patient 100) was discharged home to an environment that was unsafe and did not meet his needs. Patient 100 was an elderly male who had a history of vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes), diabetes mellitus (DM; a group of common endocrine diseases characterized by sustained high blood sugar levels) and was bed-bound (inability to leave the bed; unable to stand, transfer, or walk independently). While in the ED from 1/26/24 to 2/2/24: a) Patient 100 exhibited hostile behaviors including refusal of care and medications and yelling profanities and insults at staff; b) Patient 100’s mentation (ability to think or reason) ranged from oriented and cognitively clear to confused; c) Per Hospital 1’s PT (Physical Therapy) evaluation, Patient 100 required, “24-hour assistance...” with toileting, mobility, and ADLs (activities of daily living, fundamental skill required to independently care for oneself, such as eating, bathing, and mobility); and, d) Patient 100’s family moved out of the family home, citing their inability to provide for his care. Hospital 1 discharged Patient 100 to his home with four hours of daily caregiver assistance (trained staff to provide care), indicating he would be alone in his house for 20 hours per day. This deficiency: 1) Caused Patient 100 to have no food for approximately 12 hours, placing him at risk of diabetic coma (a life-threatening condition caused by dangerously high or low blood sugar levels, rendering a person unconscious); 2) Prevented Patient 100 from calling for assistance when he was unable to access his phone; 3) Placed him at risk of harm when he was unable to call for help or walk to safety in the event of an emergency (e.g., fire); 4) Caused Patient 100 to be alone in his home from 1 a.m. until the following morning, when emergency responders arrived; 5) Caused Patient 100 to be transported back to the ED approximately 12 hours after his was discharged home due to emergency responders’ determination that he was not safe; and, 6) Caused Patient 100 psychosocial distress when he verbalized he felt abandoned. Findings: Review of Patient 100’s ambulance trip sheet, dated 1/26/24 (the beginning of Patient 100’s seven-day stay in the ED) indicated EMS found Patient 100 lying in bed, alert but refusing to answer orientation questions (cognitive assessment tool used in healthcare settings to evaluate a patient’s cognitive abilities), and, “extremely verbally abusive.” EMS documented, “... Per family on the scene, pt’s (patient’s) caregiver had not been to the residence in over 4 days and pt (patient) noted to be covered in feces and urine.” EMS documented family reported Patient 100 had bed sores (ulcers/wounds on the skin surface due to prolonged pressure). EMS documented, “Family stated that they have requested multiple caregiving agencies to assume care of the pt, however many have either quit or refused to provide services. Pt is bed bound and cannot perform basic activities of daily living such as feeding or cleaning himself on his own. Pt was found in diapers and blankets with copious amounts of feces and urine...” EMS documented they transported Patient 100 to Hospital 1 (ED). During a concurrent interview and emergency medical record review on 6/11/24 at 9:10 a.m., Assistant Nurse Manager G stated Patient 100 arrived in the ED, via ambulance and alone, on 1/26/2024 at 11:48 a.m. She stated he was triaged (prioritization of injured/sick patients based on their need for emergency treatment) at an ESI (Emergency Severity Index) level of three (urgent). His nurse documented he had bed sores, was agitated, and was alert and oriented x2 (to person and place, but not time and situation). She stated he was diagnosed with major vascular neurocognitive disorder and unspecified agitation. [Orientation Tool: Alert and Oriented (A&O) x1, x2, x3, x4 - stands for orientation to person (x1), place (x2), time (x3), and situation (x4). A patient who is oriented x1 means they are only oriented to themselves (confused about place/time/situation). A patient A&O x2 is oriented to themselves and where they are but confused about time/situation. A patient A&O x3 is oriented to themselves, where they are, and what time it is. A patient A&O x4 means they are oriented to themselves, where they are, what time it is, and what situation they are in (e.g., in a hospital due to a fall). This tool is commonly used to describe the mental status of patients in healthcare settings. It serves as an evaluation tool for understanding a patient’s cognitive abilities and identifying potential areas of concern.] A review of Patient 100’s ED Provider Notes, dated, “1/26/2024 5:48 PM,” indicated, “History of Present Illness: [Patient 100] was a 77-year-old male with a prior stroke, vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain [mayoclinic.org], diabetes and hypertension ... they (family) have been unable to fully clean or turn him. He is incontinent of urine and stool, so he has essentially been sitting in incontinence for several days ... patient’s wife is disabled (does not walk) and [son] himself is also disabled and is too weak to turn his father ... recommended to [son] take [Patient 100] to the emergency room again for assistance in finding SNF (Skilled Nursing Facility) placement as his current situation at home is very unsafe ... Patient’s son arrived ... States ... the patient cannot come back home under any circumstances. ‘The doors will be locked.’ ...” Review of Patient 100’s medical record indicated a social worker (SW T) submitted an Abuse Report (regarding Patient’s 100 home living situation) to (local county) Adult Protective Services (APS) on 1/26/24 at 3:50 p.m., that indicated Patient 100 was an elderly male with, “...vascular dementia, diabetes, prior stroke, diabetes... who came to the ED with caregiver concerns. SW T documented Patient 100, “...Has multiple caregivers quit because patient is verbally abusive ... patient’s son states that since they brought (Patient 100) home from the emergency room on 1/23/2024, they have been unable to fully clean or turn him... They have been unable to find a caregiver to assist in the past 3 days. It is highly likely that the wounds noted to the buttocks on 1/23 in the ED have grown significantly worse... current situation at home is very unsafe...” Review of a Physical Therapy (PT) evaluation, dated 1/30/2024 (three days prior to discharge home), indicated Patient 100 was not fully cognitively intact at the time of the assessment. The evaluation indicated Patient 100’s cognition was, “Alert and Oriented to: person...” and his safety judgment was, “fair based on his limited cognition...” The evaluation further indicated, “...Patient currently unaware where he is located...” (i.e., not oriented to place). The evaluation indicated Patient 100, “Requires 24-hour assistance...” with toileting, mobility, and ADL’s (Activities of Daily Living, a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. [National Institutes of Health.gov]). Continued review of the PT evaluation, dated 1/30/2024, further indicated Patient 100’s current level of function was, “bed level only.” The evaluation indicated Patient 100 was able to move in bed (scooting, rolling, sitting) with, “moderate assistance.....The patient is able to voluntarily assist in a task but requires a moderate amount of contact assistance... The therapist performs 25% to 75% of the task for the patient.” The evaluation indicated Patient 100 was unable to transfer (sit to stand, bed to chair, chair to bed) because he was, “unable due to left lower extremity (leg) pain and weakness.” The evaluation indicated Patient 100 was unable to be assessed for Gait (walking) as he was unable to bear weight (support his body weight during activities like standing/walking). A review of Patient 100’s seven-day ED stay, from 1/26/24 to 2/2/24, indicated approximately thirty-five staff and provider medical record entries with documentation of Patient 100’s various hostile behaviors. A Nursing Note, dated, “1/26/2024 12:52 PM,” indicated, “ ...pt (patient) verbally abusive, SW (Social Worker) told to leave, pt refusing to cooperate ...” A Nursing Note, dated, “1/27/2024 12:10 PM,” indicated, “ ... Patient pleasant during this interaction. About 30 minutes later patient was yelling ...” A Nursing Note, dated “1/28/2024 5:10 AM,” indicated, “ ... Patient becoming verbally and physically aggressive with staff. Patient attempting to punch and kick staff, calling female staff bitches ... Patient continues to yell at staff ...” A Physician Consult Note, dated, “1/29/2024 12:04 PM,” indicated, “ ... Patient was uncooperative, wanted me to leave the room immediately ... subsequently after multiple attempts, patient started to yell profanities ...” A Case Management Note, dated, “1/31/2024 9:03 PM,” indicated, “ ... pt has been refusing to eat, refusing medications, refusing to cooperate with care and refused to work with PT ...” A Nursing Note, dated, “2/1/2024 6:56 AM,” indicated, “ ... Pt took a few sips of juice, then spit it on me.” Further review of Patient 100’s medical records over his seven-day stay in the ED indicated staff and providers documented his mentation fluctuated between oriented and confused: On 1/26/24 at 3:52 p.m., a social worker documented, “...MD (doctor) reports pt is alert and oriented x2...” On 1/26/24 at 5:48 p.m., Physician V documented, “ ...does not appear to understand the ramifications of his words and actions on his overall care.” On 1/26/24 at 7:22 p.m., a Registered Nurse (RN) documented, “... asking for wire cutters so he could cut his wires off and escape. Attempted to reorient patient without success ...” On 1/27/24 at 5:17 a.m., an RN documented, “Pt states he is a manager at Safeway and drives to work every day.” On 1/28/24 at 03:21 a.m., an RN documented, “Pt A&Ox3 upon assessment ...” On 1/28/24 at 05:10 a.m., an RN documented, “Patient yelling in room, wanting to know what is going on...” On 1/28/24 at 7: 49 p.m., an RN documented, “... pt states call my mom so I can get out in here...” On 1/29/24 at 12:04 p.m., a provider documented, “Patient currently unaware where he is located...” On 1/30/24 at 10:13 p.m., an RN documented, “... alert to self, mostly aware of surroundings. Occasional nonsensible, rambling statement but reorients easily...” and, On 1/31/24 at 10:16 a.m., the wound nurse documented, “Patient is awake, but not able to make needs known effectively at this time... Unable to follow simple commands...” Review of Patient 100’s medical record, dated 2/2/2024 at 9:59 a.m. (the morning of discharge), indicated Case Manager D (CM D) documented per HBS (Hospital Based Service; hospital physician [not an ED physician] care provider), “...patient is alert and oriented. SW (social worker) met with patient and plan is for home with HH RN (Home Health Registered Nurse).” She documented the RN would provide wound care and (assess) safety of home and PT and Social Worker services would be provided. CM D documented Patient 100 was agreeable to hiring a part-time caregiver, he did not want his family contacted at that time, he had a hidden key at home if there was no one home to receive him, and he would be transported by ambulance. Further review of Patient 100’s medical records indicated his inconsistent mental status on 2/2/24, the day of his discharge: At 9:01 a.m., a physician documented, “Mental Status - calm, A/O x4 ... he appeared very clear of mind... patient appears to be able to make his own medical decisions and financial decisions...” At 12:56 p.m., Physician B documented, “Addendum: Hold patient additional light (sic) since there appears to be a waxing and waning mental status pattern...” At 4:30 p.m., a social worker documented, “At 8:46 AM... they spoke with the ED MD regarding capacity letter and was informed that they are unable to sign letter due to the patient having capacity still... At 9 AM... patient was alert/oriented x 4... At 3:16 PM... Patient (sic) son was informed that patient does have the capacity to make his own decisions...” At 3:25 p.m. (the afternoon of discharge), CM D further documented, “...Canceled (ambulance) request. Patient’s mental status (was) waxing and waning therefore HBS has suspended discharge and will watch again overnight.” During an interview on 6/12/24 at 10:35 a.m., when asked about her discharge work with Patient 100, CM D stated she did not have a lot of direct interaction with Patient 100. CM D stated the Social Workers were the lead staff on his case as his needs were related to concerns at home with his family and with caregivers; she stated she addressed clinical/medical issues. CM D stated she had set up Home Health services for Patient 100 regarding his need for wound care. CM D stated Patient 100 did not want the facility to contact his family and claimed his family was financially abusing him. When asked about his mental status, CM D stated he could be both, “cooperative and not cooperative.” CM D stated Patient 100’s mental status, “was being questioned,” and many times he was alert and oriented but she thought he was overestimating his ability to care for himself. When asked about her documentation that Patient 100’s mental status was, “waxing and waning,” CM D stated he was alert and oriented x4 and then was, “less so.” CM D stated she did not directly assess his cognition herself but obtained the information from Nursing staff or the HBS. Review of a letter from Napa County Adult Protective Services, dated 2/2/2024 at 5:22 p.m., indicated APS SW (APS Social Worker) wrote to Hospital 1 about Patient 100’s impending discharge. The letter indicated, “This letter is in response to notification that your facility intends to discharge a patient back to his home. Please be advised that APS believes discharging this patient does not comply with California Health & Safety Code... and/or Medicare regulations... The services needed to ensure a safe discharge have not been put in place. APS is therefore requesting that the discharge of (Patient 100) be postponed until such time that the necessary services are in place... In the case of (Patient 100), the services necessary to meet his continuing health care needs include a caregiver or other in-home support agency that can assist (Patient 100) with meals, medications, incontinent care, and all other activities of daily life... APS is opposed to discharging (Patient 100) until such time the ‘appropriate arrangements for posthospital care’ are available. Discharging in the absence of necessary services is not an acceptable discharge plan. APS remains committed to assisting you, within the Department’s protocol and available resources, in returning (Patient 100) to the community...” During an interview on 6/12/24 at 1:50 p.m., Case Manager E (CM E) confirmed he was the case manager who took over for CM D after her shift was over at approximately 3:30 p.m., on 2/2/24. CM E stated he personally interviewed Patient 100 (on the afternoon of discharge) and he was alert at that time and a caregiver was waiting for him (to