Palmdale Regional 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: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by the facility ’ s failure to: 1. Develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), blood pressure (the pressure within the major arteries of the body), and cardiovascular (the heart [“cardio”] and vessels [“vascular”, arteries, veins, and capillaries] that make up the body ’ s circulatory system) needs for two of 34 sampled patients (Patient 32 and 33). This deficient practice had the potential to result in Patient 32 and 33 not receiving the right level of care and not meeting the needs for the identified patient concerns. (Refer to A-0396) 2. Ensure for six of 34 sampled patients (Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26), nursing care was provided when Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26 were not reassessed (reevaluation of a patient ’ s health status), in accordance with the facility ’ s policy and procedure regarding medication policies, after administration of as needed (PRN) pain medication was administered. These deficient practices had the potential to result in delayed treatment and had the potential to worsen Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26 ’ s pain to not be managed in a timely manner and may result in delayed treatment, which could worsen the patient ’ s (Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26) pain level. (Refer to A-0398) 3. Ensure one of 34 sampled patients (Patient 26) intravenous (IV - in the vein) access site (A point of access to the bloodstream, to move fluids and medications into the body) was removed prior to discharge as per facility ’ s policies and procedures. This deficient practice had the potential for Patient 26, increased risks for intravascular catheter related infections. (Refer to A-0398) 4. Ensure three of 34 sampled patients ’ (Patient 29, 30, and 31 ) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) was labeled to include the date and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient according to the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,”. This deficient practice had the potential for Patient 29, 30 and 31 ’ s, increased risks for intravascular catheter related infections. (Refer to A-0398) 5. Ensure one of two emergency crash carts (a cart stocked with emergency medical equipment [including: oxygen tank, suction set-up which is a medical device assembly used to remove fluids or secretions from a patient ’ s body cavity, etc.], supplies and medications) was completely checked and verified all equipment/materials are available in the crash cart once a shift, in accordance with the facility ’ s policies and procedures regarding emergency cart maintenance. This deficient practice had the potential for emergency medical equipment, medications, and supplies to not be readily available in the event of a medical emergency, which may result in delay provision of patient care. (Refer to A-0398) 6. Ensure one of the 34 sampled patients (Patient 30) midline (an 8-12 cm catheter in the vein inserted in the upper arm with the tip located just below the axilla) site had insertion documentation and daily assessments were completed by the Acute Rehabilitation Unit staff since the patient admission per policies and procedures. This deficient practice had a potential for Patient 30 to develop increased risks for intravascular catheter related infections. (Refer to A-0398) 7. Ensure for one of 34 sampled patients (Patient 30), the policies and procedures for fall were implemented when Patient 30, who was at high risk for fall, was not wearing a yellow wristband, external notice on patient door and yellow non-skid slipper socks indicating the patient was at high risk for fall. This deficient practice had the potential to result in an unsafe care that may lead to Patient 30 suffering from a fall injury. (Refer to A-0398) 8. Adhere to the restraint monitoring policy for one of 34 sampled patients (Patient 23), when staff failed to adequately complete a one-to-one (1:1) observation checklist (a safety document used to record continuous, direct monitoring of a patient) for Patient 23, who presented to the facility for self-inflicted cutting (deliberate act of cutting one ’ s own skin using sharp objects). This deficient practice had the potential to result in Patient 23 inflicting self-harm, death, or other safety concerns due to lack of sufficient monitoring from staff. (Refer to A-0398) 9. Ensure for one of 34 sampled patients (Patients 28), Patient 28 ’ s Percocet (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28 ’ s health and safety due to unsafe medication administration and may lead to prolonged hospitalization. (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: 45774 Based on interview and record review, the facility failed to formalize the hospital stay for one of 34 sampled patients (Patient 32), when staff failed to establish consent for admission, treatment, and financial responsibility for Patient 32 prior to hospitalization. This deficient practice resulted in non-compliance with insurance regulations and lacked transparency to ensure Patient 32 agreed with the recommended care/treatment process, financial obligations, and an understanding of their rights/policies. Findings: During a review of Patient 32 ’ s “Facesheet (a summary that provides a quick, essential overview of a patient ’ s identity, insurance, and key health data)”, undated, the facesheet indicated that Patient 32 was admitted on 3/2/2025 at 9:12 am, for hypoxia (a condition where the body ’ s tissues or organs do not receive enough oxygen to function properly), and was discharged on 3/5/2025 at 1:45 pm. During a review of Patient 32 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/2/2025 at 1:37 pm, the H&P indicated that Patient 32 had a past medical history of obesity (having an unhealthy, excessive amount of body fat that poses risks to your health) on tirzepatide (a medication used to treat diabetes and manage chronic weight loss), hyperlipidemia (HLD, having excessively high levels of fats [lipids], in the blood), hypertension (HTN, high blood pressure), hypothyroidism (an underactive thyroid that does not produce enough thyroid hormones), prior cervical myelopathy (a serious condition caused by compression [pinching] of the spinal cord in the neck) with anterior cervical discectomy and fusion (ACDF, a surgical procedure to treat compressed nerves in the neck by removing a damaged disc and fusing the vertebrae for stability), and unspecified hypercoagulable state (“sticky blood” or thrombophilia, an increased tendency for blood to form clots) undergoing bridging therapy (temporary use of short-acting blood thinners to prevent clots) to warfarin (an oral anticoagulant medication [blood thinner] used to treat and prevent blood clots) with enoxaparin (an injectable blood thinner used to prevent and treat dangerous blood clots), who presented with neck and chest pain. The admission assessment and plan indicated to admit for neurosurgery (a medical specialty focused on diagnosing and treating disorders of the brain, spinal cord, and nerves) evaluation and medical resonance imaging (MRI, a medical test that uses a strong magnetic field and radio waves to create highly detailed, 3D images of soft tissues, organs, and bones). Patient 32 reported a history of lupus anticoagulant (LA, an antibody produced by the immune system that increases the risk of blood clots [thrombosis] in the body, despite slowing down blood clotting times in laboratory tests). The physical examination (a routine assessment of a person ’ s overall health conducted by a healthcare provider) indicated that Patient 32 ’ s mental status (a person ’ s current brain functioning, including their thinking, emotions, behavior, and appearance) was oriented (a person ’ s ability to know/understand) to person, place, and time, normal affect. During a concurrent interview and record review on 2/19/2026 at 10:55 am, with the Quality Analyst (QA1) and the Intensive Care Unit Educator (ICU Ed), Patient 32 ’ s “Consents” were reviewed. ICU Ed stated that there were no conditions of admission (COA, legal document a patient [or their representative] signs upon entering a hospital to become an inpatient) located in Patient 32 ’ s electronic medical record (EMR, a digital computer-based version of a patient ’ s paper chart). QA1 stated that staff would check with the admissions department to see if the COA could be located as sometimes it required scanning into the EMR. During an interview on 2/19/2026 at 1:25 pm, with QA1, QA1 stated that the admissions department was still looking for Patient 32 ’ s COA. During an interview on 2/19/2026 at 4:12 pm, with QA1, QA1 stated that Patient 32 ’ s COA could not be located by the admissions department and administrative staff. QA1 stated that the inability to locate the COA was highly indicative that the COA was not completed and/or misplaced. QA1 further stated that having a COA was of importance to signify that Patient 32 agreed with the recommended treatment plan and not held against their will and/or forced to receive unwanted treatment. QA1 stated that the COA was also proof that Patient 32 agreed with the recommended plan as required for insurance purposes. QA1 stated the lack of an attempt to explain and obtain a signature, for a patient ’ s consent for admission, was a violation of that patient ’ s right to choose. During a review of the facility ’ s policy and procedure (P&P, a written rule or guideline stating what must be done to ensure safety, compliance, and quality care), titled “Patient Rights”, dated 3/5/2025, the P&P indicated: Your Rights as a Patient You have the right to: Considerate and respectful care, and to be made comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences. Have a family member (or other representative of your choosing) and your own physician notified promptly of your admission to the hospital. Know the name of the physician who has primary responsibility for coordinating your care and the names and professional relationships of other physicians and non-physicians who will see you. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or nontreatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of physicians, to the extent permitted by law. Examine and receive an explanation of the hospital ’ s bill regardless of the source of payment. Exercise these rights without regard to sex, race, color, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, educational background, economic status or the source of payment for care. File a grievance. If you want to file a grievance with this hospital, you may do so by writing or calling the grievance committee, which will review each grievance and provide you with a written response within ____ days. The written response will contain the name of a person to contact at the hospital, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process. Concerns regarding quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Control Peer Review Organization (PRO). File a complaint with the state Department of Public Health regardless of whether you use the hospital ’ s grievance process. The hospital maintains a patient liaison to answer questions about patients ’ rights, provide information and referrals, solve problems, investigate complaints and act as your advocate.”

