St Mary Medical Center

“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: 51973 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1. Failure to ensure that one of 30 sampled patients (Patient 9) had care plan created for hemorrhagic stroke (a life-threatening medical emergency that occurs when a blood vessel in the brain ruptures, causing bleeding into or around the brain tissue). This deficient practice had the potential for Patient 1 ’ s worsening neurological symptoms (physical, cognitive, or sensory warning signs caused by bleeding in the brain) unmanaged which can lead to coma or death (Refer to A-0396). 2. Failure to ensure intravenous (IV- a small tube inserted into a vein) sites were labeled with a date and time for two of 31 sampled patients (Patient 4 and Patient 5) who were receiving IV therapy (a process that delivers fluids, medications and nutrients directly into a person ’ s vein) per the facilities policy and procedures (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) and accepted standards of practice. This deficient practice had the potential to result in Patient 4 and Patient 5 IVs to remain in place beyond recommended timeframes, increasing the risk of infection and compromising patient safety. (Refer to A-0398). 3.Failure to ensure vital signs (measurements of the body ’ s most basic functions, which include Heart Rate (HR- how fast heart beats), Temperature (Temp-how hot or cold your body is), Respirations( Resp- how fast your breathing) were obtained and documented 15 minutes after the initiation of a blood(the red fluid that circulates in the heart, arteries, capillaries, and veins of a vertebrate animal and that brings nourishment and oxygen to and carries away waste products from all parts of the body) product transfusion (a medical procedure in which donated blood, or specific blood components (like red blood cells, platelets, or plasma), is infused intravenously into a patient’s bloodstream) for one of thirty-one sampled patients (Patient 5). This deficient practice had the potential to delay the identification and treatment of an adverse transfusion reaction (negative reactions from infusing blood), which could result in serious patient harm, deterioration in condition, or death. (Refer to A-0398) 4.Failure to ensure that one of 30 sampled patients (Patient 11) was re-assessed for pain after pain medication was administered, according to facility ’ s policies and procedures, and acceptable standards of care. This deficient practice resulted in Patient 11 not meeting goals for pain relief and management. (Refer to A-0405). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38310 Based on interview and record review the facility failed to ensure for one of 31 sampled patients (Patient 4), the Conditions of Admission (COA, a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risk and benefits]) and the Important Message from Medicare (IMM – a notice given to the patient with Medicare benefits indicating the patient ’ s rights to a hospital discharge appeal) were provided in Patient 4 ’ s native language( Spanish). The facility failed to ensure IMM was signed by Patient 4 or Patient 4 ’ s representative, and neither the COA or IMM were given to patient 4 in Spanish. This deficient practice can result in Patient 4 to not be informed of their rights as a patient, which may result in the inability to effectively make decisions regarding their care or treatment. Findings During a review of Patient 4 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 5/28/2026, indicated, Patient 4 was admitted to the facility for left facial droop. During a review of Patient 4 ’ s “Patient Insurance & Demographics Sheet” dated 05/28/2026, the sheet indicated that the preferred language for Patient 4 was Spanish. During a review of Patient 4 ’ s “COA & IMM Documents” dated 05/28/2026, the documentation indicated that each documentation was provided in English and the IMM was not signed. During a concurrent interview and record review on 06/10/2026 at 11:52AM with the Patient Registration Representative (PRR), Patient 4 ’ s COA & IMM were reviewed. The PRR stated that both documents were provided in English and the IMM was not signed. The PRR also stated some of the consequences of Patient 4 not receiving both COA & IMM in English could be confusing because he doesn ’ t know what he is signing and that it would have been helpful for the patient if the facility used an interpreter. During a review of the facility ’ s policy and procedure (P&P) titled, “Limited English Proficiency (LEP): Language Access for Patients and Companions” dated 06/2026, indicated the following: “ CommonSpirit shall provide accurate and timely communication with LEP and deaf patients and their authorized representative(s) about their medical diagnosis, plan of care, prognosis, treatments, and any other relevant information(e.g., waivers of rights, consent to treatment forms, financial and insurance benefit forms) in their preferred language. During a review of the facility ’ s policy and procedure (P&P) titled, “Regulatory Patient Notifications” dated 4/2024 indicated the following: “When delivering the IM, the following must occur: Obtain patient or representative signature. For the first IM, the patient or representative must sign, date, and time. For the follow-up IM, if using the original IM, the patient or representative must initial, date, and time. If a new IM is used, the patient or representative must sign, date, and time.