arrive) at his home. He stated the Physician (Physician B), the Social Worker, and manager were aware of Patient 100’s impending discharge. CM E stated he did not remember the contents of the APS letter that arrived around 5 p.m., and stated not only it was unusual to get a letter like this from APS, but he had also never gotten one like it in the past. When asked whom he told about the letter, CM E stated he would have to refer to his notes; he stated he was vigilant about documenting (in his notes). Review of CM E’s documented notes on 2/2/24, indicated at 4:15 p.m., CM E, “Spoke to pt at bedside who was in agreement with plan to DC (discharge) back home... Patient was oriented to name, place, time...” At 6:19 p.m. CM E documented he spoke to Director C regarding, “... letter from APS. Per management ok to send patient back home with caretaker...MD (Physician B) updated, stated ok to DC pt.” At 7:08 p.m., CM E documented, “...Currently alert to name and place (not time or situation) ...” During an interview on 6/12/24 at 2:46 p.m., Social Worker F (SW F) stated she became involved in Patient 100’s discharge at approximately 5 p.m., that evening (Social Worker U [SW U] had worked with him previously). She stated everything was, “wrapped up,” and she was trying to help get Patient 100 out the door. She stated she got the APS letter and reached out to Manager I, but she did not hear back from her as she had already left the facility; she stated she got a response from Director C. SW F stated she had never received a letter from APS like the one written for Patient 100. She stated she called APS, spoke to the APS manager (APS S) and had a long conversation regarding Patient 100’s discharge plan. Review of SW F’s medical record documentation of that evening’s events indicated she documented the incident on 2/3/24 at 6:51 p.m. (the following day). SW F documented, “(Hospital 1) received a fax from Napa County APS at 5:22PM indicating they do not feel that we have created a safe discharge for the patient and would advise against sending him home. Social worker called and spoke with... management (Director C) who state (sic) that (Hospital 1) has fulfilled its role of creating a safe discharge plan, including reaching an agreement with the patient to accept a caregiver, having a caregiver in place upon discharge, extensive conversations with family members, and the entire medical care team. Per (Director C) it is still acceptable to discharge patient. HBS doctor (Physician B) also feels that a discharge is still appropriate.” SW F documented that she called APS and had a lengthy conversation with the supervisor (APS S) about Hospital 1’s discharge plan. SW F documented, “(APS S) is still not completely confident in the discharge plan, however states that it is ultimately up to (Hospital 1) if they feel the plan is safe...” Further review of Patient 100’s medical records on the evening of his discharge indicated at 7:30 p.m., an RN documented, “... Pt is currently alert and oriented to person and place...,” and at 8:21 p.m. (immediately prior to ambulance transfer back home), an RN documented, “... Pt is currently alert to person only... He states it is 2034 (the year) ... Pt is also requesting for a phone so that he can call out sick from his job as the manager of Safeway...” Review of Patient 100’s ambulance trip sheet, dated 2/2/24 (discharge from Hospital 1 to home) indicated the EMT’s (Emergency Medical Technicians) documented the Transfer of Care form (authorization for treatment and transport) was signed by Hospital 1’s ED nurse (prior to departure) due to Patient 100’s, “...confusion.” The EMT’s documented Patient 100 required ambulance transportation, “...due to confused mental state, and being bedridden,” and indicated they arrived at Patient 100’s home at approximately 8:51 p.m. The EMT’s documented that enroute to the home, “Pt (patient) exhibited confusion during transport, continuously thought EMT was a grocery store employee and discussed being at Albertson’s instead of the Hospital.” Continued review of the 2/2/34, ambulance trip sheet indicated once at the home, the EMT’s met the new caregiver. The EMT’s documented, “...Lockbox (with house key) to house was empty, caretaker attempted contacting family with no success. Caretaker contacted Social Worker (at Hospital 1) who contacted a locksmith. Waited with the patient in ambulance to keep warm... Napa PD (Police Department) arrived for unknown reason... Locksmith was able to open door, 2 police officers cleared home premises before we took patient to bedroom, house was empty... Note: null (no) phone number entered in (Hospital 1’s)... spot (on the transfer documentation), pt does not have a phone number and family does not want to be contacted.” The EMT’s documented they transferred care of Patient 100 (to the caregiver) at 10:45 p.m. Further review of the medical record revealed SW F’s untimed note, dated 2/3/24, that indicated she received a phone call from the care agency (where the caregiver worked) and was informed Patient 100 arrived home (on 2/2/24) and was with the caregiver, however he could not find his key and no one was answering the door. SW F documented she attempted to reach Patient 100’s family but no one answered. SW F documented she informed [Hospital 1] management, who asked that a locksmith be called. SW F’s documentation indicated, “Received call from caregiver stating that she noted a mattress, sheets, and mens (sic) clothing out in the yard as if patient had been kicked out. Social worker (SW F) called ... PD (Police Department) who went out to the home. They spoke to neighbors who report that wife was home earlier today but not now. Patient was able to get into home safely with caregiver with help of locksmith and PD...” During a telephone interview on 6/13/24 at 8:26 a.m., APS Supervisor (APS S) stated she was on-call the weekend of Patient 100’s discharge on 2/2/24 (Friday), and received many calls about the situation. APS S confirmed that Hospital 1 had submitted an Abuse Report to her office when Patient 100 was first admitted to the ED on 1/26/24, regarding his family living situation. APS S stated her office was concerned all week (during Patient 100’s seven-day stay) because he had a hard time keeping caregivers, his family could not provide the care he needed, and Patient 100 did not seem to understand the level of care he actually needed. During the same interview on 6/13/24 at 8:26 a.m., APS S stated, on 2/2/24, her department advised Hospital 1 (in the letter) that the pending discharge was unsafe. APS S stated it was not common for her department to send that type of letter to Hospital 1. APS S stated she spoke to SW F, and told her APS was concerned about Patient 100’s home and care situation. SW F informed her that Patient 100 would be getting four hours of caregiver assistance per day. APS S stated she was still not comfortable with the discharge plans after speaking with SW F and felt Patient 100 was being discharged too early; she stated there was no one (family) at home, and the caregiver may not last. She stated APS tried to work with Hospital 1 because they knew discharging him home was not a viable option. APS S stated she was not aware Hospital 1 was going to discharge Patient 100 that night. She stated, “I don’t know why he couldn’t stay at (Hospital 1).” She stated Patient 100 would be going into a dark, empty house and would only get two hours of care that night (as the caregiver had been waiting two hours for him to arrive). APS S stated the best placement for Patient 100 would have been a facility like a Skilled Nursing Facility or a Board and Care but Hospital 1 was, “pushy,” regarding Patient 100’s discharge. She stated a nurse called her with concerns about, “pressure... to get him out the door,” and SW U (the Social Worker who been working on the discharge) was aggressive. APS S stated they could not prevent the discharge as it was up to the hospital. During the same interview on 6/13/24 at 8:26 a.m., APS S stated she received a call on Saturday (2/3/24), from Patient 100’s family who told her they saw (on a doorbell camera) the caregiver leave the home at 1 a.m. APS S stated she called the PD to conduct a welfare check at the home in the morning. The PD reported to her that there was no caregiver present, and Patient 100 did not have access to food nor to a telephone. Review of Patient 100’s ambulance trip sheet, dated 2/3/2024, indicated a Paramedic and an EMT were on-scene at Patient 100’s house at 10:23 a.m. (approximately twelve hours after he was discharged from Hospital 1’s ED the prior night). The Paramedic and EMT documented, “...dispatched ... with pd (Police Department) on scene... pt was found laying (sic) in bed with napa fire assessing pt. no family or caregiver at home. pt A&O 4 (alert and oriented, not confused) ... (patient) stated he came home from the hospital last night via ambulance transfer. pt was released from (Hospital 1) last night. pt family was out of town. pt was left uncared for. pt stated he wasn’t sure where anyone was ‘they abandoned me’ pt did not have anything to eat or drink since leaving the hospital as pt could recall. pt does not recall a caregiver being at his home when he was there. per PD patient is being taken back to the hospital to get reevaluated and to set up a plan for pt to receive care of the hospital due to not having care for pt at home currently...” During the same interview on 6/13/24 at 8:26 a.m., APS S stated she was not surprised Patient 100 returned to the ED on 2/3/24, because it was not a safe discharge to begin with. She stated they had to wait for a locksmith to enter the house, and no one determined if there was food at the home. APS S stated SW U called her (verbalizing) she was upset, when Patient 100 returned to the ED. During a virtual/video interview on 6/13/24 at 9:27 a.m., Physician B stated he had taken over the care of Patient 100 on 1/27/24, discharged him on 2/2/24, and readmitted him on 2/3/24. He recalled the discharge had been complicated involving complicated family dynamics. Physician B stated Patient 100 had been medically cleared for discharge approximately two days prior to his 2/2/24, discharge but his family could not take care of him. He stated the Social Worker was very involved with Patient 100’s discharge and initially, Patient 100 was going to go to a Skilled Nursing (Nursing Home) or Board and Care facility, but he did not want to pay for a Board and Care, and he wanted to go home. Physician B stated Patient 100 was, “completely clear” (cognitively), when he (the patient) let him know he did not want to go to a facility (like Skilled Nursing) at discharge. During the same virtual interview on 6/13/24 at 9:27 a.m., Physician B stated he was aware of Patient 100’s, “waxing and waning,” mentation on 2/2/24, prior to discharge. Physician B stated he was holding him overnight out of abundance of caution. When asked why Patient 100 was then discharged a few hours later, Physician B stated patient discharges were a team activity, not a decision made just by him; he stated he trusted the Case Managers, Social Workers, and bedside Nurse’s judgements. Physician B stated the Social Worker was going to ensure a caregiver would be at the house to take care of him when needed. Physician B stated he was not aware that only four hours of caregiving was arranged for Patient 100. When queried if he thought four hours was enough to meet Patient 100’s daily needs, Physician B stated he refused to speculate, and added that as a Physician, this was not his area of expertise, but was up to the Case Managers and Social Workers. Physician B stated he was aware APS was in the background to ensure a safe discharge but was not sure at what point they were involved. When asked if he was aware APS wrote a letter to Hospital 1 on 2/2/24, indicating they felt his impending discharge was unsafe, Physician B stated he was not aware. During an interview on 6/13/24 at 10:22 a.m., Director C stated she oversaw Patient 100’s discharge plan over his week’s stay in the ED and ensured it was, “moving along.” She stated his plan was to return home with four hours of caregiver assistance. Director C stated Patient 100 refused twenty-four hours/day of caregiver help but agreed to a reduced amount of four hours per day. Director C was asked how four hours of daily care would meet Patient 100’s needs when Hospital 1’s PT evaluation indicated he required twenty-four hours of daily care, and she stated it was, “not an ideal plan.” When asked how Hospital 1 ensured Patient 100 would have food at home and access to food, as he was bedbound, she stated it was the care providers’ responsibility to arrange for food. When asked how Hospital 1’s discharge plan was safe, Director C stated it was the, “safest he (Patient 100) would allow.” She stated a Home Health Nurse was scheduled to go to the home three times a week, and APS was involved. When asked why Hospital 1 moved forward with the discharge when Patient 100’s mental status was documented as, “waxing and waning,” Director C stated it was her understanding that he met the two criteria for discharge: He was at his cognitive baseline, and caregivers had been arranged for him at home. She stated she was not aware Physician B had documented holding him for another night of observation. When asked why Hospital 1 moved forward with the discharge when they were notified that APS felt the discharge was unsafe, Director C stated SW F had called and spoken to APS (APS S), explained and clarified the plan, and APS S was in agreement (at the end of the conversation). During an interview on 6/12/24 at 8:35 a.m., Quality Staff W stated the facility did not have a policy specifically addressing ED Boarders (Patients like Patient 100 who stay in the ED for an extended period because they did not meet hospital admission criteria). She stated Hospital 1’s ED policies would cover these patients. Review of ED policy titled, “Patient Flow in the Emergency Department,” subtitled, “ESI Priority III - Urgent” (Approved 11/2021 and reviewed 05/2024), indicated, “Patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. If the patient is not ESI priority 1 or 2, the next decision point asks how many different resources might this patient consume in order for the physician to reach a disposition decision...” The policy identified Resources as, “Labs (blood, urine) ... ECG, Imaging including x-ray, MRI... IV fluids (hydration)... special consultation...” Review of ED policy titled, “Patient Flow in the Emergency Department,” subtitled, “5.0 Procedures” (Approved 11/2021 and reviewed 05/2024), indicated, “5.4 Discharges in the Emergency Department 5.4.1 Once the medical emergency has been determined and stabilized or resolved, the patient is admitted, transferred or discharged ... The physician collaborates with other disciplines ... to determine appropriate discharge needs ... At the time of discharge patient’s physiological and/or psychosocial special needs is taken into consideration ...””