“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: 45774 Based on interview and record review, the facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), blood pressure (the pressure within the major arteries of the body), and cardiovascular (the heart [“cardio”] and vessels [“vascular”, arteries, veins, and capillaries] that make up the body ’ s circulatory system) needs for two of 34 sampled patients (Patient 32 and Patient 33). This deficient practice had the potential to result in Patient 32 and Patient 33 not receiving the right level of care and not meeting the needs for the identified patient concerns. Findings: During a review of Patient 32 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/2/2025 at 1:37 pm, the H&P indicated that Patient 32 had a past medical history of obesity (having an unhealthy, excessive amount of body fat that poses risks to your health) on tirzepatide (a medication used to treat diabetes and manage chronic weight loss), hyperlipidemia (HLD, having excessively high levels of fats [lipids], in the blood), hypertension (HTN, high blood pressure), hypothyroidism (an underactive thyroid that does not produce enough thyroid hormones), prior cervical myelopathy (a serious condition caused by compression [pinching] of the spinal cord in the neck) with anterior cervical discectomy and fusion (ACDF, a surgical procedure to treat compressed nerves in the neck by removing a damaged disc and fusing the vertebrae for stability), and unspecified hypercoagulable state (“sticky blood” or thrombophilia, an increased tendency for blood to form clots) undergoing bridging therapy (temporary use of short-acting blood thinners to prevent clots) to warfarin (an oral anticoagulant medication [blood thinner] used to treat and prevent blood clots) with enoxaparin (an injectable blood thinner used to prevent and treat dangerous blood clots), who presented with neck and chest pain. Patient 32 ’ s potassium level was 2.8, aPTT (test measuring how long [25-35 seconds] it takes blood to clot) 41.7 seconds, and WBC (white blood cells) 14.8 on 3/2/2025 at 1:11 am. The admission assessment and plan indicated to admit for neurosurgery (a medical specialty focused on diagnosing and treating disorders of the brain, spinal cord, and nerves) evaluation and medical resonance imaging (MRI, a medical test that uses a strong magnetic field and radio waves to create highly detailed, 3D images of soft tissues, organs, and bones). Patient 32 was to continue enoxaparin, start warfarin, and discontinue some blood pressure medications (losartan and hydrochlorothiazide) due to Patient 32 having “soft” blood pressures (lower than normal, generally defined as below 90/60). Patient 32 reported a history of lupus anticoagulant (LA, an antibody produced by the immune system that increases the risk of blood clots [thrombosis] in the body, despite slowing down blood clotting times in laboratory tests). Patient 32 was started on warfarin at an outside facility with a plan for bridging therapy with enoxaparin which was continued during this hospitalization. During a concurrent interview and record review on 2/19/2026 at 10:35 am, with the Quality Analyst (QA1) and the Intensive Care Unit Educator (ICU Ed), Patient 32 ’ s “Care Plans,” undated, was reviewed. ICU Ed stated that there was no plan of care identifying Patient 32 ’ s high blood pressure (HTN) or bleeding risk associated with the use of blood thinners. QA1 stated that care plans were important to identify individualized goals related to medical conditions and identify barriers that may prevent those goals. ICU Ed stated that care plans were important to identify patient specific interventions (planned actions taken to improve a situation) to meet the patient ’ s needs and to ensure all the patient ’ s medical and psychosocial (individual ’ s thoughts, emotions and relationships) needs were met. Per ICU Ed, Patient 32 should have had a care plan addressing the risk of bleeding due to being on blood thinning medications that might cause an increased risk for hemorrhage (bleeding). A care plan was needed to identify symptoms to monitor and preventative measures for unexpected bleeding. QA1 also stated that a care plan should have been initiated addressing Patient 32 ’ s HTN due to the patient having low blood pressure readings that required medication adjustments. QA1 stated care plans could assist with identifying if a medication (intervention) was working, parameters for use, and when an adjustment may be needed. During a review of Patient 32 ’ s “Medication Administration Record (MAR, a document that provides a list of all medications given to a patient by a healthcare professional)”, indicated that Patient 32 ’ s previously taken home medication losartan (a medication used to treat high blood pressure, manage heart failure, and protect kidneys from damage) and hydrochlorothiazide (a medication used to treat high blood pressure and edema [fluid retention] by acting as a diuretic) were discontinued due to Patient 32 having low blood pressure readings. Patient 32 remained on Coreg (a medication used to treat high blood pressure, heart failure, and ventricular dysfunction after a heart attack), with parameters to hold the medication for a heart rate less than 55 beats per minute (bpm) and systolic blood pressure (SBP, the top or first number in a blood pressure reading) less than 110. Patient 32 received enoxaparin and warfarin for bridge therapy, venous thromboembolism (VTE, a serious medical condition where a blood clot forms in a vein, usually the deep veins of the leg) prophylaxis (prevention), and nonvalvular atrial fibrillation (nonvalvular AFib, an irregular, rapid heart rhythm that occurs without significant damage to the heart valves). During a review of Patient 32 ’ s “Discharge Summary”, dated 3/5/2025 at 11:55 am, the discharge summary indicated that Patient 32 ’ s discharge diagnosis was hypoxia (body tissue do not received enough oxygen), neck pain, and acute respiratory distress. Patient 32 was discharged with continuation of coreg, enoxaparin, hydrochlorothiazide, losartan, and warfarin, amongst other medications. Patient 32 was instructed to have close follow up with their primary care provider within 3-5 days for ongoing warfarin maintenance as well as international normalized ratio (INR, a blood test that tests how long it takes for a person ’ s blood to clot) checks. Patient 32 was also instructed to follow up with a cardiologist (doctor who monitor patients with heart problems). Patient 32 was also instructed to follow a cardiac diet. During a review of the facility ’ s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care”, 5/20/2025, the P&P indicated: I. PURPOSE To coordinate the interdisciplinary care for each patient and manage the documentation of that care and teaching that is given. The Interdisciplinary plan of care is documented within the electronic medical record under IPOC. The interdisciplinary care plan is individualized to each patient. II. GUIDING PRINCIPLES Interdisciplinary plan of care must be documented and followed for each patient. Whenever the term patient care plan is used, it is acknowledged that the term will be used interchangeably with interdisciplinary plan of care or IPOC. A complete care plan should be prepared within 24 hours of admission incorporating patient’s perceived needs and goals. Outcome criteria should be measurable and realistic. Patient documentation should reflect the patient’s plan of care. The care plans shall be reviewed and updated each shift. The patient care plan shall include all clinical services involved with care planning and coordination. The patient is matched with appropriate disciplines within the continuum. Coordination may include, but is not limited to, discharge planning, communication to facilitate family support, social work, nursing care, primary physician care, procurement of durable medical equipment (DME), or post discharge services. The goal of the care process provides individualized patient care needs. During a review of Patient 33 ’ s “History and Physical “ (H&P), dated 3/4/2025 at 12:45 am, indicated that Patient 33 had a past medical history of Klinefelter ’ s syndrome (a genetic condition in males born with an extra X chromosome, leading to lower testosterone, small testes, infertility, and potential learning or developmental delays). Patient 33 presented to the hospital with chest pain after lifting weights. Patient 33 also had sinus bradycardia (a