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51973 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 9) had care plan created for hemorrhagic stroke (a life-threatening medical emergency that occurs when a blood vessel in the brain ruptures, causing bleeding into or around the brain tissue). This deficient practice had the potential for Patient 1 ’ s worsening neurological symptoms (physical, cognitive, or sensory warning signs caused by bleeding in the brain) unmanaged which can lead to coma or death Findings: During a review of Patient 9 ’ s face sheet (a summary document providing a quick overview of essential information, including demographics, insurance, and emergency contact information, for healthcare providers), dated 7/10/2024, indicated Patient 9 was admitted to the intensive care unit (ICU – a specialized unit that provides round-the-clock monitoring and advanced life support for patients with life-threatening illnesses or severe injuries), with a diagnosis of Cerebrovascular Accident (CVA – aka stroke – a medical emergency that requires immediate attention to minimize brain damage). During a concurrent interview with the emergency department charge nurse (EDCN) and record review of Patient 9 ’ s ambulance run sheet (documentation of what transpired during ambulance transport of the patient), dated 7/10/2024, on 6/9/2026, at 11:03 AM, , the EDCN stated Patient 9 ’ s family complained that Patient 9 was acting inappropriately for several days. And Patient 9 had complained to them feeling weak, with a brain fog, and concerns of left-sided weakness with a headache. Patient 9 stated to the family he felt “off” for a month. Patient 9 was then transported via ambulance to the hospital for further evaluation and treatment. During concurrent interview on 6/9/2026 at 11:03am and record review of Patient 9 ’ s Emergency Department (ED) Physician Notes, dated 7/10/2024, EDCN stated the chief complaint (primary problem of being in the hospital) were headache and weakness for one month, with loss of sensation in the left arm, for one week. During a review of the Computed tomography angiogram (CTA – a non-invasive imaging test that uses a combination of CT scans and a contrast dye to visualize blood vessels for a 3-dimensional pictures to identify blockages, plaque buildup, aneurysms, or blood clots) of the head and neck indicated a hemorrhage with mild to moderate swelling in the right temporal lobe of the brain. A Consultation ordered for neurology surgeon. And a plan to admit patient to ICU for additional work-up. During a review of Patient 9 ’ s consultation note (formal medical documents pecialist ’ s expert opinion), dated 7/10/2024, indicated the Patient reported he went to another General acute Care Hospital (GACH) facility ’ s Emergency department (ED), last week, but was never seen because he left the facility. Patient 9 complained of worsening headache and left arm weakness and numbness, which worsened. Patient 9 ’ s family called emergency Medical Services (EMS) for concerns for Patient 9 ’ s altered mental status. The Cat Scan (CTA) of the brain indicated hemorrhage. And the Patient was admitted to ICU for monitoring, anti-seizure medication, neurology consult, and laboratory studies were ordered. During a review of Patient 9 ’ s Stroke Services Note(document use to diagnosis, evaluate, treat a patient who suffer a stroke), dated 7/10/2024, indicated Patient 9 appeared to be blind in left eye. And Patient 9 was unable to make a fist with the left hand and complained of decreased sensation of the left arm. The Patient 9 ’ s nurse reported that Patient 9 had a seizure for 10-15 seconds. During a review of Patient 9 ’ s Progress Note (document completed after patient examine), dated 7/11/2024 at 5:45 AM, indicated Patient 9 had a seizure episode – generalized tonic clonic (abnormal activity of brain resulting in body stiffening and then jerking). Patient 9was loaded on anti-seizure medication (Keppra) in 3% saline. Assessment/plan – acute hemorrhagic stroke, NIH (physical and mental exam to measure severity of a stroke) score 1 with a left arm drift, right temporal(front) lobe hemorrhage, continue nicardipine drip (use to manage high blood pressure), neuro checks (rapid evaluation to monitor the brain) every hour, follow up on EEG (measure electrical activity of the brian), neurology surgeon consultation, keep head of bed (HOB) greater than 30 degrees. During a concurrent interview with the EDCN and record review of Patient 9 ’ s care plans on 6/10/2026, at 1:47 PM, he EDCN stated there was no care plans developed after Patient 9 had a Code Stroke (emergency hospital protocol that activated to treat patients with acute signs of stroke), had a neurology consult, stroke nurses were evaluating patient daily, and had a seizure, during hospital stay. During