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 41337 Based on observation, interview and record review, the facility failed to provide a medically prescribed diet and lunch on 6/3/24 that was appropriate for Patient 12’s medical condition of colitis (a chronic digestive disease characterized by inflammation of the inner lining of the colon), when the Patient 12 received beans, corn and raw vegetables which were contraindicated for Patient 12’s medical diagnosis. This had the potential to exacerbate Patients 12’s GI (gastrointestinal tract - The organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces) symptoms. Findings: During an observation and concurrent interview with Patient 12 on 6/3/24, at 12:06 pm, Patient 12 was lying in her bed; she appeared in discomfort. She stated she ate a few bites of her turkey sandwich but it was her first time eating in a week, and she wanted something more plain. She stated she asked for mashed potatoes and gravy and toast three hours ago and she just now received it. She stated she came into the hospital last Sunday, and she was diagnosed with colitis. Patient 12’s lunch was on her bedside table; it consisted of a turkey sandwich on wheat bread, lettuce, tomato, baby carrots, and black bean and corn salad. Patient 12 stated she could not eat raw vegetables and beans with her current condition. During an interview with the Registered Dietitian (RD-M), on 6/6/24, at 10:31 am, RD-M stated Patient 12 was NPO (nothing by mouth) for seven days. He stated the Doctor advanced Patient 12’s diet from diabetic clear liquid (diet that is made up of only liquids and foods that are clear liquids at room temperature. Clear liquids are easy to digest and include water, broth, gelatin, plain tea and coffee, popsicles and juices) to a regular diet. He stated he should have recommended to start her with a full liquid diet (no solid foods and only consumes liquids, such as soups, juices, and smoothies) and then advanced her to a low fiber diet (is for people who need to rest their digestive system and includes cooked vegetables, fruits, white breads, and meats and avoids beans, whole grains, and raw vegetables). During a review of the facility, “Diet Manual,” dated March 2021, indicated, “A low fiber diet may be used with a reduction in stool frequency and volume is desirable. Diet is generally for short-term use following colitis, partial bowel obstruction, diverticulitis or recent intestinal surgery.” In addition, “Foods to avoid: products made from whole grain such as whole grain bread, raw vegetables, corn and potatoes with skins. Dried peas, beans, or legumes.” During a review of Patient 12’s medical record, a document titled, “Medical Nutrition Therapy Assessment,” dated 6/3/24, indicated, “patient medical history: diverticulosis, patient was admitted for colitis.” During a review of Patient 12’s medical record, a document titled, “Progress Note,” dated 6/424, indicated, “80 y/o (year old) female with hx (history) of DM2 (diabetes mellitus 2 - Type 2 Diabetes is characterized by high levels of sugar in the blood), HTN (high blood pressure- is when the pressure in your blood vessels is too high -140/90 mmHg or higher), gastritis (when your stomach lining gets red and swollen/inflamed), diverticulosis (the formation of abnormal pouches in the bowel wall) ... Pt was admitted for colitis....Assessment: ongoing nausea and abdominal pain, poor intake ...””

“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: 41337 Based on observation, interview and record review, the facility failed to screen and assess the nutrition status of patients during their long-term (greater then 24 hours) stay in the Emergency Room, when: 1. Patient 11 had a long-term Emergency Room stay that lasted 27 days and was admitted for failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function (body’s natural defense system that fights infections is impaired), and low cholesterol) and during that time lost one kilogram (unit of measure for weight) of body weight. Unintentional weight loss in elderly patients is associated with an increased risk of morbidity and mortality (having an illness or health condition and death rate). 2. In addition, during a look-back period of three months, Patient 1, 2, 3, 4, 5 and 6, also had long-term Emergency Department stays (greater than 24 hours) and were not screened for nutrition risk. This system failure resulted in seven of 30 medically compromised sampled patients to not be screened for nutrition risk, which could negatively affect their nutrition status and further compromise their health status. Findings: 1. During a review of Patient 11’s medical record, a document titled, “H&P (History and Physical),” dated 2/3/24, indicated Patient 11 was a 77 year-old male admitted to the Emergency Room with a chief complaint of, “Failure to Thrive.” Patient 11 had a history of, “Diabetes Mellitus 2 (also know as Type 2 Diabetes is characterized by high levels of sugar in the blood), Hypertension (high blood pressure- is when the pressure in your blood vessels is too high, 140/90 mmHg or higher), HLD (Hyperlipidemia - is the clinical term for an imbalance of LDL (“bad”) cholesterol), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients), and stroke (occurs when something blocks blood supply to part of the brain).” A document indicated, “patient does not qualify for Hospice (Medical care for people with an anticipated life expectancy of six months or less, and the focus shifts to symptom management and quality of life) despite declining to eat and drink but about every 48 hours he eats a meal.” During a review of Patient 11’s medical record, a document titled, “HBS (History, Behavior and Symptom) Progress Note,” dated 2/21/24, indicted, “he (Patient 11) is not eating meals but drinking intermittently”. During a review of Patient 11’s medical record, a document titled, “Weight & Height,” undated, indicated, “February 3, 2024 Patient 11 weighed 67 kilograms (kg), on February 19, 2024 patient weighed 66.2 kg.” During a review of Patient 11’s medical record, a document titled, “Progress Note,” on the date of discharge 3/2/24, indicated, “Admission date February 3, 2024, Today’s date March 2, 2024, hospital stay: 27 days.....Hospital summary: 77-year-old male with history of vascular dementia with left hemiplegia (a symptom that causes complete or severe paralysis on one side of the body) requiring higher level of care, boarding in the emergency department for 25 days due to lack of indication for hospital admission and lack of safe disposition.....Physical Exam: General appearance- sleeping but arousable, chronically ill and frail appearing.” During an interview with the Director of Food and Nutrition Services (DFNS) on 6/4/24, at 9:55 am, the DFNS stated that usually in the Emergency Department they only do nutrition assessments when ordered by the Physician. During an interview with Registered Nurse-H (RN-H), at 11:53 am, on 6/4/24, RN-H stated Patient 11 refused to eat, but they could sometimes get him to drink fluids. RN-H stated Patient 11 did not want to eat at normal times. RN-H stated it was rare to have patients in the Emergency Room (ER) for extended periods of time. He stated, since they usually did not have patients in the ER for that long, that may be why Patient 11 was never triggered for a Registered Dietitian (RD) consult. He stated they did not do nutrition screening in the ER. During an interview with the Registered Nurse -I (RN-I), at 12:07 pm, on 6/4/24, RN-I stated they did not ever request for Registered Dietitian (RD) consults in the Emergency Room (ER). He stated the typical stay in the ER was three to five hours. During an interview with the Registered Dietitian (RD-J) at 2:25 pm, on 6/5/24, RD-J indicated that for the Emergency Room (ER) Physicians would usually consult an RD to make tube feeding orders (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) or for nutrition education for the patient. RD-J stated nutrition screening was triggered on admission to the hospital and would not be done in the ER. RD-J stated Patient 11 would have most likely been a moderate or high nutrition risk if he was admitted to the hospital. She stated there was no way to know if Patient 11’s nutrition status was being monitored if an RD was not called for consult. During an interview with Hospitalist Physician-L (HP-L) (a physician who works exclusively in a hospital and provides medical care to inpatients) on 6/6/24 at 3:33 pm, HP-L indicated Patient 11 was boarding in the Emergency Room (ER) because he did not meet the criteria for admission to the hospital, and they could not find placement for him. HP-L stated nurses in the Emergency Room could request a nutrition consult. He stated that during the time Patient 11 was in the ER, the ER was primarily staffed by ER nurses. HP-L stated medical surgery (med surg) nurses (med-surg nurses provide direct care to hospitalized patients) were more astute to identifying patient needs for a dietary consult. He stated the med-surge nurses were more used to long-term hospital stays and documenting patient meal intake. 2. During an observation and concurrent interview with Patient 6, on 6/3/24, at 3:15 pm, Patient 6 was pacing back and forth in his room in the Emergency Room (ER). Patient 6 stated his lunch was fine, and he did not want to answer any more questions. During an interview with the Emergency Department Nurse (EDN-K) on 6/3/24, at 3:18 pm, EDN-K stated Patient 6 had been in the Emergency Room (ER) for 291 hours, since 5/22/24. EDN-K stated he was a psych (psychiatric) patient and was awaiting placement in another facility. During a review of Patient 6’s medical record and concurrent interview with the Registered Dietitian (RD-J) and the Director of Food and Nutrition Services (DFNS) on 6/4/24, at 9:55 am, RD-J indicated Patient 6 was not screened for nutrition risk. DFNS stated, usually in the ER they only do a nutrition assessment by consult from the Physician. During an interview with the Registered Dietitian (RD-J), on 6/5/24, at 2:25 pm, RD-J stated there was no way to know Patients 6’s nutrition risk without a nutrition screen. During a review of the medical record document titled, “ED (Emergency Department) Progress,” dated 6/2/24, indicated Patient 6 was an, “ED boarder....Awaiting affirmation of placement with [hospital name].” During a review of an ED log for a look-back period from 31/24 to 5/31/24, five other patients (Patients 1, 2, 3, 4 and 5) were also identified to have long-term Emergency Room admissions: Patient 1 stayed for nine days (from 3/9/24 to 3/17/24); Patient 2 stayed for seven days (from 3/13/24 to 3/19/24); Patient 3 stayed for nine days (from 3/17/24 to 3/25/24); Patient 4 stayed for nine days (from 3/20/24 to 3/29/24); and, Patient 5 stayed for six days (from 5/15/24 to 5/21/24). During a concurrent interview and review of Patient 1, 2, 3, 4 and 5’s ED records, with EDN-N, on 6/5/24 at 4:09 p.m., EDN-N confirmed all five patients were in the ED longer than five days and did not get nutritional risk screening during their ED stay, nor were nutrition consults ordered for them. During the same interview on 6/6/24 at 3:33 p.m., HP-L stated nutrition consults could be ordered for any ED patient, should they require it. HP-L stated Patient 11 could have benefited from a nutrition consult. During a review of the facility policy titled, “Provision for Clinical Nutritional Care- Medical Nutrition Therapy and Nutrition Care Practices,” dated August 2023, indicated, “Patients admitted to [Hospital Name] will receive a level of nutritional care consistent with organization, the joint commission (an independent organization that evaluates and accredits healthcare facilities), HIPPA (acronym for the Health Insurance Portability and Accountability Act regulates the use and disclosure of protected health information), and state regulations.....The initial nutritional screening is completed by nursing personnel in the first 24 hours of admission using the MST (malnutrition screening tool) tool in [Facility Organization Initials]. (See attachment #1). A secondary nutritional screening is preformed by the DTR/RD (Dietetic Technician Registered/Registered Dietitian) within 24 hours using the nursing MST (malnutrition screening tool) score and the department clinical nutrition screening protocol. (See Attachment #2) Exceptions to this process are patients admitted to L&D (Labor and Delivery) and Maternity. These patients are evaluated upon request from nursing, MD (Medical Doctor) or if length of stay is >5 (greater than 5) days they will be screened using standard hospital screening criteria.” During a review of the facility policy document titled, “Attachment #2”, dated August 2023, indicated, “1-day assessment (high) - burns, compartment syndrome (a buildup of pressure around your muscles), Enteral/Parental (Enteral nutrition is delivered through a tube to your stomach or the small intestine/Parenteral feeding refers to liquid nutrition processed by the veins) Nutrition Support, Failure to Thrive.” 