slow heart rate, typically fewer than 60 beats per minute) noted and an elevated troponin level (measures the level of specific proteins [Troponin T or I] in the blood that are released when the heart muscle is damaged) at 171. During a review of Patient 33 ’ s “Facesheet (a summary that provides a quick, essential overview of a patient ’ s identity, insurance, and key health data), undated, indicated that Patient 33 was admitted for a non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack caused by a partial blockage in a coronary artery, reducing oxygen flow to the heart muscle) on 3/3/2025 at 10:13 pm. During a concurrent interview and record review on 2/19/2026 at 9:55 am, with the Quality Analyst (QA1) and the Intensive Care Unit Educator (ICU Ed), Patient 33 ’ s “Care Plans,” undated, was reviewed. ICU Ed stated that there was no care plan addressing Patient 33 ’ s cardiovascular needs. ICU Ed stated that Patient 33 should have had a plan of care based on the admitting diagnosis being a new condition for the patient. A plan of care was needed to educate the patient on lifestyle changes that may be required, knowledge of the new diagnosis, to identify treatments (interventions) that may be required, and preventative measures to prevent the symptoms from returning. QA1 stated that the patient should have been involved in a plan of care to assist with an agreed treatment plan and identify barriers to reaching the desired goals. During a review of Patient 33 ’ s “Progress Note-Physician”, dated 3/4/2025 at 11:33 am, the progress note indicated that Patient 33 had a peripheral pulse rate (the number of heartbeats felt per minute in the arteries far from the heart, typically at the wrist or neck, with normal adult resting range of 60-100 bpm) ranging from 46 bpm to 59 bpm. The physician ’ s assessment included NSTEMI with an unclear etiology (cause). During a review of Patient 33 ’ s “Discharge Summary (a clinical document that outlines a patient ’ s entire hospital stay)”, dated 3/5/2025 at 11:25 am, the discharge summary indicated that Patient 33 ’ s discharge diagnosis was chest pain, NSTEMI, and Klinefelter syndrome (a genetic condition in males born with an extra X chromosome, leading to lower testosterone, small testes, infertility, and potential learning or developmental delays).. Patient 33 remained with a critical (something that was extremely important or urgent) elevated troponin level at 154.76 on 3/4/2025. Patient 33 also had an elevated low-density lipoprotein direct (LDL direct, a blood test that measures the amount of “bad” cholesterol in the blood, that can cause buildup of plaque in the arteries). Patient 33 was followed by a cardiologist (a doctor who specializes in diagnosing, treating, and preventing diseases of the heart and blood vessels) during the hospital course, and was instructed to follow up in six months with a repeat echocardiogram (a test that uses ultrasound [sound waves] to evaluate the heart ’ s size, shape, pumping strength, and how well the valves are functioning). During a review of the facility ’ s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care”, 5/20/2025, the P&P indicated: I. PURPOSE To coordinate the interdisciplinary care for each patient and manage the documentation of that care and teaching that is given. The Interdisciplinary plan of care is documented within the electronic medical record under IPOC. The interdisciplinary care plan is individualized to each patient. II. GUIDING PRINCIPLES A. Interdisciplinary plan of care must be documented and followed for each patient. Whenever the term patient care plan is used, it is acknowledged that the term will be used interchangeably with interdisciplinary plan of care or IPOC. B. A complete care plan should be prepared within 24 hours of admission incorporating patient’s perceived needs and goals. Outcome criteria should be measurable and realistic. C. Patient documentation should reflect the patient’s plan of care. D. The care plans shall be reviewed and updated each shift. E. The patient care plan shall include all clinical services involved with care planning and coordination. F. The patient is matched with appropriate disciplines within the continuum. Coordination may include, but is not limited to, discharge planning, communication to facilitate family support, social work, nursing care, primary physician care, procurement of durable medical equipment (DME), or post discharge services. The goal of the care process provides individualized patient care needs. III. PROCEDURE Patients and families will be involved in developing the plan of care with collaboration of the interdisciplinary care team. The daily plan will be written on the communication board in the patients room The plan of care will be reviewed with the patient and or family at minimum but not limited to the following interactions: a.Bed side shift report b.When there is a change in the care plan c.During care transitions d.When planning for discharge”

“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: 45774 Based on observation, interview, and record review, the facility failed to: Ensure for six of 34 sampled patients (Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26), nursing care was provided when Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26 were not reassessed (reevaluation of a patient ’ s health status), in accordance with the facility ’ s policy and procedure regarding medication policies, after administration of as needed (PRN) pain medication was administered. These deficient practices had the potential to result in delayed treatment and had the potential to worsen Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26 ’ s pain to not be managed in a timely manner and may result in delayed treatment, which could worsen the patient ’ s (Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, and Patient 26) pain level. Ensure one of 34 sampled patients (Patient 26) intravenous (IV - in the vein) access site (A point of access to the bloodstream, to move fluids and medications into the body) was removed prior to discharge as per facility ’ s policies and procedures. This deficient practice had the potential for Patient 26’s increased risks for intravascular catheter related infections. Ensure three of 34 sampled patients (Patient 29, Patient 30, and Patient 31 ) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) was labeled to include the date and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient according to the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,”. This deficient practice had the potential for Patient 29, Patient 30 and Patient 31 ’ s, increased their risks for intravascular catheter related infections. Ensure one of two emergency crash carts (a cart stocked with emergency medical equipment [including: oxygen tank, suction set-up which is a medical device assembly used to remove fluids or secretions from a patient ’ s body cavity, etc.], supplies and medications) was completely checked and verified all equipment/materials are available in the crash cart once a shift, in accordance with the facility ’ s policies and procedures regarding emergency cart maintenance. This deficient practice had the potential for emergency medical equipment, medications, and supplies to not be readily available in the event of a medical emergency, which may result in delay provision of patient care. Ensure one of the 34 sampled patients (Patient 30) midline (an 8-12 cm catheter in the vein inserted in the upper arm with the tip located just below the axilla) site had insertion documentation and daily assessments were completed by the Acute Rehabilitation Unit staff since the patient admission per facility policies and procedures. This deficient practice may be resulted in negative consequences for Patient 30, increasing their risks for intravascular catheter related infections. Ensure for one of 34 sampled patients (Patient 30), the policies and procedures were implemented when Patient 30, who was at high risk for fall, was not wearing a yellow wristband, external notice on patient door and yellow non-skid slipper socks indicating the patient was at high risk for fall in accordance with the facility’s policy and procedure (P&P), titled “Fall Prevention Program,”. This deficient practice had the potential for Patient 30 to suffera fall injury. Adhere to the restraint monitoring policy for one of 34 sampled patients (Patient 23), when staff failed to adequately complete a one-to-one (1:1) observation checklist (a safety document used to record continuous, direct monitoring of a patient) for Patient 23, who presented to the facility for self-inflicted cutting (deliberate act of cutting one ’ s own skin using sharp objects). This deficient practice had the potential to result in Patient 23 inflicting self-harm, and even death to selfdue to lack of sufficient monitoring. Findings: 1. A. During a review of Patient 14 ’ s Face Sheet (the front part of the chart that contains a summary of basic information about the patient), dated 1/07/2025, the Face Sheet indicated, Patient 14 is 17 years old. During a review of Patient 14 ’ s “ED (ED, Emergency Department: a specialized 24/7 hospital area designed to provide immediate, unscheduled care for acute, life-threatening or severe health conditions ) Physician Record,” dated 1/07/2025, the ED Physician Record indicated, Patient 14 arrived at the ED for a chief complaint (the primary reason a patient seeks medical care) of “...right knee pain s/p (status post, meaning after or following an event) fall last night.” During a review of Patient 14 ’ s “X-Ray (a non-invasive medical imaging test) Report of Tibia/Fibula (two bones in the lower leg, connecting the knee and ankle joints), Right,” dated 1/07/2025, the X-ray report indicated Patient 14 had a “mildly displaced spiral fracture (a bone break caused by a twisting force where the fracture line wraps around the bone, resulting in a separation of the bone fragments) through the proximal fibular metadiaphysis (upper region of the bone near the knee).” During a concurrent interview and record review on 2/18/2026 at 11:55 a.m. with ED Nurse Educator (EDNE), Patient 14 ’ s Vital Signs Results Review dated 1/07/2025 for 4:39 p.m. was reviewed. The Vital Signs Results Review screen indicated Patient 14 had a FACES Pain Scale Score of 4 out of 10 (FACES Pain Scale Score, a tool with a range of faces used by healthcare professionals to measure a child ’ s pain intensity, with a face at 0 indicating not hurt, a face at 4 indicating hurts a little, and a face at 10 indicating hurts worse). During a concurrent interview and record review on 2/18/2026 at 11:55 a.m. with ED Nurse Educator (EDNE), Patient 14 ’ s Medication Administration Record (MAR) dated 1/07/2025 was reviewed. The MAR indicated, on 1/07/2025 at 6:24 p.m., acetaminophen (a medication which provides pain and inflammation relief) 1000 milligrams (mg – metric unit of measurement, used for medication dosage and/or amount) was administered to Patient 14 for a FACES Pain Scale Score of 4. During the same interview and record review, EDNE indicated there was no pain score reassessment in the time following the acetaminophen administration. During a review of the facility ’ s policy and procedure (P&P) titled, “Nursing (Nsg)– Pain Assessment and Management,” revised 11/2025, the P&P indicated: a. Pain is reassessed after each pain intervention. This includes pharmacological (medication ) and non-pharmacological (non-medication) interventions. b. Reassess pain within two (2) hour (sic) of intervention and document the result in EHR (electronic health record). c. Staff documentation: All assessments and reassessments ...and Reassessment within 2 hour of pain intervention. 1. B. During a review of Patient 15 ’ s Face Sheet (the front part of the chart that contains a summary of basic information about the resident), dated 1/07/2025, the Face Sheet indicated, Patient 15 is 11 years old. During a review of Patient 15 ’ s “ED (ED, Emergency Department) Physician Record,” dated 1/07/2025, the ED Physician Record indicated, Patient 15 arrived at the ED with a chief complaint (the primary reason a patient seeks medical care) of left shoulder/arm pain. During a review of Patient 15 ’ s “X-Ray (a non-invasive medical imaging test) Report of Shoulder Complete Left,” dated 1/07/2025, indicated Patient 14 had a left mid-clavicular [middle of the clavicle (a bone extending from the middle of the chest to the shoulder)] acute fracture (a sudden break in a bone). During a concurrent interview and record review on 2/18/2026 at 1:54 p.m. with ED Nurse Educator (EDNE), Patient 15 ’ s Vital Signs Results Review dated 1/07/2025 for 2:11 p.m. was reviewed. The Vital Signs Results Review screen indicated Patient 15 had a Pain Scale Score of 7 out of 10 (pain scale score, a tool used by healthcare professionals to measure pain intensity with 0 indicating no pain, 7 indicating severe to very severe pain, and 10 indicating the worst pain a patient has experienced). During a concurrent interview and record review on 2/18/2026 at 1:54 p.m. with ED Nurse Educator (EDNE), Patient 15 ’ s Medication Administration Record (MAR) dated 1/07/2025 was reviewed. The MAR indicated, on 1/07/2025 at 2:28 p.m., ibuprofen (a medication which provides pain and inflammation relief) 425 milligrams (mg – metric unit of measurement, used for medication dosage and/or amount) in an oral suspension (a liquid form of a medication, designed for patients who have difficulty swallowing pills) was administered to Patient 15 for a Pain Scale Score of 7 out of 10. During the same interview and record review, EDNE indicated there was no pain score reassessment after administration of pain medication on Patient 15 ’ s chart. During an interview on 2/18/2026 at 1:54 p.m. with EDNE, EDNE stated the pain medication reassessment after ibuprofen was administered to Patient 15 was not documented. EDNE stated it was important to document the pain reassessment in order to evaluate the effectiveness of the medication given to a patient. During a review of the facility ’ s policy and procedure (P&P) titled, “Nursing (Nsg)– Pain Assessment and Management,” revised 11/2025, the P&P indicated: a. Pain is reassessed after each pain intervention. This includes pharmacological (medication ) and non-pharmacological (non-medication) interventions. b. Reassess pain within two (2) hour (sic) of intervention and document the result in EHR (electronic health record). c. Staff documentation: All assessments and reassessments ...and Reassessment within 2 hour of pain intervention. 1. C. During a review of Patient 26 ’ s “History & (and) Physical (H&P),” dated 6/7/24, the H&P indicated Patient 26 was admitted to the facility for Right hip fracture (break in bone). The H&P further indicated, Patient 26 ’ s active hospital problem list included thrombocytopenia (a condition characterized by a low platelet [stop bleeding by forming clots] count causing increased risk of bruising and bleeding). During a review of Patient 26 ’ s “Medication Administration Report (MAR)” dated 6/8/2024, the MAR indicated a physician ’ s order for Patient 26 to receive the following: - Dilaudid (pain medication) 0.2 milligram (mg-a unit of measurement) intravenous (IV, in the vein) every 4 hours as needed (PRN) for moderate pain (pain score of 4-6 is moderate pain), with a start date of 6/8/24. During a concurrent interview and record review, on 2/18/26 at 9:36 a.m., with Nurse Educator Medical Surgical (MSE), MSE verified Patient 26 ’ s MAR indicated on 6/10/24 at 12:18 p.m., Patient 26 was administered Dilaudid 0.2 mg IV. The corresponding pain assessment indicated Patient 26 ’ s pain score was 10 (severe pain [pain score of 8-10 is severe pain]). During a concurrent interview and record review, on 2/18/26 at 10:30 a.m., with MSE, the MSE verified there was no documentation of Patient 26 ’ s pain reassessment after pain medication was administered on 6/10/24 at 12:18 p.m. The MSE stated the nurse should reassess the patient 26 ’ s pain within 2 hours after administration of IV pain medication to know if the medication was working and to follow the physician’s order. During a review of the facility ’ s policy and procedure (P&P) titled, “Nsg – Pain Assessment and Management,” revised 11/2025, the P&P indicated, “C. Pain Reassessment, 1. Pain is reassessed after each pain intervention. This includes pharmacological and non-pharmacological interventions. 2. Reassess pain within two (2) hour of intervention and document the result in EHR (electronic health record) ...E. Documentation 2. Staff documentation: a. All assessments and reassessment b. Reassessment within 2 hour of pain intervention ...” 