a review of facility ’ s policy, Interdisciplinary Plan of Care, dated 6/2026, indicated the following: All patient care will be planned by an interdisciplinary care team member (IDT – a collaborative group of professions from diverse medical and allied health fields who work together to achieve unified, patient-centered care goals) and documented in the electronic health record. All members of the IDT, involved in the care of the patient, are responsible for contributing and evaluating progression toward meeting goals to the plan of care. The IDT included registered nurses (RN), Nurse Practitioners, Social Workers, Care Coordinators, Dieticians, Licensed/Certified Therapists/assistants, Respiratory Therapists, Chaplain, and Pharmacists. The care planning process is initiated by the admitting practitioner and takes into consideration the goals of care. The RN initiates the care plan within 24 hours of completing the initial assessment, in collaboration with the patient ’ s physician and the other team members. The care plan is reviewed and updated every shift.”

“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: 51973 Based on observation, interview and record review the facility failed to ensure: 1. Intravenous (IV- a small tube inserted into a vein) sites were labeled with a date and time for two of 31 sampled patients (Patient 4 and Patient 5) who were receiving IV therapy (a process that delivers fluids, medications and nutrients directly into a person ’ s vein) per the facilities policy and procedures (P&P- guidelines dictating an organization ’ s directions on a topic and step-by-step instructions how to carry out tasks) and accepted standards of practice. This deficient practice had the potential to result in Patient 4 and Patient 5 IVs to remain in place beyond recommended timeframes, increasing the risk of infection and compromising patient safety. 2.Vital signs (measurements of the body ’ s most basic functions, which include Heart Rate (HR- how fast heart beats), Temperature (Temp-how hot or cold your body is), Respirations( Resp- how fast your breathing) were obtained and documented 15 minutes after the initiation of a blood(the red fluid that circulates in the heart, arteries, capillaries, and veins of a vertebrate animal and that brings nourishment and oxygen to and carries away waste products from all parts of the body) product transfusion (a medical procedure in which donated blood, or specific blood components (like red blood cells, platelets, or plasma), is infused intravenously into a patient’s bloodstream) for one of thirty-one sampled patients (Patient 5). This deficient practice had the potential to delay the identification and treatment of an adverse transfusion reaction (negative reactions from infusing blood), which could result in serious patient harm, deterioration in condition, or death. Findings 1.During a review of Patient 4 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 5/28/2026, indicated, Patient 4 was admitted to the facility for left facial droop. During a review of Patient 5 ’ s “H&P” dated 6/08/2026, the H&P indicated, Patient 5 was admitted to the facility for right leg weakness. During an observation and interview on the Intensive Care Unit (ICU) on 6/08/2026 at 1:42PM with Registered Nurse 1 (RN1), Patient 5 was observed lying in bed with family at bedside. Patient 5 was observed to have two IV sites one located in the right antecubital (the region of the arm in front of the elbow) and the second on the left hand. RN1 assessed both IV sites and neither had a date, time or initials for when IV was inserted. RN1 stated that a consequence of not properly labeling IV sites can be not knowing how long they have been in, which in turn can be a risk for infection. During an observation and interview on the Intensive Care Unit (ICU) on 6/08/2026 at 1: 55PM with RN1 and RN3, Patient 4 was observed lying in bed. Patient 4 was observed to have three IV sites one located on the right jugular (major vein that takes blood from your head back to your heart), and left and right wrists. RN1 assessed all IV sites and only one was properly labeled. The other two IVs had no date, time or initials for when IV was inserted. RN3 stated that IV sites are supposed to be dated, timed and initials. During a review of the facility ’ s policy and procedure (P&P) titled, “Adult Critical Care Nursing Standards of Practice” dated 12/13/2022. The P&P indicated the following “ ....IV access should be assessed every shift, with each use, with insertion, discontinuation, and/or dressing change ... ....The dressing will be labeled with the date, time, and initials of the nurse performing the dressing.” 