41175”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 31424 Based on observation, interview, and record review, the facility: 1) Failed to ensure medical staff established and implemented policies and procedures governing the care for 1 of 30 sampled Boarder Status patients (Patient 11; Boarder status patients are that can spend several days and nights in the hospital but are not formally admitted as inpatients) and 7 unsampled Patients (Patients 1, 2, 3, 4, 5, 6 and 11). This failure: 1) Caused 1 outpatient ED Boarder (Patient 11), who was diagnosed with failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function (body’s natural defense mechanism does not effectively protect against infection), and low cholesterol) to lose weight; he was in the ED for approximately 27 days without receiving a nutritional assessment; Unintentional weight loss in elderly patients is associated with an increased risk of morbidity (having a specific illness or condition) and mortality (number of deaths due to a specific illness or condition ); 2) Contributed to 7 outpatient CDA patients (Patients 1, 2, 3, 4, 5, 6 and 11) being in the ED for over five days; they were not screened for nutritional risk, which could negatively affect their nutrition status and further compromise their health status. Findings During an observation and tour of the ED on 6/4/24 at 3:15 p.m., Manager D stated the ED had CDA patients, and staff generally placed them in the D-pod (a designated area in the ED where more stable patients were roomed) to assist with nursing assignments. During an interview on 6/5/24 at 10:30 a.m., Quality Staff R (QS-R) was asked to provide a Scope of Service (policy identifying a department’s goal of service, type of patients served, standards of practice, staffing, etc.) for CDA patients in the ED. QS-R stated CDA patients were part of the ED, and the ED BUCS (Basic Unit of Care Standards; policy and procedure for various hospital departments) would cover these patients. During an interview on 6/5/24 at 11 a.m., Quality Staff Q (QS-Q) and QS-R stated the Standards of Care (treatments/practices that are appropriate for specific disease that are both accepted by medical authorities and widely used by healthcare professionals; also called best practice) for CDA patients were covered, in the Medical/Surgical/Telemedicine policy standards (medical patients, surgical patients, and patients who are having their hearts monitored - telemetry). QS-Q stated the facility had no other policies specific to CDA-status patients. Review of the BUCs titled, “Basic Unit Gare Standards (BUGS), Med/Surg Units” (approved 7/2022), revealed CDA and Boarder-status patients were not identified/included in the policy. Review of the BUCs titled, “Basic Unit of Gare Standards for the Emergency Department” (revised 5/2024), revealed CDA and Boarder-status patients were not identified/included in the policy. During a review of Patient 11 ‘s medical record, a document titled, “Progress Note,” on the date of discharge, 3/2/24, indicated, “Admission date February 3, 2024, Today’s date March 2, 2024, hospital stay: 27 days .... Hospital summary: 77-year-old male with history of vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes) with left hemiplegia (total or nearly complete paralysis on one side of the body), boarding in the emergency department for 25 days due to lack of indication for hospital admission and lack of safe disposition .... Physical Exam: General appearance- sleeping but arousable, chronically ill and frail appearing” During a review of Patient 11’s medical record, a document titled, “HBS (Hospital Based Service; a physician) Progress Note,” dated 2/21/24, indicted, “he (Patient 11) is not eating meals but drinking intermittently.” During a review of Patient 11’s medical record, a document titled, “Weight & Height,” undated, indicated, “February 3, 2024, Patient 11 weighed 67 kilograms (kg), on February 19, 2024, patient weighed 66.2 kg.” During an interview with the Registered Dietitian (RD-J) at 2:25 p.m., on 6/5/24, RD-J indicated the ED Physicians usually consulted an RD for nutrition education for the patient. RD-J stated nutrition screening was triggered on admission to the hospital and would not be done in the ED. RD-J stated Patient 11 would have most likely been a moderate or high nutrition risk if he was admitted to the hospital. She stated there was no way to know if Patient 11’s nutrition status was being monitored if an RD was not called for consult. During a review of an ED log for a look-back period from 3/1/24 to 5/31/24, five patients (Patients 1, 2, 3, 4 and 5) were identified to have long-term Emergency Room admissions (ED Boarders): Patient 1 stayed for approximately eight days (from 3/9/24 to 3/17/24), Patient 2 stayed for approximately six days (from 3/13/24 to 3/19/24), Patient 3 stayed for approximately eight days (from 3/17/24 to 3/25/24), Patient 4 stayed for-approximately nine days (from 3/20/24 to 3/29/24), and Patient 5 stayed for approximately six days (from 5/15/24 to 5/21/24). During a concurrent interview and review of Patient 1, 2, 3, 4 and 5’s ED records with Emergency Department Nurse N (EDN-N) on 6/5/24 at 4:09 p.m., EDN-N confirmed all five patients were in the ED longer than five days and did not get nutritional risk screening during their ED stay, nor were nutritional consults ordered for them. During an interview on 6/6/24 at 10 a.m., Manager D and Administration Officer (AO) were asked about the Scope of Service for CDA patients and Boarders in the ED. Manager D confirmed the CDA scope of service was not included in the 2024, Plan for Provision of Patient Care (approved by the Medical Executive Committee on 12/28/23). When queried why CDA patients were not in policies covering ED patients, Manager D stated she would need to follow-up. When queried why long-term patients (like Boarders) were not included in ED policies or procedures, Manager D stated she needed to follow-up. When asked what the standard of care expectation was for long-term (Boarders) patients in the ED, Manager D stated it was, “MD (Physician) order driven.” She stated the standard of care was similar to care received by inpatients (people admitted to the hospital). During an interview on 6/6/24 at 10:13 a.m., Quality Leader X (QL-X) stated having long-term boarders (in the ED) was not a new practice, and it was utilized, “all over” (in other sister-facilities). During an interview on 6/6/24 at 11:02 a.m., QL-X, Manager D, AO, and Director B discussed CDA patients at the facility. Director B stated CDA was a classification for patients, and they were managed as observation patients, and there were no policies and procedures nor BUCs guiding their care. She stated their care was based on unit care standards and provider (Physician) orders. Director B stated observation-status patients received the same nursing care as admitted patients. When asked why the CDA patient status was not included in any policies and procedures, Director B stated she could not speak to that. During an interview with Hospitalist Physician-L (HP-L) on 6/6/24 at 3:33 p.m., HP-L indicated Patient 11 was boarding in the Emergency Room (ER) because he did not meet the criteria for admission to the hospital, and they could not find placement for him. He stated a hospital boarder was a patient in the ED or CDA area who had a hospital stay longer than 24 hours. HP-L stated nurses in the Emergency Room could request a nutrition consult. HP-L stated ED Boarders were treated (medically) the same as patients admitted to inpatient status, and CDA patients were treated by Hospitalist’s (Physicians treating inpatients, not ED Physicians) after they were in the ED for twenty-four hours. During a virtual interview and concurrent record review on 6/7/24; 11 :10 a.m., Director Z, COO, Director B, Director W, QL-X, Quality Staff Y, Quality Staff Q, and Director C discussed the care and services of ED patients who stayed in the ED over 24-hours. A list of CDA patients (from April and May 2024) was referenced, and the COO confirmed multiple patients were in observation (outpatient) status for over twenty-four hours, and one 94-year-old patient (Patient 13) was in observation status for eighty-six hours (from 5/16/24 through 5/20/24). One virtual attendee stated a patient (Patient 11) was held in the ED (as a Boarder/ outpatient status) for twenty-seven days because he did not meet hospital admission criteria, and the facility was arranging his discharge to a Board and Care home.”

“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: 38088 Based on observations, interviews and record review, the Governing Body failed to determine, implement, and monitor patient safety and patient staffing issues in the emergency room, and held the ultimate responsibility for the hospital’s compliance with the specific Condition of Participation (CoP) for the provision of services, when: 1. There was no comprehensive plan to address the inability of the facility to divert patients. (Cross Reference A-1112) 2. There was not enough emergency room staff to provide effective emergency care when patients were not assessed and monitored. (Cross Reference A-1112) The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment, and an inability to comply with the statutorily mandated Condition for Coverage for Governing Body. 38335”

“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: 38088 Based on interviews, and document review, the hospital failed to ensure a Quality Assurance Process Improvement (QAPI) which reflected the care and services provided to patients when: 1. A performance improvement plan to implement a licensed nurse in the Emergency Room waiting area was not implemented thoroughly, assessed, and monitored by the Quality Assessment Performance Improvement (QAPI) Committee to ensure staff understanding of the patient safety duties and responsibilities of the position. (Cross Reference A-1112) 2. The Emergency Room had no strategic plan for a patient surge during a staffing shortage. This failure to ensure staffing resulted in the waiting area Licensed Nurse being reassigned in the Emergency Room, leaving the patients in the Emergency Room waiting area unmonitored by Licensed Staff, and potentially contributed to the death of one patient (Sampled Patient 1). (Cross Reference A-1112) The cumulative effect of this systemic problem resulted in the facility’s inability to ensure the provision of quality health care in a safe environment in the Emergency Room, and an inability to comply with the statutorily mandated Condition of Participation for QAPI. 38335”

“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: 38335 Based on interviews, and document review, the hospital failed to ensure nursing services met patient needs and were provided following standards of practice as evidenced by its failures to implement its policies and procedures on ED patient re-assessment, restraints, and pain re-assessment (Cross Reference A-0398). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment, in accordance with the statutorily mandated Conditions of Participation for Nursing Services. 41175”

“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: 38335 Based on observations, interviews, and record reviews, the hospital failed to ensure the Emergency Services functioned effectively to meet the emergency needs of patients in accordance with acceptable standards of practice and facility policy and procedures as evidenced by its failure to maintain adequate staff to monitor two of 19 sampled walk-in patients (Patient 1 and Patient 2) who had been triaged but awaited room placement in the ED lobby, without timely re-assessments and emergency medical screening exams, resulting in the death of Patient 1 and a decline in Patient 2’s mental status. (Cross Reference A-1112). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment. 41175”

“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: 38088 Based on interview and record review, the facility did not follow policy and procedures for four of 33 sampled patients when: 1. Two ED patients (Patient 1 and 2) were not reassessed after triage and while awaiting care in the waiting area, 2. One patient (Patient 3) with physician orders for restraints, did not have any documentation for 11.5 hours, and 3. One patient’s pain level was not reassessed after pain medication was administered (Patient 7). These failures resulted in: 1. delayed the provision of medical screening examination (MSE) for Patients 1 and 2, and potentially caused Patient 1’s emergency medical condition to worsen without monitoring or detection, resulting in his death, 2. increased risk of patient harm or death if restraints were not administered, monitored, and discontinued according to facility Policy and Procedure (P&P), and, 3. potential for unrelieved pain and suffering of patients. Findings: 1. During a record review on 12/19/23 on 11:12 a.m., Patient 1’s “ED Encounter” dated 12/8/23 was reviewed. Record review revealed the following timeline: 15:44 (3:44 p.m.): Patient 1 arrived (walked-in) to the ED with complaints of chest discomfort. 15:49 (3:49 p.m.): an EKG (or ECG, is a test that checks how the heart is functioning by measuring the electrical activity of the heart) was performed on Patient 1 and yielded a sinus rhythm result (normal). 15: 52 (3:52 p.m.): Patient 1’s vital signs were checked: Blood pressure (BP) = 170/85, Heart Rate (HR) = 70, Resp (Respirations) = 16, SpO2 (oxygen saturation) = 100, Temp (Temperature) = 98.1. Patient 1 reported a pain score of 7 out of 10. 15:55 (3:55 p.m.): Patient 1 was triaged and identified as ESI Priority 2. [The Emergency Severity Index (ESI) is an emergency nursing association (ENA) and American College of Emergency Physicians (ACEP) approved triage system using a five-level triage scale where ESI level 1 is the highest severity. ESI Level 1 concerns the highest acuity patients requiring immediate, life-saving interventions without delay. ESI Level 2 is a patient with an illness or injuries that place them at high risk for deterioration, or signs of a time-critical problem that require prompt attention. ESI Level 3 is a patient with illnesses or injury that is stable but require prompt medical attention and require two or more resources. ESI Level 4 is a patient who has no medical emergency and has an illness or injury that requires one resource. ESI priority 5 is a patient who has no medical emergency and requires no resources, such as seeking care for a chronic or routine problem.] 16:11 (4:11 p.m.): Blood samples, including troponin (the biomarker of choice for detecting heart muscle damage) were obtained from Patient 1. 16:54 (4:54 p.m.): Patient 1’s blood sample results indicated normal troponin levels. 17:29 (5:29 p.m.): Patient 1’s vital signs were rechecked; BP = 126/78, HR = 72, Resp = 16, SpO2 = 95. Patient 1 reported a pain level of 10. 