1. D. A review of Patient 16 ’ s face sheet, dated 1/6/2026, indicated patient was admitted to the facility with a diagnosis, which included, subarachnoid hemorrhage (bleeding in the brain). On 2/18/2026, at 9:45 AM, during concurrent interview with ICU director (Dir ICU) and ICU educator (ICU Ed) and record review of Patient 16 ’ s vital signs and pain assessment, dated 1/6/2026, ICU Ed stated the following: Patient complained of head pain 4/10 at 4:37 AM, pain 5/10 at 8:00 AM, pain 8/10 at 9:30 AM, pain 5/10 at 12:00 PM and 4:00 PM, pain 9/10 (severe) at 6:50 PM and 8 PM, and pain 7/10 - with no documentation of interventions to relieve pain. Patient fell on the floor on 1/6/2026, at 9:25 AM. The nurses who cared for the patient should have documented interventions to relieve pain, including non-pharmacological treatments, and assessed the patient ’ s acceptable pain goal for pain relief. 1. E. A record review of Patient 17 ’ s face sheet (a concise, one-page summary of a patient ’ s key demographic, insurance, and essential medical information used in healthcare settings for quick reference), dated 7/2/2025, indicated patient was a minor and admitted to the facility with a diagnosis of high fever and diarrhea. On 2/18/2026, at 2:15 PM, during concurrent interview with nurse manager of emergency department (ED – a specialized 24/7 hospital area designed to provide immediate, unscheduled care for acute, life-threatening or severe health conditions) and record review of Patient 17 ’ s medical records, dated 7/2/2025, ED nurse manager (EDNM) stated the following: On 7/2/2025, at 12:20 AM, Patient was brought in by parents. At 12:33 AM, Patient had a fever with a temperature of 103.1 degrees Fahrenheit, with initial vital obtained. At 1:59 AM, Patient ’ s temperature was re-checked, without the rest of the Vital signs (VS-essential objective measurements of the body ’ s most basic life-sustaining functions, including body temperature, pulse rate, breathing rate, and blood pressure). At 3:00 AM, Patient was discharged home with his parents, without any VS obtained and no pain reassessment, within 30 minutes prior to being discharged home. In the ED, VS sould be taken every two hours, with pain assessment, and again 30 minutes prior to discharge. 1. F. A record review of Patient 18 ’ face sheet, dated 1/2/2025, indicated that patient was admitted with a diagnosis of heart failure. On 2/18/2026, at 3:28 PM, during concurrent interview with Emergency Department Nurse Manager (EDNM )and record review of Patient 18 ’ s ED vital signs (VS – essential objective measurements of the body ’ s most basic life-sustaining functions, including body temperature, pulse rate, breathing rate, and blood pressure) and pain assessment, dated 1/2/2025, EDNM stated the following: In the ED, VS were taken every two (2) hours with pain assessment. On 1/2/2025, at 12:49 PM, patient ’ s VS were obtained with pain score of 4/10 – no location of pain was documented. At 2:18 PM, VS were obtained without pain assessment done. At 2:37 PM, pain score was 10/10 (worst possible pain) – no location of pain documented. Concurrently, patient received Dilaudid 0.5 milligrams by vein for pain. At 2:52 PM, patient was reassessed for pain and had a pain score of 5/10 (moderate pain) – no location of pain documented. At 3:00 PM, 5:00 PM, 6:51 PM, and 8:27 PM, VS were obtained without pain assessment, including pain score. At 8:11 PM, patient left the ED and was admitted to telemetry unit (specialize unit in the hospital that monitor patient ’ s heart activity). In ED, patient ’ s VS were not obtained, with pain score, prior to being transferred to telemetry unit. A review of facility ’ s Plan for the Provision of Patient Care Services policy, dated 7/2025, indicated the following: Patient care services are designed to provide safe, effective, and timely patient care and treatment. Plans for patient care adhere to all legal, regulatory standards and requirements. Patients may expect to receive care within a safe environment. Patients may expect to have effective management of pain. Registered Nursing are responsible for assessing patients, involving patients in their care, educating patients, documenting their care (including assessments, reassessments, interventions, patient response to interventions, outcome of interventions), acting as patient advocates, and performing their duties in compliance with regulatory agencies and hospital policies and procedures. A review of facility ’ s Pain Assessment and Management policy, dated 2/2026, indicated the following: All patients will undergo comprehensive pain assessments upon admission, and at regular intervals, using validated tools appropriate to the patient ’ s age, condition, and ability to communicate. Pain management plans are individualized based on assessment findings, patient preferences, and treatment goals. Pain assessment included assessing the cause, location, intensity, duration, aggravating/relieving factors, effects on daily activities/ sleep patterns/psychological aspects, the effectiveness of current strategies, with a rating pain scale, and patient ’ s personal pain relief goal. Pain is assessed upon entry into the care delivery areas and at appropriate interval, as scheduled/as needed using appropriate pain measurement tools. Pain is assessed after each pain intervention – both pharmacological and non-pharmacological interventions. Reassess pain within two hours of intervention and document in the medical records the intervention efficacy based on intervention or with new reports of pain by patients. Notify the attending or consulting physician if pain intervention are ineffective. Orders for pain must clearly state the specific condition or pain level for which the medication is prescribed, including patient preferences in pain medication. Staff documentation included: all assessments/reassessments, reassessment within two hours after pain intervention, effectiveness towards achieving pain management goals, patient preferences on pain interventions, communication with physician, and initiation of interdisciplinary plan of care. 2. During a review of Patient 26 ’ s “History and Physical (H&P),” dated 6/7/2024, the H&P indicated Patient 26 was admitted to the facility for Right hip fracture (break in bone). The H&P further indicated, Patient 26 ’ s active hospital problem list included thrombocytopenia (a condition characterized by a low platelet [platelet, stop bleeding by forming clots] count causing increased risk of bruising and bleeding). During a concurrent interview and record review, on 2/18/2026 at 9:36 a.m., with Nurse Educator Medical Surgical (MSE), MSE verified Patient 26 ’ s order for peripheral IV catheter insertion was entered on 6/7/2024 at 1:08 p.m. MSE verified Patient 26 ’ s “Peripheral IV flowsheet,” dated 6/8/2024, the flowsheet indicated Patient 26 had an IV inserted to her left forearm. During a concurrent interview and record review, on 2/18/2026 at 10:00 a.m., with MSE, the MSE verified Patient 26 ’ s order for peripheral IV removal was entered on 6/11/2024 at 12:10 a.m. MSE verified Patient 26 ’ s “Peripheral IV flowsheet,” dated 6/10/2024, the flowsheet indicated Patient 26 had an IV to her left forearm and documented as assessed. MSE stated there was no documentation that indicated the IV catheter was removed prior to Patient 26 ’ s discharge. The MSE stated Patient 26 ’ s nurse should have documented in the medical record the date and time of peripheral IV catheter removal to follow the physician’s order. During a review of the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,” revised in 6/1/ 2024, the P&P indicated, “G. Removal 2. All peripheral IVs are discontinued prior to discharge. 3. Provide patient education to notify clinician for any site concerns. 4. Document in medical record the date/time of peripheral IV catheter removal.” 3. A. During an observation and interview, on 2/17/2026 at 12:14 p.m., in the medical surgical unit (a unit that provides care for adults with a variety of health issues that are non-critical), with Registered Nurse (RN) 1, inside Patient 29 ’ s room, l Patient 29 ’ s IV access site on the right hand was observed with dressing without a label indicating date when the dressing was placed and initials of who place the IV dressing. This was verified by RN 1 that the label was missing. . RN 1 further stated, it was important to date and initial the IV access site to know when it was placed. During a review of Patient 29 ’ s “History and Physical (H&P),” dated 2/10/2026, the H&P indicated Patient 29 was admitted to the facility for left total hip arthroplasty (replaces a diseased left hip joint with artificial components to relieve chronic pain and improve mobility). During a review of the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,” revised in 6/1/ 2024, the P&P indicated, “2. Dressings will be labeled with date and clinical staff ’ s initials to identify when the dressing was placed.” 