2.During a review of Patient 5 ’ s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient ’ s current illness, medical history, and a physical examination) dated 3/11/2026, indicated, Patient 5 was admitted to the facility for right leg weakness. During a review of Patient 5 ’ s “Physician Orders” dated 06/08/2026, the order indicated for Patient 5 to receive a transfusion (a procedure in which whole or parts of blood are put into a patient ’ s vein) of platelets (tiny cells in your blood that stick together to help stop bleeding). During a review of Patient 5 ’ s “Blood Product Transfusion Tag” dated 06/08/2026, the tag indicated that vital signs were taking pre transfusion at (4:25 AM) and the transfusion began at 4:30 AM. The tag also indicated that there were no vital signs assessed 15 minutes after the initiation of the platelets. During a review of Patient 5 ’ s “Anesthesia Record” dated 06/08/2026, the record indicated that Patient 5 ’ s vital signs were taken and recorded at 5:00 AM (30 minutes after the initiation of the blood product transfusion). During a concurrent interview and record review on 06/08/2026 at 4:05 PM with the Emergency Department Educator (EDEDU), Patient 5 ’ s “Vitals Section Flowsheet” and “Anesthesia Record” both dated 06/08/2026 were reviewed. The EDEDU stated that consequences of not documenting vital signs 15 minutes after administration of a blood product was that Patients could have transfusion reactions, which may include back pain, fever, shortness of breath. During a review of the facility ’ s policy and procedure (P&P) titled, “Administration of Blood and Blood Components” dated 12/2024. The P&P indicated the following: “ .....Observe the patient closely for 15minutes for signs of a transfusion reaction, I. e. fever, chills, urticaria and shortness of breath. ... ...Check and record the vital signs at the following intervals 15minutes after the transfusion has begun.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 51973 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 11) was re-assessed for pain after pain medication was administered, according to facility ’ s policies and procedures, and acceptable standards of care. This deficient practice resulted in Patient 11 not meeting goals for pain relief and management. Findings: During a review of Patient 11 ’ s face sheet (a summary document providing a quick overview of essential information, including demographics, insurance, and emergency contact information, for healthcare providers), dated 8/15/2025, indicated patient was admitted to the neonatal intensive care unit (NICU – a specialized unit that provides around-the-clock advanced medical care for newborns who are born prematurely, have low birth weights, or suffer from critical health conditions) with a diagnosis of infant of a substance abusing mother. , During a concurrent interview with RN 6 and MCH Dir and record review of Patient 11 ’ s history and physical (H&P – the foundational medical assessment performed by a heath care provider that forms the baseline of a patient ’ s medical record, and directly guiding all diagnostic tests and treatment plans), dated 8/15/2025 on 6/10/2026, at 4:00 PM, indicated: 1.The maternal information – 30-year-old mother with no prenatal care(preventive healthcare provided to pregnant individuals)who planed to feed baby with formula; 5th pregnancy, 5 live births. Birth history – Patient 11 was born on 8/15/2025, at 7:30 AM and was admitted to the NICU. 2. Patient 11 ’ s Reason for NICU admission – hypothermia (a dangerous condition where a baby ’ s core body temperature drops below 36.3 degrees Celsius). 3. Patient 11 ’ s Vital signs (VS – critical clinical measurements that indicate the state of a body ’ s essential life-sustaining functions, used by health care providers to monitor overall health, to detect medical problems, and to evaluate immediate physical condition, including body temperature, pulse rate, respiratory rate, and blood pressure) were: temperature of 35.9 Celsius (normally 36.4 to 37.4 Celsius), heart rate of 144 (normally 100-160 beats per minute), respiratory rate of 39 (normally 40-60 breaths per minute), blood pressure of 75 systolic (normally 60-90 millimeters of mercury) and 34 diastolic (normally 20-60 millimeters of mercury). 4. Patient 11 ’ s Physical examination: gestational age – 38 weeks, weight 5 lbs. 4 ounces – small gestational age. 5. Patient 11 ’ s Admission indications – hypothermia. Patient 11was taken to the NICU due to low temperature and was placed in an incubator and warmed up. Patient 11 ’ s mother was homeless, using methamphetamines, unaware of her pregnancy, and received no prenatal care. 6. Patient 11 ’ s Neonatal drug withdrawal –Patient 11 showed increased tone and shrill cry (loud high pitch sound). Patient 11 would be montored with newborn abstinence scores (evaluate withdrawal symptoms in infants). Urine toxicology and meconium toxicology screens ordered for Patient 11. Both mother and baby tested positive for methamphetamines in the urine. Withdrawal medications may need to be ordered. 7. Patient 11 ’ s Temperature regulation disturbance – because of temperature instability, laboratory specimen ordered for infection work up. Both Patient 11 ’ s mother r and Patient 11 tested positive for syphilis (a sexually transmitted infection) – baby was treated with one dose of antibiotics. 