17:30 (5:30 p.m.): Patient 1 was sent back to the ED lobby and awaited room placement for an MSE. 23:30 (11:30 p.m.): Patient was roomed to TR14, asystole (no heartbeat) from triage, CPR (or cardiopulmonary resuscitation is an emergency technique used on someone whose heart or breathing has stopped) in progress. Official time of death was called at 23:59 (11:59 p.m.). During a concurrent interview and record review on 12/19/23 at 11:35 a.m. with Director B, Patient 1’s ED Encounter on 12/8/23 was reviewed. Director B confirmed there were no notes between Patient 1’s vital signs at 5:29 p.m., and his CPR Notes at 11:30 p.m. When pointed about the six-hour span, Director B nodded and stated, “There was a gap.” Director B stated Patient 1 was brought back out to the waiting room and was never assigned a physician. During an interview on 12/20/23 at 3:08 p.m., RN C stated bed placement in the ED depended on the patient’s ESI priority. RN C stated a patient with an ESI 2 level was urgent, but not critical, and was ideally roomed as soon as possible. RN C stated ANMs (Assistant Nurse Managers) were notified when room placement was needed. RN C stated ESI 2 patients were reassessed every two hours and have their vital signs retaken and monitored for any changes of condition. When asked how Patient 1 was not reassessed during a six-hour period, RN C stated she was “literally checking in patients one after another that night” and added it was the triage nurse or the “Nurse First” who did the patient reassessments. RN C stated, “There’s usually another triage nurse and a Nurse First, but I think I was the only triage nurse that night.” During an interview on 12/21/23 at 3 p.m., ED Clerk F stated she recalled the night Patient 1 came in, accompanied by his family, for chest pain. ED Clerk F stated she put an “EKG Alert” on Patient 1, a protocol for every patient coming in with chest pain. ED Clerk F stated a nurse and tech came to evaluate Patient 1, then Patient 1 went back out to the waiting room. ED Clerk F stated sometime after, she saw fire trucks drive outside the building. ED Clerk F stated she got up and went to the lobby, found Patient 1 on a wheelchair with his family members, speaking with the fire emergency crew. ED Clerk F stated the family had called 911, and she heard the fire emergency crew tell Patient 1 that they could not do anything because he’s inside the [hospital] facility. ED Clerk F stated she wheeled Patient 1 back to the EKG room and notified the nurse of Patient 1’s continued pain. ED Clerk F stated she was not sure what happened to Patient 1 after. ED Clerk F stated the ED was “crazy busy” that night, with maybe 30 or 40 patients around, and added the waiting area was almost “standing room only”. ED Clerk F stated she recalled seeing Patient 1 seated on a wheelchair, at the overflow hall with his family, later that night. When asked if anyone checks on the patients while they wait in the waiting room, ED Clerk F stated the Nurse First usually did, every two hours. ED Clerk F stated the Nurse First had left at 6 p.m. that evening. During an interview on 12/22/23 at 11:30 a.m. RN G stated she was the “Nurse First” the evening of 12/8/23. When asked what her role was as “Nurse First,” she stated you are at the front desk re-assessing patients (taking vital signs, and draw bloods for the lab, and room patients inside the ED) after they have been triaged until they are roomed for an MSE. RN G stated she only worked from 4:30 p.m. to 6:30 p.m. that evening, during that time the ED was extremely busy, and she was pulled to assist patients that were inside the ED to help with patient lab draws, and x-rays. RN G stated there was only one triage nurse on that evening and there was no “Nurse First” during the day shift or on the night shift after she left. During an interview on 12/22/23 at 12:21 p.m., when asked what the expectation was if a patient was triaged with an “ESI of 2,” ANM H stated her expectation was patient’s received continuous care and reassessment and roomed as soon as possible. The role of the “Nurse First” was to ensure the patients’ that had been triaged were re-assessed in the waiting room every 2 to 4-hours or as needed. During a record review on 12/22/23 at 12:40 p.m., Patient 2’s “ED records” dated 12/8/23 were reviewed. Record review revealed the following timeline: 15:06 (3:06 p.m.) Patient 2 was wheeled over to the ED from internal medicine department by wheelchair with complaints of “Shortness of Breath.” 15:32 (3:32 p.m.) Patient 2 was triaged as an ESI-3- Urgent, Patient 2’s vital signs were BP = 98/47, HR = 54, Resp = 20, SpO2 = 96%, Temp. 97.1F. 23:03 (11:03 p.m.) Patient 2’s next set of vital signs were BP = 108/48, HR = 54, Resp = 18, SpO2 = 98%. 23:15 (11:15 p.m.) Diagnostic imaging (Head CT) was ordered for Patient 2, History and Physical notes indicated that Patient 2 was alert and oriented when arrived but seems to have become delirious. 12/9/23 01:51 (01:51 a.m.) Patient 1 was roomed. 12/9/23 03:24 (3:24 a.m.) an MSE was conducted by an MD. 12/9/23 06:17 (06:17 a.m.) Patient 2 was admitted to the ICU. During the record review, the Medical Records Assistant M was asked to verify the assessments taken in the ED for Patient 2. The Medical Records Assistant M verified the only assessments/re-assessments conducted were upon admission and after 11:03 p.m. During an interview on 1/5/23 at 10 a.m., ANM I stated the goal for ESI 2 patients was to get them roomed as quickly as possible. ANM 1 stated was aware Patient 1 was in the lobby, but he could not recall if he had specific notifications about Patient 1’s ESI 2 Level. ANM I stated the ED was busy that day, and even had to triage several ESI 2 patients in the waiting room. ANM I stated there were “significant struggles” in the back as well, with multiple Team Stats (emergencies), stroke alerts, gunshot wound patients, mass transfusions and admission holds. ANM I stated the Nurse First would reassess the patients in the waiting room and check their vital signs every two hours. ANM I stated in the absence of the Nurse First, the second triage nurse would do the reassessments. ANM I stated the facility tries to keep all three nurses at the front, but the second triage nurse could have been pulled to the back or reassigned somewhere that night. During an interview on 1/5/23 at 10:30 a.m., Physician A stated patients should have been reassessed while they were out in the waiting room and patients identified as ESI 2 should be reassessed every two hours. Physician A stated Patient 1 was neither reassessed nor had his vitals retaken and was not referred to a doctor when his pain escalated from 7 to 10. When asked if reassessments could have prevented Patient 1’s demise, Physician A stated, “It would be hard to say if that could have helped.” Physician A stated the expectation remained that reassessments should have been done per ED goals. During an interview on 1/5/23 at 11:30 a.m., RN J stated he was the second triage nurse until 7:30 p.m. the evening Patient 1 came to the ED, then was “floating all over the place” helping with transporting patients and expediting discharges. RN J stated patients in the waiting room get reassessed, but as the ED was so busy, with patients waiting and coming in at the same time, patients waiting in the other hallway and some just leaving, it was “impossible” to get back to all of them. During an interview on 1/5/23 at 3:01 p.m., ED Tech L stated recalling doing the EKG on Patient 1 the evening he came to the ED. ED Tech L stated Patient 1 was brought back out to the waiting room after the EKG. ED Tech L stated ED techs rechecked the vital signs of patients “sometimes”, “as needed”, or “when asked by the nurses”. ED Tech L stated she could not recall any nurse requesting her to recheck Patient 1’s vital signs that night. During an interview on 1/5/23 at 3:18 p.m., Director B stated Patient 1 had no reassessments done after his vital signs were last checked. Director B stated triage nurses were expected to reassess patients while they were in the waiting area. Director B stated patient reassessment was important to catch emergencies, prevent any delay of care, and prevent such things [Patient 1’s demise] from happening. During a review of the facility’s policy and procedure titled, “Basic Unit of Care Standards for the Emergency Department”, dated “10/2022”, indicated, “Patients with an EDI level of 1 will be directly roomed. ESI 2 will be roomed as soon as possible. If no room available, the triage registered nurse will communicate with the ANM prioritize availability. These patients will be rechecked a minimum of every 2 hours while waiting to be roomed. The recheck will include vital signs ...” During a review of the facility’s procedure titled, “Nurse First”, no date, indicated, Primary Role of the Nurse First was to recognize and facilitate treatment of deteriorating patients in the lobby through subjective and objective observations and second to facilitate throughput of stable patients in lobby. “Nurse First Duty highlights,” indicated, Be Present-As much as possible stay in the clerk box, Reassess- Complete every 2-hours, and take this time to update their status, back up triage if no RN2 is present. 2. During an interview on 1/8/24, at 11:15 a.m. RN M stated when a patient is a danger to themselves or others, restraints were applied, with a doctor’s order. The Physician and nurse have to document why restraints are needed. She stated the patient had to have been observed at least every 15 minutes if the restraints were for violent behaviors. She stated monitoring occurred to be sure patient was safe, extremities were not having circulation issues related to restraints, or potential for choking themselves with the restraint device. She stated there had to be a physician’s order to put on restraints and to take them off. During an interview and record review on 1/8/24, at 12:30 p.m., Unlicensed Staff O stated the P&P for restraints was in a book at the nursing station. He stated patients in restraints require every 15-minute monitoring by either a staff or security guard to be sure the patient was safe. He stated patients had restraints to protect themselves and others who are trying to help them. He stated the risk of not monitoring patients in restraints was they could choke and not be able to sit up and clear their own airway or strangulate themselves if they tried to get out of bed while in restraints, and if no monitoring they potentially could die. During an interview on 1/8/24, at 12:53 p.m., Unlicensed Staff P stated patients in restraints or on suicide prevention, were documented as being observed for safety every 15 minutes. He stated restraint observation and documentation was part of keeping patients safe because patients in restraints had a risk from hurting themselves from choking or strangulation. During a concurrent interview and record review on 1/9/24, at 11 a.m., Unlicensed Staff S stated restraint audits are completed for all emergency room patients to determine compliance with Restraint P&P. She stated it was a patient safety quality issue that was being monitored by the facility. During a concurrent interview and record review on 1/9/24 at 11:20 a.m., with RN R, the Electronic Medical Record (EMR) for Patient 3, indicated he was admitted to the emergency room (ER) 11/29/23 at 5:15 p.m. for confusion after pulling out his urinary catheter (A soft, flexible drainage tube into the bladder through the opening where urine comes out of the body. It is secured in the bladder by inflation of a small balloon on the tip of the catheter.), at home, after a surgical procedure. RN R stated for Patient 3 on 11/30/23 at 12:47 a.m., there was a physician order for soft restraints to both wrists and a vest on 11/30/23 at 12:47 a.m. the order indicated “Clinical Reason PULL OUT LINES?DRESSINGS INTERFERING WITH MEDICAL TREATMENT.” A review of a document titled All Flowsheet Data (11/29/23 0000(midnight) - 12/01/23 2359 (11:59 p.m.), indicated restraint monitoring occurred every 15 minutes from 11/30/23 at 12:50 a.m. to 11/30/23 at 2:36 a.m. Unlicensed Staff S stated the monitoring occurred every 15 minutes, according to the facility P&P for restraints. RN R stated Patient 3 was transferred to the fourth floor 11/30/23 at 2:36 a.m. and there was no restraint documentation after transfer to the floor. RN R stated there were no discontinuation orders for the restraints after the patient was transferred up to the floor. Director T stated if an ER patient on restraints was admitted to the hospital and transferred to the floor there should have been documentation about the patient’s restraints. During a concurrent record review and interview, on 1/9/24, at 2:37 p.m., RN N reviewed the fourth-floor documentation for Patient 3, and stated there was no restraint documentation after the patient was transferred to the floor. He stated if the patient was restrained there should have been a physician order for restraints, or a nursing note and he could not find documentation about restraints once the patient was transferred to the fourth floor. RN N stated Patient 3 was discharged from the hospital 11/30/23 at 2:07 p.m. Review of a document titled “Discharge Summary Hospital Course and Significant Findings:” dated 12/1/23 at 8:24 p.m., it indicated “ Brought to hospital in late evening after became more agitated, Seroquel 50 and Haldol 3 mg given in ER and required restraints. Currently patient is alert oriented time 1, trying to get up and pulling his restraints.” RN Q, RN R, Director T did not provide statement or documents to indicate the restraint order had been discontinued or the restraints had been removed at any time, up to and including discharge home. They did not respond when asked if the facility followed the P&P for Restraints. RN N stated he could not find restraint assessment, restraint monitoring notes, care plan for restraints, or discontinue orders in the EMR for Patient 3. He stated for 11 hours and 30 minutes, there was no restraint documentation. RN N stated the facility P&P for restraints was not followed and the risk to the patient was harm or potential death from choking, airway blocked or strangulation. During a concurrent record review and interview with RN W, 1/10/24, at 1;05 p.m., she reviewed Patient 3 EMR and stated she could not find any physician orders for restraints or any documentation that the restraints were monitored according to facility P&P. She stated if the restraints were discontinued the EMR should have a physician’s discontinue restraints order. She stated the restraint policy stated if restraints are removed, there should be documentation the patient’s condition had changed and been assessed to reflect the removal of the restraints. She stated it appeared the EMR did not indicate the facility P&P for restraints was followed. She stated the risk of not following the P&P for restraints was the potential for harm or death to the patient. A review of a facility P&P titled “Restraints NCAL Regional Policy,” reviewed 11/5/2020, indicated “Each episode of restraint use must be initiated in accordance with the order of an MD /LIP. Staff cannot discontinue restraints and restart without obtaining a new physician order.” “ Discontinuation of restraints the patient should be assessed to determine the patient’s condition and whether restraint can be discontinued. The physician or nurse responsible for the patient’s care has the authority to discontinue restraints based on patient assessment. The decision to discontinue the restraint should be based on the determination that the patient is no longer a threat to themselves or others (i.e., no longer exhibiting violent, or self-destructive behavior), the unsafe situation no longer exists, or the patient’s safety can be maintained, and care needs met with less restrictive methods.” A review of a document titled “(Lippincott) Restraint application, limb” reviewed: February 20, 2023, indicated “Documentation associated with limb restraint application includes: ...conditions or behaviors necessary for discontinuing the restraints.” A review of a document titled “Order,” dated 11/30/23 at 12:47 a.m. indicated “RESTRAINTS FOR NON-VIOLENT BEHAVIOR Restraint placement location(s)? Both Wrists; Clinical reason for restraints? PULL OUT LINES/DRESSINGS, INTERFERING WITH MEDICAL TREATMENT ...” A review of a document titled “ED Provider Notes,” dated 11/29/23, at 5:17 p.m., indicated “Chief Complaint: Patient presents with FOLEY PROBLEM PATIENT HAD PART OF PROSTRATE (A gland located just below the bladder in men and surrounds the top portion of the tube that drains urine from the bladder.) REMOVED THIS MORNING , WENT HOME PULLED FOLEY OUT HERE NOW FOR REPLACEMENT.” “Care Timeline 11/29 1717 (5:17 p.m.) arrived ...11/30/23 0156(1:56 a.m.) Placed in Observation 11/30/23 0237 (2:37 a.m.) Transferred to 4WT (fourth floor nursing unit). 