3. B. During an observation and interview, on 2/17/2026 at 1:04 p.m., in Acute Rehabilitation Unit with Charge Nurse 1 (CN 1), inside Patient 30 ’ s room, Patient 30 ’ s IV access site on right upper arm was observed with dressing without a label indicating date when the dressing was placed and initials of who place the IV dressing. This was verified by CN 1 that the label was missing. CN 1 further stated, it is important to date and initial the IV access site to know when it was placed and to flush the site daily. During a review of Patient 30 ’ s “History & (and) Physical (H&P),” dated 2/6/2026, the H&P indicated Patient 30 was admitted to the facility for subdural hematoma (a life threatening, dangerous collection of blood between the brain ’ s surface and its outer covering). The H &P further indicated, Patient 30 had history of “generalized weakness with multiple falls.” During a review of the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,” revised in 6/1/ 2024, the P&P indicated, “2. Dressings will be labeled with date and clinical staff ’ s initials to identify when the dressing was placed.” 3. C. During an observation and interview, on 2/17/2026 at 2:54 p.m., with Registered Nurse (RN) 3, in the Intensive Care Unit (ICU, a specialized department with intensive monitoring and treatment for patients with life-threatening illnesses or severe injuries), inside Patient 31 ’ s room, RN 3 stated Patient 31 ’ s left forearm IV site was missing a label with date and initials of IV access site insertion into the patient. RN 3 stated the IV site had dry blood under the dressing. RN 3 further stated, it is important to date and initial the IV access site to know when it was placed. RN 3 stated, she would change the IV dressing immediately to avoid risk for infection to the IV site. During a review of Patient 31 ’ s “History and Physical (H&P),” dated 2/14/2026, the H&P indicated Patient 31 was admitted to the facility for Bowel perforation (a life-threatening hole in the gastrointestinal tract, allowing digestive contents to leak into the abdomen, causing severe infection). The H&P further indicated, Patient 31 ’ s active hospital problem list included Acute Kidney Injury (occurs when kidneys suddenly lose their ability to filter waste from the blood, developing within hours or days). During a review of the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter Insertion and Maintenance,” revised in 6/1/ 2024, the P&P indicated, “1. Peripheral IV dressings are changed every four (4) days and PRN for soiled, loosened and/or contaminated equipment ...2. Dressings will be labeled with date and clinical staff ’ s initials to identify when the dressing was placed.” 4. During a concurrent observation and interview on 2/17/2026 at 12:33 p.m. with Charge Nurse 1 (CN 1), in the Acute Rehabilitation Unit, CN 1 verified that Crash Cart 1 had not been completely checked by the charge nurse on 2/8/2026 during the AM (day) shift and on 2/11/2026 during the AM (day) shift. CN 1 stated the nurse should check for the presence of an oxygen tank, back board, defibrillator (device that applies an electric charge to the heart to restore a normal heartbeat), suction machine, expiration dates of medications and supplies, and Ambu bag (handheld device used to help patient breathe when not breathing). During a concurrent interview and record review on 2/17/2026 at 12:33 p.m., with the CN 1, CN 1 verified Crash Cart 1’s “Crash Cart Checklist” log, dated 2/2026, was not completed by the charge nurse on 2/8/2026 and on 2/11/2026 (no initials of a charge nurse indicating the cart was checked for the following: oxygen tank and back board), present and inspected. CN 1 stated the emergency crash cart should be checked every shift to ensure the supplies were present and readily available in case of emergency or a code (code blue, when a patient requires resuscitation [the act of reviving someone from apparent death or from unconsciousness] or in need of immediate medical attention). During a review of the facility’s policy and procedure (P&P) titled, “Emergency Crash Cart Management,” 7/28/2024, the P&P indicated the following: “Charge Nurse/Designee of each unit will be responsible in checking the Emergency cart two times daily, at the start of each shift (0700 shift and 1900 shift) and documented accordingly. Responsibilities: Responsibilities of RN/Charge Nurse or Designee: Completes a crash cart check at the beginning of each day shift: Verifies lock number, verifies that lock is intact, Verifies earliest expiration date is > 1 week away, Please note: if earliest expiration date is < 1 week away, notify Materials and Pharmacy, Checks and verifies all equipment/materials on outside of cart.” 5. During an observation and interview, on 2/17/2026 at 1:04 p.m., in Acute Rehabilitation Unit with Charge Nurse 1 (CN 1), inside Patient 30 ’ s room, Patient 30 was observed in her chair with a midline (an 8-12 cm catheter in the vein inserted in the upper arm with the tip located just below the axilla) to her right upper arm, the dressing had folds to the edges with extra tape covered over the transparent dressing. Patient 30 stated her midline had not been flushed for more than 3 days. CN 1 further stated, it is important to flush the site daily. During a review of Patient 30 ’ s “History and Physical (H&P),” dated 2/6/2026, the H&P indicated Patient 30 was admitted to the facility for subdural hematoma (a life threatening, dangerous collection of blood between the brain ’ s surface and its outer covering). The H &P further indicated, Patient 30 had history of “generalized weakness with multiple falls.” During a concurrent interview and record review, on 2/17/2026 at 3:22 p.m., with Registered Nurse 2 (RN 2), RN 2 verified Patient 30 ’ s midline to right arm was not documented on admission to the Acute Rehabilitation Unit on 2/5/2026. RN 2 verified “Midline IV (in the vein) flowsheet,” dated 2/5/2026 to 2/16/2026 (total of 11 days), the flowsheet indicated Patient 30 did not have any activity/assessment/dressing care documented for the midline IV. RN 2 stated the importance of dating a midline dressing is to do weekly dressing change and know the time and day it was inserted. RN 2 stated is important to document the assessment and flushing the midline daily. During a concurrent interview and record review, on 2/19/2026 at 4:28 p.m., with Nurse Educator of Medical Surgical (MSE), MSE verified Patient 30 did not have documentation by the nurse that assessed the midline catheter upon admission to ARU on 2/5/2026 to 2/16/2026 (total of 11 days). MSE stated per policy the nurses are to document information regarding insertion, assessments, or actions about the midline catheter. During a review of the facility ’ s policy and procedure (P&P) titled, “Midline Intravenous Catheter Adult Guidelines,” revised 8/2022, the P&P indicated, “Patients requiring Midline catheters will receive appropriate care to ensure patency, to reduce the incidence of infections, and reduce complications ...Assessment: 1. Assessment shall be done every shift ...Dressing should be clean and intact or it shall be changed ...Documentation: 1. Information regarding insertion, assessments, or actions about the midline catheter will be completed by the RN that places the device. 2. Documentation regarding the midline catheter should be completed with other invasive lines in the patient ’ s electronic medical record. F. Dressing Changes-dressing shall be changed anytime the dressing is no longer intact to the skin, weekly on Sundays, and anytime it becomes wet or contaminated.” 