8. Patient 11 ’ s Diagnosis – single live birth in the hospital with maternal substance abuse affecting the Patient 11. During concurrent interview on 6/10/2026 at 4:00p.m.,with RN 6 and record review of Patient 11 ’ s nursing flowsheet for pain assessment, dated 8/15/2025, at 12:00 PM, RN 6 stated patient had a pain score of 5 and an acceptable pain score of 3. During a concurrent interview on 6/10/2026 at 4:20p.m., with RN 6 and record review of Patient 11 ’ s physician orders, dated 8/15/2025, at 1:16 PM, RN 6 stated physician ordered oral liquid acetaminophen (pain medication) 15 milligrams (mg) per kilogram (kg) once, with a priority of statim (stat – immediately or without delay). During concurrent interview on 6/10/2026 at 4:30p.m. with RN 6 and record review of Patient 11 ’ s medication administration record (MAR – an official, ongoing legal document used by health care professionals to track all medications a patient has been prescribed and the doses they have received), dated 8/15/2025, at 4:03 PM, RN 6 stated patient was administered pain medication, acetaminophen 40.125 mg orally, for a pain score of 5. RN 6 stated Patient 11 was not administered pain medication immediately, as ordered; it was administered three hours after the order was written. During a concurrent interview on 6/10/2026 at 4:35p.m., with RN 6 and record review of Patient 11 ’ s nursing flowsheet for pain assessment, dated 8/15/2025, at 5:16 PM, RN 6 stated patient had a pain score of 5 with an acceptable pain score of 3. RN 6 stated the physician was not notified of Patient 11 ’ s undesirable response to pain medication with a pain score of 5, which was moderate to severe pain for the baby. A review of facility ’ s policy, Pain Management in the Neonate, dated 2/22/2024, indicated the following: 1.All neonates will be assessed and reassessed for pain on an ongoing basis for prompt and adequate pain management. 2.Assessment of the neonatal pain will be based on behavioral, physiological, and biochemical responses. 3.All neonates will be assessed by a licensed nurse for the presence of pain upon admission and with each interaction using a neonatal pain assessment tool (N-PASS). 4.An N-PASS score of 4 or less is mild pain and required non-pharmacologic comfort measures. 5.An N-PASS score of 5 or more is moderate to severe pain and most likely required pharmacologic interventions in conjunction with comfort measures. 6.Conditions to be reported to the physician included pain score greater than 3, and no pain relief with measures prescribed and utilized. 7.When pharmacologic measures are used, reassess the patient 30 minutes after medication was administered. 8.Notify physician if the pain management was inadequate.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 38310 Based on observations, interviews and record reviews, the facility failed to ensure overall health and safety for their patients in the following areas: Emergency department (ED) – infant warmers not stored in a manner that is free from clutter and maintained the cleanliness of the equipment, per manufacturer ’ s instructions for use (MIFU). Neonatal Intensive Care Unit (NICU – specialized hospital unit dedicated to the medical care of fragile, premature, or critically ill newborn infants) – scrub sinks with laminar flow aerators were not maintained per manufacturer ’ s instructions for use (MIFU). These deficient practices had the potential for: Delay in stabilizing activities, due to the clutter of medical supplies, stored on top of the mattress and in the way of providing prompt access and care to infants, born in Emergency Department (ED). Transmission of infectious agents to staff and visitors to the facility, while hand washing. Findings: 1.On 6/8/2026, at 11:40 AM, during initial tour of the emergency department (ED) with quality-patient safety program manager (QPSM) 3 and emergency department charge nurse (EDCN), a radiant warmer (an advanced compact equipment used in labor and delivery units to provide uninterrupted thermal support, resuscitation, and monitoring for newborns) was observed cluttered with multiple medical supplies stacked on top of the baby mattress. Concurrently, EDCN stated if needed, the items on top would be removed, the radiant warmer would be cleaned and disinfected, clean linen would be placed on the baby mattress, and the warmer would be turned on to warm up a baby immediately. On 6/10/2026, at 2:35 PM, during concurrent interview with maternal-child health director (MCH Dir.) and review of photograph of ED ’ s radiant warmer taken during initial tour of the ED, MCH Dir stated that the radiant warmer should not be stored with multiple medical supplies stacked on top of the mattress and uncovered, as pictured, because the supplies would have to be removed and the radiant warmer would have to be cleaned and disinfected, prior to use, which takes some time to clean and disinfect it, and time for the baby mattress to be warmed up – this process will delay the care for the infant in need for immediate care, after birth. A review of the facility ’ s policy, Medical Supply Storage, dated 2/2024, indicated that the medical supplies must be kept clean and clear from dust, dirt particles and paper trash. A review of the facility ’ s Medical Supply Storage Area policy, dated 2/2024, indicated that medical supplies (equipment) must be kept clear from dust, dirt particles, and paper trash. A record review of the facility ’ s manufacturer ’ s instructions for use (MIFU) of the infant radiant warmer, dated 2025, indicated the following: Before and after each use, clean and disinfect the device and accessories warmer and the resuscitation system, which included a three-step process of cleaning to remove soil, disinfection to kill the germs, and rinsing to remove the leftover chemicals which can harm the patient. The device starts in Warmup Mode, where the radiant warmer operates at 100% power, which takes seven minutes for warm up to be completed. 