41175 3. During a concurrent observation and interview on 1/9/24 at 11:39 a.m., Patient 7 stated he just had surgery and reported pain. Patient 7 pushed his call light and RN U came into the room. RN U reminded Patient 7 that she had just given him morphine a few minutes ago. RN U stated the patient’s pain level was to be rechecked 30-60 minutes after pain medication was provided, and offered to call the physician if the pain was unrelieved. During a concurrent record review and interview on 1/10/24 at 2:30 p.m. with Manager V, Patient 7’s medical records were reviewed. Patient 1’s “Pain Management Flowsheet”, dated “1/10/24”, indicated, “0929 (9:29 a.m.): Pain Score = 7 (out of 10) ... Acceptable Level (Pain) = 4 ... Location = Abdomen ... Character = Sharp; Cramping ... Duration = Intermittent ... Aggravating Factors = Unknown ... Alleviating Factors = Medication ... Pain Intervention = Medication.” A review of Patient 7’s “Medication Administration Report”, dated “1/10/24”, indicated he received 2 mg (milligrams) of morphine (a pain medication) intravenously (IV, through the veins) at 9:29 a.m. Manager V stated a patient’s pain level was supposed to be reassessed 30 minutes after an IV pain medication was given, or 60 minutes after for oral pain medications. Manager V stated there was no documented reassessment of Patient 7’s pain level after the morphine was administered. Manager V stated there should have been a pain reassessment after Patient 7 was given the pain medication. During an interview on 1/10/24 at 3:55 p.m., Manager V stated pain assessment was important as the goal of pain control was to keep the patients’ pain at a level that was acceptable enough for them to continue to do ADLs (Activities of Daily Living, such as eating, hygiene and mobility) and other activities for their recovery. Manager V stated pain assessment was also an opportunity for the nurse to reach out to the physicians if the pain medications were ineffective. A review of the facility policy titled, “Medication Administration Owner Patient Care Services”, dated, “09/2021”, indicated, “6.6.3. Monitor and document patient response to medications when required (e.g., when administering pain medication, antiemetics, or antipyretics ...” A review of the facility policy titled, “BASIC UNIT CARE STANDARDS (BUCS), Med/Surg Units”, dated “7/22”, indicated, “A registered nurse (RN) will provide a timely patient assessment, reassessment and individualized plan of care based on the Guiding Principles, regulatory requirements and patient’s condition. Assessments and re-assessment of the patient will be done according to unit standard ... Assessment of patient’s pain/comfort level on admission, every shift, as needed, and within one hour of intervention ...””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 41175 Based on staff interviews, Emergency Department’s (ED) policy and procedures, and ED patient record reviews, the facility failed to provide adequate staff to reassess walk-in patients who had been triaged but awaited room placement in the ED and ensure timely triage and emergency medical screening for two of 19 sampled patients (Patient 1 and Patient 2). These failures did not comply with facility policy and delayed the provision of medical screening examination (MSE), and potentially caused Patient 1’s emergency medical condition to worsen without monitoring or detection, resulting in his death eight hours after arrival to the ED. Findings: During an interview on 12/18/23 at 2:34 p.m., Confidential Complainant (CC) stated a patient (Patient 1) expired in the ED without being seen by a physician. CC stated the ED was understaffed, and there were 30-40 patients waiting in the ED at the time. During a record review on 12/19/23 on 11:12 a.m., Patient 1’s “ED Encounter” dated 12/8/23 was reviewed. Record review revealed the following timeline: a. 15:44 (3:44 p.m.): Patient 1 arrived (walked-in) to the ED with complaints of chest discomfort. b. 15:49 (3:49 p.m.): an EKG (or ECG, is a test that checks how the heart is functioning by measuring the electrical activity of the heart) was performed on Patient 1 and yielded a sinus rhythm result (normal). c. 15: 52 (3:52 p.m.): Patient 1’s vital signs were checked: Blood pressure (BP) = 170/85, Heart Rate (HR) = 70, Resp (Respirations) = 16, SpO2 (oxygen saturation) = 100, Temp (Temperature) = 98.1. Patient 1 reported a pain score of 7 out of 10. d. 5:55 (3:55 p.m.): Patient 1 was triaged and identified as ESI Priority 2. [The Emergency Severity Index (ESI) is an emergency nursing association (ENA) and American College of Emergency Physicians (ACEP) approved triage system using a five-level triage scale where ESI level 1 is the highest severity. ESI Level 1 concerns the highest acuity patients requiring immediate, life-saving interventions without delay. ESI Level 2 is a patient with an illness or injuries that place them at high risk for deterioration, or signs of a time-critical problem that require prompt attention. ESI Level 3 is a patient with illnesses or injury that is stable but require prompt medical attention and require two or more resources. ESI Level 4 is a patient who has no medical emergency and has an illness or injury that requires one resource. ESI priority 5 is a patient who has novmedical emergency and requires no resources, such as seeking care for a chronic or routine problem.] e. 16:11 (4:11 p.m.): Blood samples, including troponin (the biomarker of choice for detecting heart muscle damage) were obtained from Patient 1. f. 16:54 (4:54 p.m.): Patient 1’s blood sample results indicated normal troponin levels. g. 17:29 (5:29 p.m.): Patient 1’s vital signs were rechecked; BP = 126/78, HR = 72, Resp = 16, SpO2 = 95. Patient 1 reported a pain level of 10. h. 17:30 (5:30 p.m.): Patient 1 was sent back to the ED lobby and awaited room placement for an MSE. i. 23:30 (11:30 p.m.): Patient was roomed to TR14, asystole (no heartbeat) from triage, CPR (or cardiopulmonary resuscitation is an emergency technique used on someone whose heart or breathing has stopped) in progress. Official time of death was called at 23:59 (11:59 p.m.). During a concurrent interview and record review on 12/19/23 at 11:35 a.m. with Director B, Patient 1’s ED Encounter on 12/8/23 was reviewed. Director B confirmed there were no notes between Patient 1’s vital signs at 5:29 p.m., and his CPR Notes at 11:30 p.m. When pointed about the six-hour span, Director B nodded and stated, “There was a gap.” Director B stated Patient 1 was brought back out to the waiting room and was never assigned a physician. During an interview on 12/19/23 at 11:55 a.m., Director B stated the ED has 52 beds and staffing ratio was 1:4 (one nurse to four patients), with the ratio being lower for critical patients. Director B stated staffing ratios were met in the ED rooms, but with the higher census (number of patients) and acuity in the ED [waiting room], they “needed more help.” During a concurrent interview and record review on 12/19/23 at 1:20 p.m., the “DAILY ASSIGNMENT PM SHIFT” dated “12/8/23” was reviewed with Director B. Review of a document provided by the facility indicated, “ED Census 12/8/23 @ (at) 0600: 25 ... ED Census 12/8/23 @ 2122 (9: 22 p.m.): 69...” During an interview on 12/20/23 at 3:08 p.m., RN C stated after a patient was checked in by the ED Clerk, the triage nurse would take the patient into the triage room for vital signs and ask them why they are here, take their history. RN C stated based on that information, the triage nurse would determine the patient’s ESI level. RN C stated bed placement in the ED depended on the patient’s ESI priority. RN C stated a patient with an ESI 2 level was urgent, but not critical, and was ideally roomed as soon as possible. RN C stated the ED was “very busy with a lot of patients” the night Patient 1 came in. RN C stated ESI 2 patients were reassessed every two hours and have their vital signs retaken and monitored for any changes of condition. RN C stated it was the triage nurse or the Nurse First who did the patient reassessments, but the ED did not always have a Nurse First. RN C stated, “There’s usually another triage nurse and a Nurse First, but I think I was the only triage nurse that night.” When asked how Patient 1 was not reassessed during a six-hour period, RN C stated they were “very short-staffed that night”, and she was literally checking in patients one after another. During an interview on 12/21/23 at 1:38 p.m., RN D stated a “Nurse First” was a licensed nurse assigned to sit in the waiting room to see over the patients who have been triaged, and constantly observe for any changes among the patients. RN D stated part of the Nurse First role was to do additional assessments such as vital signs, start order protocols, answer patient questions, and explain what is going on to the patients. RN D stated patient reassessments in the waiting room were done at least every two hours. RN D stated that in the absence of a Nurse First, the triage nurse would do the patient reassessments. During an interview on 12/21/23 at 2:21 p.m., RN E stated patients in the ED go through triage and get roomed depending on their level of severity, while some would have to wait for beds. RN E stated there is a nurse that recheck the patients’ vital signs while they wait for beds. RN E stated ESI Level 2 patients could be “heavy” and need to be roomed as quickly as possible. During an interview on 12/21/23 at 3 p.m., ED Clerk F stated she recalled the evening Patient 1 came to the ED. ED Clerk F stated Patient 1 came in, accompanied by his family, for chest pain. ED Clerk F stated she asked Patient 1 for some history, and Patient 1 denied any history of heart attacks or surgeries. ED Clerk F stated she put an “EKG Alert” on Patient 1, a protocol for every patient coming in with chest pain. ED Clerk F stated a nurse and tech came to evaluate Patient 1, then Patient 1 went back out to the waiting room. ED Clerk F stated sometime after, she saw fire trucks drive outside the building. ED Clerk F stated she got up and went to the lobby, found Patient 1 on a wheelchair with his family members, speaking with the fire emergency crew. ED Clerk F stated the family had called 911, and she heard the fire emergency crew tell Patient 1 that they could not do anything because he’s inside the [hospital] facility. ED Clerk F stated she wheeled Patient 1 back to the EKG room and notified the nurse of Patient 1’s continued pain. ED Clerk F stated she was not sure what happened to Patient 1 after. ED Clerk F stated the ED was “crazy busy” that night, with maybe 30 or 40 patients around, and added the waiting area was almost “standing room only”. ED Clerk F stated she recalled seeing Patient 1 seated on a wheelchair, at the overflow hall with his family, later that night. ED Clerk F stated it was around the end of her shift at 11:30 p.m. when nurses responded to an overhead page about an emergency in the ED lobby. When asked if anyone checks on the patients while they wait in the waiting room, ED Clerk F stated the Nurse First usually did, every two hours. ED Clerk F stated the Nurse First had left at 6 p.m. that evening. During an interview on 1/5/24 at 10 a.m., ANM stated he had been the ED ANM for about 11 years at the facility. ANM I stated parts of his responsibility as an ANM were to guide the movement and flow of the patients coming in from triage to the physician or a room or a nurse and monitor the ED as a whole. ANM I stated he worked until 7 p.m. the evening Patient 1 came to the ED. ANM I stated the goal for ESI 2 patients was to get them roomed as quickly as possible. ANM 1 stated was aware Patient 1 was in the lobby, but he could not recall if he had specific notifications about Patient 1’s ESI 2 Level. ANM I stated the ED was busy that day, and even had to triage several ESI 2 patients in the waiting room. ANM I stated there were “significant struggles” in the back as well, with multiple Team Stats (emergencies), stroke alerts, gunshot wound patients, mass transfusions and admission holds. ANM I stated the Nurse First would reassess the patients in the waiting room and check their vital signs every two hours. ANM I stated in the absence of the Nurse First, the second triage nurse would do the reassessments. ANM I stated the facility tries to keep all three nurses at the front, but the second triage nurse could have been pulled to the back or reassigned somewhere that night. During an interview on 1/5/23 at 10:30 a.m., Physician A stated patients should have been reassessed while they were out in the waiting room and patients identified as ESI 2 should be reassessed every two hours. Physician A stated Patient 1 was neither reassessed nor had his vitals retaken and was not referred to a doctor when his pain escalated from 7 to 10. When asked if reassessments could have prevented Patient 1’s demise, Physician A stated, “It would be hard to say if that could have helped.” Physician A stated the expectation remained that reassessments should have been done per ED goals. During an interview on 1/5/24 at 11:30 a.m., RN J stated his shift was supposed to end at 7:30 p.m. the night Patient 1 came to the ED but stayed until 10:30 p.m. because “he knew they (ED) needed help.” RN J stated he was the second triage nurse until 7:30 p.m., then was “floating all over the place” helping with transporting patients and expediting discharges. RN J stated the roles of the second triage nurse included helping with second triage, keeping eyes on the next patient, making sure orders were done, and catching up with the triage nurse in the front. RN J stated it was “so busy” that night with a gunshot wound, two strokes, an overdose, and a massive transfusion protocol in the ED. RN J stated patients in the waiting room get reassessed, but as the ED was so busy with patients waiting and coming in at the same time, patients waiting in the other hallway and some just leaving, it was impossible to get back to all of them. During an interview on 1/5/23 at 3:01 p.m., ED Tech L stated recalling doing the EKG on Patient 1 the evening he came to the ED. ED Tech L stated Patient 1 was brought back out to the waiting room after the EKG. ED Tech L stated ED techs recheck the vital signs of patients “sometimes” or “as needed” or “when asked by the nurses.” ED Tech L stated she could not recall any nurse requesting her to recheck Patient 1’s vital signs that night. During an interview on 1/5/23 at 3:18 p.m., Director B stated Patient 1 had no reassessments done after his vital signs were last checked. Director B stated there was no Nurse First at the time and the triage nurses were expected to reassess the patients in the waiting area in the absence of a Nurse First. Director B stated patient reassessment was important to catch emergencies, prevent any delay of care, and prevent such things [Patient 1’s demise] from happening. 