6. During an observation and interview, on 2/17/2026 at 1:04 p.m., in Acute Rehabilitation Unit with Charge Nurse 1 (CN 1), inside Patient 30 ’ s room, Patient 30 was observed in her chair without a yellow wristband or yellow non-skid socks in place. Patient 30 ’ s door did not have a fall risk notice to indicate the patient was at high risk for fall. During a concurrent observation and interview, on 2/17/2026 at 1:04 p.m., with CN 1, CN 1 stated Patient 30 was at high risk for fall. CN 1 stated fall risk intervention included a yellow wristband, yellow socks, and signage on the patient ’ s room. CN 1 stated Patient 30 was not wearing a yellow wristband. CN 1 stated the importance of the fall risk armband, yellow socks and signage on patient ’ s room is so that anyone that comes in Patient ’ s 30 room would monitor the patient closely to prevent a fall. During a review of Patient 30 ’ s “History and Physical (H&P),” dated 2/6/2026, the H&P indicated Patient 30 was admitted to the facility for subdural hematoma (a life threatening, dangerous collection of blood between the brain ’ s surface and its outer covering). The H &P further indicated, Patient 30 had history of “generalized weakness with multiple falls.” During a review of Patient 30 ’ s “Morse Fall Risk” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 2/17/2026, at 08:45 a.m., the flowsheet indicated Patient 30 score of a 65 on the Morse Fall Risk Score (a tool used to assess a patient ’ s risk of falling in a healthcare setting 0-24 indicates low fall risk, universal interventions, 25-44 indicate moderate risk for fall and 45 and above indicate high fall risk implement (start) high risk fall interventions). During a review of the facility’s policy and procedure (P&P), titled “Fall Prevention Program,” dated 2/4/2026, the P&P indicated, “Interventions: High Risk Patients (Patients who score greater than 45 on the Morse scale, may have cognitive deficits, demonstrates non-compliance with the call light, history of fall in the unit or have functional deficits impacting their ability to prevent a fall.) A. Interventions for those at high risk for falls include all interventions for low and standard risks with the addition of: 1. Use of yellow wristband and non-skid slipper socks to communicate risk to interdisciplinary partners. 2. External notice on patient door to communicate fall risk to interdisciplinary partners ...” 7. During a review of Patient 23 ’ s “Facesheet” (a summary that provides a quick, essential overview of a patient ’ s identity, insurance, and key health data), undated, indicated that Patient 23 was admitted on 2/15/2026 at 7:28 pm, for behavioral concerns. During a review of Patient 23 ’ s “Emergency Department (ED) Physician Record”, dated 2/15/2026 at 7:46 pm, the emergency department (ED) physician record indicated that Patient 23 was brought in by (BIB) ambulance for suicidal attempt (a non-fatal, self-directed, potentially injurious behavior with intent to die) with superficial abrasions (minor shallow scrapes that remove only the top layer of skin) to left arm and leg from razor blades after an argument with the sister and mother. Patient 23 had a past medical history of depression (a serious mood disorder characterized by persistent, long-lasting feeling of sadness or a loss of interest in activities). Patient 23 ’ s mother reported that Patient 23 had prior psychiatric (the medical study, diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) admission(s) and ongoing behavioral concerns, including aggression (any verbal or physical behavior intended to cause harm, pain, or injury to another person, animal, or object) toward family. Patient 23 endorsed self-harm (deliberately harming your own body on purpose) intent without clear suicidal intent. Patient 23 ’ s examination impression (a doctor ’ s initial, expert interpretation of findings) included intentional self-harm, abnormal behavior, and agitation. During a review of Patient 23 ’ s “Emergency Department (ED) Physician Record”, dated 2/16/2026 at 7:00 am, the ED physician record indicated that Patient 23 denied intent to die, and described the behavior as self-harm rather than suicide attempt. Patient 23 endorsed ongoing thoughts of self-harm but denied thoughts of harming others. Patient 23 reported poor sleep, averaging about five hours per night. Patient 23 reported previously receiving a prescription for Prozac (an antidepressant medication used to treat some mood disorders including depression) but was not actively being taken. Patient 23 ’ s drug screen (a quick analysis test to detect the presence of specific illegal drugs or prescription medication misuse) resulted positive for Cannabinoids (a type of chemical in marijuana that causes a drug-like effects all through the body). During a review of Patient 23 ’ s “Consult – Psychology Report”, dated 2/16/2026 at 12:59 pm, the psychology report indicated that Patient 23 ’ s father had a history of bipolar disorder as does the paternal aunt. Patient 23 reported not getting along with older sister, not listened to by mother resulting in “acting out by cutting”, and did not like self. On examination, Patient 23 had poor judgement and a depressed mood. Patient 23 was reported to have some suicidal ideation without intent (plan). Patient 23 was placed on a 5585 hold (an involuntary 72-hour psychiatric detention of a minor [under 18] experiencing a mental health crisis, by California law) pending transfer to an age-appropriate Lanterman-Petris-Short facility (LPS, a California-designated, secure, or locked mental health treatment facility authorized to hold and treat individuals involuntarily). Patient 23 was inconsistently taking the prescribed medication by cheeking medications (concealing medication in the mouth to avoid taking). During a concurrent observation and interview on 2/17/2026 at 3:00 pm, with emergency department director (EDD), in the emergency department (ED) near rooms nine through 11, there were two rooms on the right of the hallway and two rooms on the left. The area was squared in shape. There were two security guards seated facing one another, immediately outside the four rooms. The guards were seated at a bedside table/desk documenting on the one-to-one observation checklist for their assigned patients. EDD stated that when the rooms are occupied by patients with behavioral concerns, two staff members remain in the observation area (the hallway centered, equally between the four rooms) monitoring the patient(s) at all times. Per EDD, the “sitter” (a person hired to temporarily watch over someone else) does not leave their post without another staff member available to provide coverage. EDD further stated that the observation checklists are required to be completed, per policy, for all patients on psychiatric holds, requiring a sitter, or with positive behavioral screening imposing a safety risk. During a concurrent interview and record review on 2/19/2026 at 2:10 pm, with EDD, Patient 23 ’ s “Suicide One-to-One Observation Checklist”, dated 2/16/2026 and 2/17/2026 was reviewed. The observation checklist (log) was missing documentation on 2/16/2026 from 6:15 am to 7:15 am. EDD stated, “I ’ m not sure why this (Patient 23 ’ s observation log) was not completed. It should have been completed for the entire length of time that the patient required monitoring”. Per EDD, the assigned sitter was supposed to observe the patient every 15 minutes, documenting their location and activity. The sitter may also document when a patient is off the unit (diagnostic testing, etc.), per EDD. EDD further stated an observation log should be thoroughly and accurately completed to ensure the patient ’ s safety while monitoring for potential harm and or undesired behaviors. It also tracks behaviors to assess how a patient was responding to treatment(s) and/or if behavioral symptoms improved. However, the primary goal was safety. During a review of the facility ’ s policy and procedure (P&P), titled “Nursing (Nsg) – Restraints”, dated 2/4/2026 (original 2/2012), the P&P indicated: F. Ongoing Monitoring: 1. Violent/ Self-Destructive: The patient shall have documented assessment every 15 minutes while in restraints by the RN or assigned staff. The selection of an intervention and determination of the frequency of assessment and monitoring needs to take into consideration the patient’s condition, cognitive status, and risks associated with the use of the chosen intervention. The assessment includes: Signs of any injury associated with the use of restraint Circulation and skin integrity Mental status Level of distress and agitation Readiness for discontinuation of restraint Range of motion and release of limbs will be done minimally every 1 hour Fluids and an opportunity for toileting shall be offered at least every 2 hours Vital signs shall be taken upon initiation and as clinically indicated, but at least every 2 hours ii.The patient restrained for violent/ self-destructive purpose is monitored by continuous in-person observation by an assigned staff member who is competent and trained in the use of restraints. In-person does not include the use of audio-visual equipment.”