2.On 6/8/2026, at 1:52 PM, during initial tour of the NICU, with the director of maternal – child health (MCH – area of care focusing on maternal health of women during pregnancy/ labor, and care of the newborn), two scrub sinks were observed with attachments on the faucets. MCH director stated she did not know what kind of faucets were in the two scrub sinks and called staff from facilities department for assistance. Concurrently, during observation of the NICU scrub sinks and interview with facilities manager (Fac Mgr), Fac Mgr stated the two scrub sinks, in NICU, were laminar flow faucets and were different from aerator faucets. Fac Mgr stated the laminar flow faucet delivered air-free water to avoid excessive splashing of water while washing hands. Fac Mgr stated the facility ’ s sinks were changed from aerator flow faucets to laminar flow faucets to reduce splashing of water and noise, while handwashing. Concurrently, during interview with NICU charge nurse, NICU charge nurse stated she has never observed the housekeeping staff removing the faucet attachments of the NICU scrub sinks with a wrench, soaking the faucet attachments in a cleaning solution and replacing the attachments back on the faucets. Concurrently, Fac Mgr stated the housekeeping staff do not have the equipment to remove/re-attach the faucet attachments and to clean the faucet attachments. On 6/8/2026, at 3:30 PM, during concurrent interview with interim director of quality and risk (DQR) and record review of facility ’ s manufacturer ’ s instructions for use of the laminar flow faucet attachments, dated June 2014, DQR stated the facility does not have a system in place to clean the faucet attachments every year, as recommended by the faucet manufacturer. A review of the facility ’ s Post Installation report, dated June 2014, indicated the following: Completion of the installation of 702 faucet laminar flow control devices to the facility. The faucets were installed with laminar flow faucets to provide a splash free, non-aerated stream of water to prevent airborne bacteria from entering the water system. Faucet attachments have a dome screen, which might get clogged because of accumulation of debris, which can be removed, flushed clean and replaced. The manufacturer recommended annual flushing of the faucet attachment, which included removing the faucet spout with an aerator wrench, removing old washer, and cleaning threads of the faucet with a nylon brush and soaking the faucet attachment in acidic solution.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 39890 Based on interview and record review, the facility’s Medical Staff failed to conduct complete reappraisals for two (2) of seven practitioners (Medical Doctor 1 [MD 1] and MDA 2). MD 1 and MDA 2 did not have a peer (person equal in qualifications and abilities) reference letter for their most recent reappointment period (MD 1 for the period spanning 3/1/2022 to 2/29/2024 and MDA 2 from 2/1/2023 to 1/31/2024). This deficient practice resulted in MD 1 and MDA 2 providing medical care to patients in the facility without having their proper qualifications and current clinical competencies corroborated by peers. Findings: On 12/13/2023 at 5:10 p.m., during a concurrent interview with Director of Medical Staff Administration (DMSA) and record review of seven medical staff (practitioners) credential files with the DMSA and the Director of Quality and Risk Management (QM), the files of MD 1 and MDA 2 were noted to be lacking documentation of the practitioners’ appraisal by peers for the current reappointment period (MD 1 from 3/1/2022 to 2/29/2024 and MDA from 2/1/2023 to 1/31/2024). The DMSA verified and stated no peer reference letters could be located from these two physicians’ files (MD 1 and MDA 2) for their most recent reappointment cycle and confirmed that reappointment of members to the Hospital Medical Staff requires a minimum of one peer reference. A review of the facility’s Medical Staff Bylaws, approved by the Community Board on 9/19/2019, indicated under Section 1.2, “The purpose of the Medical Staff shall be [ ...] to assure a high level of professional performance of all Practitioners authorized to practice in the Hospital through an ongoing review and evaluation of each Practitioner’s performance in the Hospital.” Section 4.6.1 of the Bylaws indicated, “Each Medical Staff member shall submit to the Medical Staff Office the completed application for reappointment to the Medical Staff and a completed privilege sheet for renewal or modification of clinical privileges. The application form shall include all information necessary to update and evaluate the qualifications of the applicant, including without limitation, the matters set for the in Section 4.5.1, as well as other relevant matters.” Section 4.5.1 of the Bylaws, under Application for Initial Appointment and Reappointment, indicated, “The [application] form shall require detailed information which shall be verified by the Medical Staff and include, but not be limited to, information concerning: [ ...] peer references familiar with the applicant’s professional competence and ethical character.””