38335 During an interview on 12/22/23 at 11:30 a.m. RN G stated she was “Nurse First” the evening of 12/8/23. When asked what her role was as “Nurse First,” she stated you are at the front desk re-assessing patients (taking vital signs, and draw bloods for the lab, and room patients inside the ED) after they have been triaged until they are roomed for an MSE. RN G stated she only worked from 4:30 p.m. to 6:30 p.m. that evening, during that time the ED was extremely busy, and she was pulled to assist patients that were inside the ED helped with patient lab draws, and x-rays. RN G stated there was only one triage nurse on that evening and there was no “Nurse First” during the day shift or on the night shift after she left. RN G was asked if she felt comfortable asking the charge nurse for additional staff to help. RN G stated she did request additional help from the nurse manager, but there was not enough staff that evening. During an interview on 12/22/23 at 12:21 p.m., ANM H was asked if she remembered the events of the evening of 12/8/23. ANM H stated she had left before the incident occurred, but remembered the ED was extremely busy that evening with long wait times. When asked if the triage nurse spoke with her about finding a room for Patient 1, ANM H stated she did not remember speaking with the triage nurse about Patient 1. When asked what the expectation was if a patient was triaged with an “ESI of 2,” ANM H stated her expectation was patient’s received continuous care and reassessment and roomed as soon as possible. The role of the “Nurse First” was to ensure the patients’ that had been triaged were re-assessed in the waiting room every 2 to 4-hours or as needed. The first nurse helped expedite the medical orders and recommended a patient to be roomed. When asked if ANM H asked for additional help for the ED that evening, ANM H stated she did ask for additional help, but there wasn’t any available staff. During a record review on 12/22/23 at 12:40 p.m., Patient 2’s “ED records” dated 12/8/23 were reviewed. Record review revealed the following timeline: a. 15:06 (3:06 p.m.) Patient 2 was wheeled over to the ED from internal medicine department by wheelchair with complaints of “Shortness of Breath.” b. 15:32 (3:32 p.m.) Patient 2 was triaged as an ESI-3- Urgent, Patient 2’s vital signs were BP = 98/47, HR = 54, Resp = 20, SpO2 = 96%, Temp. 97.1F. c. 23:03 (11:03 p.m.) Patient 2’s next set of vital signs were BP = 108/48, HR = 54, Resp = 18, SpO2 = 98%. d. 23:15 (11:15 p.m.) Diagnostic imaging (Head CT) was ordered for Patient 2, History and Physical notes indicated that Patient 2 was alert and oriented when arrived but seems to have become delirious. e. 12/9/23 01:51 (01:51 a.m.) Patient 1 was roomed. f. 12/9/23 03:24 (3:24 a.m.) an MSE was conducted by an MD. g. 12/9/23 06:17 (06:17 a.m.) Patient 2 was admitted to the ICU. During the record review, the Medical Records Assistant M was asked to verify the assessments taken in the ED for Patient 2. The Medical Records Assistant M verified the only assessments/re-assessments conducted were upon admission and after 11:03 p.m. 38088 During an interview in the Emergency Room on 1//8/24, at 11 a.m., Emergency Room Director B stated the role of a nurse in the Emergency Room waiting area was to assess patients, perform clinical interventions if necessary and patient safety. She stated the licensed nurse position was titled Nurse First position and was supposed to provide 24/7 nursing judgement at the point of contact with patients. She stated the Emergency Room piloted the Nurse First position February 2023, in response to the staff concerns related to patient safety and staffing. During an interview on 1/8/24, at 11:15 a.m., in the emergency room hallway, Physician A stated, “Issues in the ER are staffing, concerns when short staffed and when nursing is out of ratio.” He stated the emergency department prioritized patient care and to move patients either into the emergency room for evaluation and then up to the floor for care, or discharge patients with follow up instructions.” He stated if the hospital could not move patients up to the floor, patients who need to be admitted to the hospital wait in the emergency room. He stated if the emergency room is full of patients who were waiting to be transferred up to the floor, then patients in the reception area would have to wait for longer and longer times to be evaluated. Physician A stated if nursing was short staffed, and the emergency room was full, then “Bad things could happen.” During the interview on 1/8/24, at 11:15 a.m., Physician A stated there was an “incident in December.” He stated a patient had come into the waiting area of the Emergency Room on a busy night and complained of chest pain. Physician A stated the nurse that was supposed to be in the waiting room to monitor patients was not present. He stated the patient continued to complain of chest pain, but there were no available spaces in the Emergency Room, so he had to wait in the waiting room where the patient experienced a heart attack and expired. He stated there was a surge of patients, nursing was short staffed, and we were extremely busy, and we could not divert ( When a hospital and its emergency room are overloaded to the point that they can no longer safely accommodate another patient. The hospital will declare itself on a ‘diversion’ status, meaning that they cannot accept new ambulance arrivals until they can recover to what they deem is a safer time.) patients. Physician A stated the facility evaluated the incident and concluded that low staffing, escalation of issues did not happen, and that resulted in the patient’s death. During an interview on 1/8/24, at 12:30 p.m., Unlicensed Staff O stated the Emergency Room staffing is not consistent. He stated “Usually something bad happens then we get a flood of staffing and then over time staffing gets low.” He stated management tried to cut back so staffing always went up or down. He stated lack of staffing contributed to strain at work, staff fatigue and risk to patient safety. He stated he was aware of the patient death in December. Unlicensed Staff O stated “We could have done better as a department. Staffing was a problem that night and were swamped.” He stated the patient was checked into the waiting are and should have been reassessed every two hours, but it was not done. He stated if the patient had chest pain he should have been immediately assessed by a nurse and physician. He stated “There wasn’t enough staff, and we were full. We couldn’t move patients out to floor because they were full too.” He stated on the night of the incident patients were waiting eight to nine hours to be seen. During an interview with the Physician Quality Leader and the Medical Executive Chair, on 1/9/24 at 1 p.m., they stated the Quality Policies and Procedures and the annual Quality Plan were approved by the Governing Body. They stated the Quality Committee is combined with the Medical Executive Committee. They stated the committee ensures oversight on any facility system that needs improvement. They stated they determine priorities for the Quality Program by reviewing high risk, high volume and problem prone events, and reducing patient harm event. When asked what performance improvement projects were currently being monitored, they were unsure and stated they would have to review the QAPI (Quality Assurance/ Performance Improvement) minutes. During the interview they did not indicate an Emergency Room patient safety issue or nurse staffing shortages and long wait times. During a concurrent interview on 1/10/24, at 1:30 p.m., Chief of Medicine stated the Governing Body heard about the incident and it was a tragic set of circumstance. He stated the facility was not permitted to divert, even if we have no patient beds. He stated the plan for patient care included working with supervisors, managers to keep patients moving from the Emergency Room to the floor or stabilize them and send them home. Chief of Medicine stated if a patient was in ER and complained of chest pain, he should have been seen immediately. He stated the patient was not monitored because there was no licensed nurse in the lobby because the Emergency Room was full, and the waiting room nurse had been pulled into the Emergency Room to help because the department was short staffed. CEO stated he had heard about the incident, and it was tragic set of circumstances. He stated staffing had never been an issue. He stated he spoke with staff and usually the complaints of short staffing were from a bad night they experienced. He stated the facility cannot shut down the Emergency Room if there were no beds available. CEO stated the facility strategy to keep treating emergency room patients was to work with supervisors, managers and send emergency room patients to the floor if possible. A review of the facility’s policy and procedure titled, “Basic Unit of Care Standards for the Emergency Department”, dated “10/2022”, indicated, “ESI 2 will be roomed as soon as possible. If no room available, the triage registered nurse will communicate with the ANM prioritize availability. These patients will be rechecked a minimum of every 2 hours while waiting to be roomed. The recheck will include vital signs...” “This policy defines the standards of care for all patients in the Emergency Department (ED) ... All patients will receive care that is safety focused, minimizing risk , and preventing harm.” During a review of an undated facility procedure titled, “Nurse First”, indicated, “Primary Role of the Nurse First was to recognize and facilitate treatment of deteriorating patients in the lobby through subjective and objective observations and second to facilitate throughput of stable patients in lobby. “Nurse First Duty highlights,” indicated, “Be Present-As much as possible stay in the clerk box, Reassess- Complete every 2-hours, and take this time to update their status, back up triage if no RN2 is present.” A review of an undated facility policy titled, “2023 Plan for Provision of Patient Care” indicated, “VI. Staffing: Staffing needs are assessed continuously and are based on operational need. The type and number of procedures performed determine assignment of patient care. The assignment is made by the manager or designee and reflects the degree of complexity of the procedure, the awareness of our patient population, the degree of supervision needed by the assigned individual and the technology used. Staffing is adjusted based on the above parameters.” Review of a facility document titled “2023 Plan for Provision of Patient Care,” dated November 23, 2022, indicated “Unit Name: Emergency Department ...The department is responsible for the immediate evaluation of any medical or surgery emergency, for initiating life-saving procedures in all types of emergency situations and for providing emergency services.” “ Methods Used to Assess and Meet Patient Care Needs: Quality Improvement is an ongoing performance program in the Emergency Department.” “These plans are designed to measure and assess the performance of the staff and thus improving the outcome of a patient care Quality indicators are based on the Emergency Department’s degree of service with consideration to high volume, high risk and problem prone activities. The ED reports quarterly to the Medical Executive Committee the activities of the previous quarter. Several other resources used to determine the focus of the ED quality program include: patient satisfaction surveys, unusual occurrence reports, staff suggestions, patient care outcomes, case review, ... quality improvement plan evaluations and program findings.” Review of a facility document titled “THE RULES AND REGULATIONS OF THE PROFESSIONAL STAFF,” dated 2023, indicated “ATTENDANCE OF PATIENTS IN EMERGENCY SITUATIONS,”An appropriate medical screening examination within the capability of the hospital (including ancillary services) shall be provided to all individuals who come to the emergency department or labor and delivery and request (for on whose behalf a request is made) examination or treatment. ...Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facility and qualified personnel available to provider such services or care.” Review of a facility document titled “2023 Quality Improvement Plan / ED Triage Process,” indicated “Quality Improvement Plan Goal Name: Improve Safety of Patients in Emergency Department Waiting Room.” “Process Measure(s) Development of nursing process for safe management of patient reassessment in ED waiting Room. Goal Nov 1, 2023 Goal met. Developed the Nurse First Program in March 2023 that includes nursing reassessment requirements, recognize change in patient status, facilitation throughput, and escalation process.” Further review indicated the facility did not meet a goal to decrease ED waiting room length of Stay (LOS) in ED waiting room >20%. The document indicated “In Progress: After implementation of Nurse First program: Avg Length of Stay (LOS) in waiting room: March-Sept 2023: Decreased16%.” There was no indication that the Quality document included a surge plan or community need was reviewed or updated for 2023.”

“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: 38335 Based on staff interviews, Emergency Department’s (ED) policy and procedures, and ED patient record reviews, the hospital failed to comply with 42 CFR § 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases. This failure compromised one patient’s (Patient 1) medical status and could potentially affect other patients in need of emergency services in the hospital. Findings: During an EMTALA Survey on 12/21/23 to 1/8/24, the survey team determined the ED, failed to ensure two Patients (Patient 1 and Patient 2) received safe and timely re-assessments after triage, leading up to no or delayed Medical Screening Exams (MSE). The ED staff failed to re-assess Patient 1, according to hospital policy and procedure, to ensure his medical condition was stable, resulting in Patient 1’s cardiac arrest and death in the ED lobby 8-hours after his arrival. The ED staff failed to ensure Patient 2 was re-assessed, according to hospital policy and procedure, to ensure her medical condition was stable, resulting in a decline of Patient 2’s mental and physical status, until she received an MSE 11-hours after her arrival. (Cross Reference A-2406).”

“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: 38335 Based on staff interviews, Emergency Department’s (ED) policy and procedures, and ED patient record reviews, the facility failed to re-assess walk-in patients who had been triaged, but awaited room placement in the Emergency Department (ED). These failures did not comply with facility policy, delayed the provision of medical screening examination (MSE), and potentially caused one Patient’s emergency medical condition to worsen without monitoring or detection, resulting in death. Findings: During an interview on 12/18/23 at 2:34 p.m., Confidential Complainant (CC) stated a patient (Patient 1) expired in the ED without being seen by a physician. CC stated the ED was understaffed, and there were 30-40 patients waiting in the ED at the time. During a record review on 12/19/21 on 11:12 a.m., Patient 1’s “ED Encounter” dated 12/8/23 was reviewed. Record review revealed the following timeline: 15:44 (3:44 p.m.): Patient 1 arrived (walked-in) to the ED with complaints of chest discomfort. 15:49 (3:49 p.m.): an EKG (or ECG, is a test that checks how the heart is functioning by measuring the electrical activity of the heart) was performed on Patient 1 and yielded a sinus rhythm result (normal). 15: 52 (3:52 p.m.): Patient 1’s vital signs were checked: Blood pressure (BP) = 170/85, Heart Rate (HR) = 70, Resp (Respirations) = 16, SpO2 (oxygen saturation) = 100, Temp (Temperature) = 98.1. Patient 1 reported a pain score of 7 out of 10. 5:55 (3:55 p.m.): Patient 1 was triaged and identified as ESI Priority 2. [The Emergency Severity Index (ESI) is an emergency nursing association (ENA) and American College of Emergency Physicians (ACEP) approved triage system using a five-level triage scale where ESI level 1 is the highest severity. ESI Level 1 concerns the highest acuity patients requiring immediate, life-saving interventions without delay. ESI Level 2 is a patient with an illness or injuries that place them at high risk for deterioration, or signs of a time-critical problem that require prompt attention. ESI Level 3 is a patient with illnesses or injury that is stable but require prompt medical attention and require two or more resources. ESI Level 4 is a patient who has no medical emergency and has an illness or injury that requires one resource. ESI priority 5 is a patient who has no medical emergency and requires no resources, such as seeking care for a chronic or routine problem.] 16:11 (4:11 p.m.): Blood samples, including troponin (the biomarker of choice for detecting heart muscle damage) were obtained from Patient 1. 16:54 (4:54 p.m.): Patient 1’s blood sample results indicated normal troponin levels. 17:29 (5:29 p.m.): Patient 1’s vital signs were rechecked; BP = 126/78, HR = 72, Resp = 16, SpO2 = 95. Patient 1 reported a pain level of 10. 17:30 (5:30 p.m.): Patient 1 was sent back to the ED lobby and awaited room placement for an MSE. 23:30 (11:30 p.m.): Patient was roomed to TR14, asystole (no heartbeat) from triage, CPR (or cardiopulmonary resuscitation is an emergency technique used on someone whose heart or breathing has stopped) in progress. Official time of death was called at 23:59 (11:59 p.m.). During a concurrent interview and record review on 12/19/23 at 11:35 a.m. with Director B, Patient 1’s ED Encounter on 12/8/23 was reviewed. Director B confirmed there were no notes between Patient 1’s vital signs at 5:29 p.m., and his CPR Notes at 11:30 p.m. When pointed about the six-hour span, Director B nodded and stated, “There was a gap.” Director B stated Patient 1 was brought back out to the waiting room and was never assigned a physician. During an interview on 12/20/23 at 3:08 p.m., RN C stated after a patient was checked in by the ED Clerk, the triage nurse would take the patient into the triage room for vital signs and ask them why they are here, take their history. RN C stated based on that information, the triage nurse would determine the patient’s ESI level. RN C stated bed placement in the ED depended on the patient’s ESI priority. RN C stated a patient with an ESI 2 level was urgent, but not critical, and was ideally roomed as soon as possible. RN C stated ANMs (Assistant Nurse Managers) were notified when room placement was needed. RN C stated the ED was very busy with a lot of patients the night Patient 1 came in. RN C stated, “There’s usually another triage nurse and a Nurse First, but I think I was the only triage nurse that night.” RN C stated she notified the ANMs that shift of Patient 1’s ESI level but was told that there were no beds available. RN C stated ESI 2 patients were reassessed every two hours and have their vital signs retaken and monitored for any changes of condition. When asked how Patient 1 was not reassessed during a six-hour period, RN C stated she was literally checking in patients one after another that night. RN C stated it was the triage nurse or the “Nurse First” who did the patient reassessments. RN C stated they were very short-staffed that night. During an interview on 12/21/23 at 1:38 p.m., RN D stated a “Nurse First” was a licensed nurse assigned to sit in the waiting room to see over the patients who have been triaged, and constantly observe for any changes among the patients. RN D stated part of the Nurse First role was to do additional assessments such as vital signs, start order protocols, answer patient questions, and explain what is going on to the patients. RN D stated patient reassessments in the waiting room were done at least every two hours. RN D stated that in the absence of a Nurse First, the triage nurse would do the patient reassessments. During an interview on 12/21/23 at 2:21 p.m., RN E stated patients in the ED go through triage and get roomed depending on their level of severity, while some would have to wait for beds. RN E stated there is a nurse that recheck the patients’ vital signs while they wait for beds. RN E stated ESI Level 2 patients could be “heavy” and need to be roomed as quickly as possible. During an interview on 12/21/23 at 3 p.m., ED Clerk F stated she recalled the evening Patient 1 came to the ED. ED Clerk F stated Patient 1 came in, accompanied by his family, for chest pain. ED Clerk F stated she asked Patient 1 for some history, and Patient 1 denied any history of heart attacks or surgeries. ED Clerk F stated she put an “EKG Alert” on Patient 1, a protocol for every patient coming in with chest pain. ED Clerk F stated a nurse and tech came to evaluate Patient 1, then Patient 1 went back out to the waiting room. ED Clerk F stated sometime after, she saw fire trucks drive outside the building. ED Clerk F stated she got up and went to the lobby, found Patient 1 on a wheelchair with his family members, speaking with the fire emergency crew. ED Clerk F stated the family had called 911, and she heard the fire emergency crew tell Patient 1 that they could not do anything because he’s inside the [hospital] facility. ED Clerk F stated she wheeled Patient 1 back to the EKG room and notified the nurse of Patient 1’s continued pain. ED Clerk F stated she was not sure what happened to Patient 1 after. ED Clerk F stated the ED was “crazy busy” that night, with maybe 30 or 40 patients around, and added the waiting area was almost “standing room only”. ED Clerk F stated she recalled seeing Patient 1 seated on a wheelchair, at the overflow hall with his family, later that night. ED Clerk F stated it was around the end of her shift at 11:30 p.m. when nurses responded to an overhead page about an emergency in the ED lobby. When asked if anyone checks on the patients while they wait in the waiting room, ED Clerk F stated the Nurse First usually did, every two hours. ED Clerk F stated the Nurse First had left at 6 p.m. that evening. During an interview on 12/22/23 at 11:30 a.m. RN G stated she was “Nurse First” the evening of 12/8/23. When asked what her role was as “Nurse First,” she stated you are at the front desk re-assessing patients (taking vital signs, and draw bloods for the lab, and room patients inside the ED) after they have been triaged until they are roomed for an MSE. RN G stated she only worked from 4:30 p.m. to 6:30 p.m. that evening, during that time the ED was extremely busy, and she was pulled to assist patients that were inside the ED to help with patient lab draws, and x-rays. RN G stated there was only one triage nurse on that evening and there was no “Nurse First” during the day shift or on the night shift after she left. RN G was asked if she felt comfortable asking the charge nurse for additional staff to help. RN G stated she did request additional help from the nurse manager, but there was not enough staff that evening. During an interview on 12/22/23 at 12:21 p.m., ANM H was asked if she remembered the events of the evening of 12/8/23. ANM H stated she had left before the incident occurred, but remembered the ED was extremely busy that evening with long wait times. When asked if the triage nurse spoke with her about finding a room for Patient 1, ANM H stated she did not remember speaking with the triage nurse about Patient 1. When asked what the expectation was if a patient was triaged with an “ESI of 2,” ANM H stated her expectation was patient’s received continuous care and reassessment and roomed as soon as possible. The role of the “Nurse First” was to ensure the patients’ that had been triaged were re-assessed in the waiting room every 2 to 4-hours or as needed. The first nurse helped expedite the medical orders and recommended a patient to be roomed. When asked if ANM H asked for additional help for the ED that evening, ANM H stated she did ask for additional help, but there wasn’t any available staff. During a record review on 12/22/23 at 12:40 p.m., Patient 2’s “ED records” dated 12/8/23 were reviewed. Record review revealed the following timeline: 15:06 (3:06 p.m.) Patient 2 was wheeled over to the ED from internal medicine department by wheelchair with complaints of “Shortness of Breath.” 15:32 (3:32 p.m.) Patient 2 was triaged as an ESI-3- Urgent, Patient 2’s vital signs were BP = 98/47, HR = 54, Resp = 20, SpO2 = 96%, Temp. 97.1F. 23:03 (11:03 p.m.) Patient 2’s next set of vital signs were BP = 108/48, HR = 54, Resp = 18, SpO2 = 98%. 23:15 (11:15 p.m.) Diagnostic imaging (Head CT) was ordered for Patient 2, History and Physical notes indicated that Patient 2 was alert and oriented when arrived but seems to have become delirious. 12/9/23 01:51 (01:51 a.m.) Patient 1 was roomed. 12/9/23 03:24 (3:24 a.m.) an MSE was conducted by an MD. 12/9/23 06:17 (06:17 a.m.) Patient 2 was admitted to the ICU. During the record review, the Medical Records Assistant M was asked to verify the assessments taken in the ED for Patient 2. The Medical Records Assistant M verified the only assessments/re-assessments conducted were upon admission and after 11:03 p.m. During an interview on 1/5/23 at 10 a.m., ANM stated he had been the ED ANM for about 11 years at the facility. ANM I stated parts of his responsibility as an ANM were to guide the movement and flow of the patients coming in from triage to the physician or a room or a nurse and monitor the ED as a whole. ANM I stated he would know of patients’ ESI levels through the board, or they would get notified via phone or radio by the triage nurse. ANM I stated he worked until 7 p.m. the evening Patient 1 came to the ED. ANM I stated the goal for ESI 2 patients was to get them roomed as quickly as possible. ANM 1 stated was aware Patient 1 was in the lobby, but he could not recall if he had specific notifications about Patient 1’s ESI 2 Level. ANM I stated the ED was busy that day, and even had to triage several ESI 2 patients in the waiting room. ANM I stated there were “significant struggles” in the back as well, with multiple Team Stats (emergencies), stroke alerts, gunshot wound patients, mass transfusions and admission holds. ANM I stated the Nurse First would reassess the patients in the waiting room and check their vital signs every two hours. ANM I stated in the absence of the Nurse First, the second triage nurse would do the reassessments. ANM I stated the facility tries to keep all three nurses at the front, but the second triage nurse could have been pulled to the back or reassigned somewhere that night. During an interview on 1/5/23 at 10:30 a.m., Physician A stated patients should have been reassessed while they were out in the waiting room and patients identified as ESI 2 should be reassessed every two hours. Physician A stated Patient 1 was neither reassessed nor had his vitals retaken and was not referred to a doctor when his pain escalated from 7 to 10. When asked if reassessments could have prevented Patient 1’s demise, Physician A stated, “It would be hard to say if that could have helped.” Physician A stated the expectation remained that reassessments should have been done per ED goals. During an interview on 1/5/23 at 11:30 a.m., RN J stated his shift was supposed to end at 7:30 p.m. the night Patient 1 came to the ED but stayed until 10:30 p.m. because “he knew they (ED) needed help.” RN J stated he was the second triage nurse until 7:30 p.m., then was “floating all over the place” helping with transporting patients and expediting discharges. RN J stated the roles of the second triage nurse included helping with second triage, keeping eyes on the next patient, making sure orders were done, and catching up with the triage nurse in the front. RN J stated it was “so busy” that night with a gunshot wound, two strokes, an overdose, and a massive transfusion protocol in the ED. RN J stated patients in the waiting room get reassessed, but as the ED was so busy, with patients waiting and coming in at the same time, patients waiting in the other hallway and some just leaving, it was “impossible” to get back to all of them. During an interview on 1/5/23 at 3:01 p.m., ED Tech L stated recalling doing the EKG on Patient 1 the evening he came to the ED. ED Tech L stated Patient 1 was brought back out to the waiting room after the EKG. ED Tech L stated ED techs recheck the vital signs of patients “sometimes” or “as needed” or “when asked by the nurses. ED Tech L stated she could not recall any nurse requesting her to recheck Patient 1’s vital signs that night. During an interview on 1/5/23 at 3:18 p.m., Director B stated Patient 1 had no reassessments done after his vital signs were last checked. Director B stated triage nurses were expected to reassess patients while they were in the waiting area. Director B stated patient reassessment was important to catch emergencies, prevent any delay of care, and prevent such things from happening [Patient 1’s demise]. During a review of the facility’s policy and procedure titled, “Basic Unit of Care Standards for the Emergency Department”, dated “10/2022”, indicated, “Patients with an EDI level of 1 will be directly roomed. ESI 2 will be roomed as soon as possible. If no room available, the triage registered nurse will communicate with the ANM prioritize availability. These patients will be rechecked a minimum of every 2 hours while waiting to be roomed. The recheck will include vital signs ...” During a review of the facility’s procedure titled, “Nurse First”, no date, indicated, Primary Role of the Nurse First was to recognize and facilitate treatment of deteriorating patients in the lobby through subjective and objective observations and second to facilitate throughput of stable patients in lobby. “Nurse First Duty highlights,” indicated, Be Present-As much as possible stay in the clerk box, Reassess- Complete every 2-hours, and take this time to update their status, back up triage if no RN2 is present.”