“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: 46333 Based on observation, interview, and record review, the facility’s perioperative staff (RN 3) failed to ensure one (1) of thirty (30) sampled patients (Patient 2) was secured while on the operating table) with the three-point straps (arm strap, a chest strap, and safety belt across the mid-thigh) in accordance with the facility’s policy and procedure for positioning patient. This deficient practice resulted in Patient 2 sliding off the operating table during surgery and delayed completion of Patient 2’s surgery. Patient 2 required to have a computed tomography (CT, a diagnostic imaging procedure that combines images taken from the body) to check for injuries and returned back to the OR a second time to complete Patient 2’s surgery. Findings: During a review of Patient 2’s History and Physical (H&P), dated 10/9/23, indicated Patient 2’s past medical history included a diagnosis of pandiverticulosis (outpouching of the lining of the colon) in the colon. The patient was referred for surgical intervention (requiring surgery) for a laparoscopic cholecystectomy (surgery to remove the gallbladder). During an interview, on 12/11/23 at 2:30 p.m. Registered Nurse 1 (RN 1) stated this year there was a case where a patient (Patient 2) slipped off the operating table while the surgeon was performing a laparoscopic cholecystectomy. RN 1 stated, “At that time, the policy indicated that three straps (safety securing devices designed to secure patients to the operating table) should be in place for any patient placed in the Trendelenburg (position the operating table placing a patient with the head was down and feet were up) position during surgery. The patient (Patient 2) did not have on the third strap.” RN 1 stated after the incident all staff in the operating room (OR) received education on proper positioning and reiterated that three-point straps were required when patients were placed in the Trendelenburg position. During an interview on 12/11/23 at 2:38 p.m. the Director of the Operating Room 1 (DOR 1) , stated after Patient 2 was put into a steep Trendelenburg position, Patient 2 slid off the operating room table. DOR 1 stated Patient 2’s surgery was stopped, and Patient 2 was transferred to a CT scan to ensure Patient 2 did not sustain injury. DOR 1 stated the CT scan results were normal. DOR 1 stated that Patient 2 was brought back into the operating room to complete the surgery. During a concurrent interview and record review of Patient 2’s Surgical Documents, on 12/12/23 at 11:25 a.m., the Interim Director of Perioperative Services (IDPS), Patient 2’s Surgical Documents, dated 10/9/23, were reviewed. The surgical documents indicated, “Arm Strap, Ulnar Pad(s), bath blanket, blanket under head and shoulders, and one wrapped around head, left arm tucked and padded with ulnar (forearm) pads. The surgical document indicated Patient 2’s right arm was on the arm board and secured with an arm strap. Patient 2’s had safety belt across the mid-thigh and the position was verified by the medical doctor (MD) and anesthesiologist (MDA 2, MD administering and monitoring patient’s sedation). IDPS stated RN 3 did not apply all three safety straps . IDPS stated the foot board and the chest strap were not placed. IDPS stated when Patient 2 was placed in a Trendelenburg position, a minimum of three straps must be applied according to the facility policy and procedure. During a review of the facility’s policy and procedure (P&P) titled “Positioning the Patient,” dated 2/23/23, indicated the following: The perioperative staff will implement safe practices for the positioning of patients undergoing operative and other invasive procedures. The Safe Positioning Practices included: a. A minimum of two-point restraints must be used for all patient positioning. b. A minimum of three-point restraints (straps) must be used for the following patient positions: Reverse Trendelenburg (position the operating table placing a patient with the head was up and feet were down) , Trendelenburg, and Lateral Side Up (patient lies on their left or right side with the operative side up). c. The surgeon and the surgical team will apply additional positioning aids as needed.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to establish a safe process to secure a patient on the operating table, requiring repositioning to a reverse Trendelenburg (position for the operating table place, a patient with the head up and feet down) for one (1) of the thirty (30) sampled patients (Patient 1). Patient 1 was placed in the reverse Trendelenburg position of the OR table during a surgery. This deficient practice resulted in Patient 1 falling off the operating table during surgery and sustaining a liver laceration (cut to the liver) and had the potential to put other patients requiring reverse Trendelenburg at risk for falling while on the operating table. Findings: During a review of Patient 1’s History and Physical (H&P),dated 9/8/2021, indicated, Patient 1 medical history included cerebrovascular accident (CVA, loss of blood flow to part of the brain) with left-sided deficit (a common after-effect of stroke that causes weakness on one side of the body), hypertension (high blood pressure), and gallstones (harden deposits that form in the gallbladder). Patient 1 was sent into the emergency department by Patient 1’s primary care doctor for persistent right upper quadrant abdominal (stomach) pain for two days. During a concurrent interview and record review of Patient 1’s Operative Report, on 12/12/2023 at 10 a.m., the Manager of Patient Safety Officer (PSO) reviewed and verified Patient 1’s Operative Report, dated 9/9/2021 indicated the surgery had started and incisions were made on Patient 1’s upper left part of the abdomen, and supra umbilicus (above the bellybutton). The operative report indicated, “At this time, the patient’s arms became loose, and her upper body sided off the OR table, followed by her lower body. She was extubated (the tube that provides oxygen was accidentally removed), and her IV (tube that goes in the vein to administer medication and fluid) was dislodged.” The PSO stated, “The patient (Patient 1) sustains a liver laceration (deep cut) as a result of the fall.” A record review of Patient 1’s Anesthesia Physician Note, dated 9/16/2021, indicated, “The patient (Patient 1) was positioned in reverse Trendelenburg and left tilt of the bed (operating table). A few minutes later, (name of the surgeon [MD 1]) requested additional reverse Trendelenburg. A few minutes later he (MD 1) requested that the bed height be increased. As the table was rising the upper half of the patient suddenly and quickly fell off the bed to the left. The upper part of her body hit the ground, and the ETT (endotracheal tube, to provide a passageway to deliver oxygen to the patient) and IV were pulled out. Her (Patient 1) legs and hips were still on the OR bed.” During an interview on 12/14/2023 at 3:55 p.m., the Interim Director of Perioperative Services (IDPS) stated that in 2021, there was no other process in place regarding securing the patient when placed in reverse Trendelenburg during surgery. IDPS confirmed that the facility’s positioning policy and procedure in 2021 indicated the circulating Registered Nurse (RN) was responsible for securing the patient during surgery. IDPS stated the patient’s positioning during surgery requires a collaborative team effort to maintain safety and prevent injuries. IDPS confirmed that the facility’s policy and procedure for patient positioning in the operating room were revised in 6/2022 to indicate that the perioperative staff are responsible for ensuring the patient is secure during surgery. A review of the facility’s policy and procedure (P&P) titled, “Patient Positioning: Operative,” dated 10/24/2018, the P&P indicated, “ It is the policy of the facility to optimize patient positioning during surgical procedures while providing optimum exposure and access to the operative site, sustain circulatory and respiratory function, support musculoskeletal and neurological structures, preserve skin integrity, and prevent injury and complications while maintaining patient dignity, comfort, and safety. The P&P indicate the circulating RN performed the following: 1. Preoperative assessment for positioning the patient to include: a. Type of procedure, b. Patient age, height, weight, and body mass index (BMI, measurement of body fat), c. Skin condition, d. Nutritional status, e. Neuropathies (nerve damage leads to pain, weakness, numbness or tingling), f. Preexisting disease conditions, g. Physical limitations, h. Presence of implanted devices or prosthetics, i. Presence of catheters drains and/or orthopedic immobilizers. 2. Identifies risk factors that can increase skin, respiratory, nerve or cardiovascular compromise related to positioning. 3. Determines the correct position and positioning devices for the patient based on the procedure to be performed, patient assessment, surgeon’s preference(s), and injury prevention...” A review of the facility’s P&P titled, “Patient Positioning: Operative,” reviewed date 6/2022 and effective date 2/23/2023, indicated “The perioperative staff (surgical team [nurses and surgeons]) will implement safe practices for the positioning of patients undergoing operative and other invasive procedures.” The P&P indicates that safe positioning practices include the following: a. A minimum of three-point restraints (straps) must be used for the following patient positions: Reverse Trendelenburg, Trendelenburg (position the operating table placing a patient with the head was down and feet were up), Lateral Side up. b. The surgeon and the surgical team will apply additional positioning aids as needed.”