“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: 45774 Based on interview and record review, the facility failed to ensure for one of 34 sampled patients (Patients 28), Patient 28 ’ s Percocet (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28 ’ s health and safety due to unsafe medication administration and may lead to prolonged hospitalization. Finding: During a review of Patient 28 ’ s “History and Physical (H&P),” dated 11/17/2025, indicated Patient 28 was admitted to the facility for lumbar spinal stenosis (a medical condition that occurs when the spinal canal narrows in the lower back, putting pressure on the spinal cord and nerves) During a review of a Patient 28 ’ s “Medication Administration Report (MAR),” dated 11/17/2025, indicated a physician ’ s order for Patient 28 to receive the following: Percocet 10-325 milligram (mg-a unit of measurement) 1 tablet by mouth every 4 hours as needed (PRN) for moderate pain (pain score 4-6 is moderated pain) with a start date of 11/17/2025; and, Dilaudid 0.2 mg intravenous (IV- in the vein) every 2 hours PRN for severe pain (pain score 7-10 is severe pain) with a start date of 11/17/2025. During a concurrent interview and record review on 2/19/2026 at 4:30 p.m., with Nurse Educator Medical Surgical (MSE), MSE verified the following: - Patient 28 ’ s MAR indicated on 11/17/2025 at 04:11 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 9 (severe pain). - Patient 28 ’ s MAR indicated on 11/17/2025 at 8:41 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 7 (severe pain). - Patient 28 ’ s MAR indicated on 11/18/2025 at 12:23 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 7 (severe pain). -Patient 28 ’ s MAR indicated on 11/18/2025 at 11:20 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 7 (severe pain). -Patient 28 ’ s MAR indicated on 11/19/2025 at 2:52 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 8 (severe pain). -- Patient 28 ’ s MAR indicated on 11/20/2025 at 1:24 p.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 7 (severe pain). -- Patient 28 ’ s MAR indicated on 11/21/2025 at 3:34 a.m., Patient 28 was given Percocet 10-325 mg 1 tablet by mouth. The corresponding pain assessment indicated Patient 28 ’ s pain score was 7 (severe pain). During a concurrent interview and record review on 2/19/2026 at 4:30p.m., with MSE, MSE stated is important to give medication according to physician ’ s orders. MSE confirmed Percocet 10-325 mg 1 tablet by mouth is for moderate pain and Patient 28 had severe pain. MSE stated the nurse should have contacted the physician to inform him that the pain medication was not effective. MSE stated there were no notes that indicated the nurse communicated to the doctor regarding pain medication was not effective. During a review of the facility ’ s policy and procedure (P&P) titled, “Medication Administration,” dated 01/2025, indicated, “Comparison of the e-MAR with the actual medication. Six rights systematically and conscientiously, reviewed at time of administration (right individual, right medication, right dose, right time, right route, right documentation). During a review of the facility ’ s policy and procedure (P&P) titled, “Patients ’ Rights and Responsibilities,” dated 03/18/2025, indicated, “Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. You may request or reject the use of any or all modalities to relieve pain, including opiate medication, if you suffer from severe chronic intractable pain””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to ensure infection control policies and procedures regarding Employee Health were implemented when the facility failed to ensure that two of six employees ’ (E9 and E10) Rubella (a highly contagious infection) and Varicella (a highly contagious infection caused by the varicella-zoster virus) titer (the measurement of the amount of a substance in a solution) results were not forwarded to the facility ’ s Infection Control Department, per facility ’ s policy and procedure, and in accordance with the regulatory requirements set by the [State] Department of Public Health (DPH) regarding Rubella and Varicella testing [checks to see if an employee has low immunity (the state of being resistant to an infection) to Rubella and Varicella]. This deficient practice had the potential to result in increased risk of exposure (contact of an organism to a substance) to viruses (an infective agent) which could lead to infection (the invasion, survival, and multiplication of harmful organisms) for the employees, the patients, and other staff. Findings: During a concurrent interview and record review on 2/20/2026 at 3:09 p.m. with the Director of Human Resources (DHR), E9 ’ s employee health immunization results (the outcome of immunization testing), dated 3/16/2025, were reviewed. The immunization results indicated, E9 had a Rubella titer of 0.35 (a result of less than 10 is considered non-immune (a person is considered susceptible or unprotected against a specific disease), a result of 10 or greater is considered immune (totally or partially resistant to a particular disease), and a result of 9-9.9 is considered borderline (the condition of being between normal and abnormal)] and considered non-immune; and a Varicella IgM (a substance produced by the immune system, acting as the first line of defense during initial exposure to an infectious agent) titer of 0.4 (a result less than 0.9 is considered negative or non-immune, a result greater than 1.1 is considered positive) and considered non-immune. DHR stated the employee health department would advise E9 the next steps to address low immunization titers. DHR stated she was unaware if any communication regarding E9 was sent from employee health to the Infection Preventionist (IP). During a concurrent interview and record review on 2/20/2026 at 3:21 p.m. with DHR, E10 ’ s employee health immunization results were reviewed. The immunization results, dated 10/28/2023, indicated, E10 had a Varicella IgG (a substance found in blood, which plays a critical role in the immune system by fighting infections) titer result of less than 135 [a result less than 135 is considered negative, a result between 135-165 is considered borderline and often requires retesting (repeating the blood test for IgG) or vaccination (a medical preparation used to provide immunity to a particular infectious disease), and a result greater than 165 is considered immune] and considered non-immune. DHR stated she was unaware if any communication regarding E10 vaccination results was sent from employee health to the Infection Preventionist (IP). During a concurrent interview and record review on 2/20/2026 at 3:55 p.m. with IP, E9 and E10 ’ s employee health immunization results from (E9) 3/16/2025 and (E10)10/28/2023 were reviewed. IP stated she was not aware of the low immunization results for E9 and E10. IP stated the facility ’ s Employee Health Department had not informed her of any employee which had a low immunization result. IP stated the facility ’ s policy titled, “Employee Health Pre-Employment and Annual Testing,” revised 11/2024, did not clearly state the steps either the employee, Employee Health Department, or the IP would take when an employee presented with low immunization results. IP stated she was not aware of the State of California ’ s (State) requirement for hospitals to offer immunizations for non-immune employees. During a review of the facility ’ s policy and procedure (P&P) titled, “Employee Health Pre-Employment and Annual Testing,” revised 11/2024, the P&P indicated: Mumps (a contagious infection affecting the area between the ear and the jaw), Rubella and measles (a highly contagious illness): All employees will have a titer drawn. If non-immune, Infection Control Department will be notified and the Measles, Mumps, and Rubella (MMR) vaccination will be given accordingly to procedure. Varicella: If the employee states no history of immunity, titer will be drawn. If the employee is non-immune the Employee Health Department will be notified and the vaccination will be given according to procedure. During a review of “California Department of Public Health (CDPH) Immunization Recommendations for California Healthcare Personnel,” dated February 2025, the form indicated: The California Division of Occupational (workplace) Safety and Health (Cal/OSHA) Aerosol (small particles or liquid droplets that are small enough to be inhaled deep into the lungs) Transmissible (the ability of an infection to go from one person to another) Diseases (ATD) standard requires that employers make available the vaccines listed below to susceptible [easily affected by a disease or infection] (non-immune) healthcare personnel (HCP) employees who are covered by the standard and at risk of occupational exposure. Employees may decline to be vaccinated but must sign a declination form. Vaccines that are required to be offered, at no cost, to non-immune HCP employees per the Cal/OSHA ATD or Bloodborne Pathogen [infectious substances that are present in the blood] (BBP) standards: ...Measles, mumps, and rubella (MMR) vaccine ...Varicella vaccine (not zoster [a disease caused by a virus that can lead to shingles – a painful rash with blisters that can lead to other complications] vaccine).”

“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: 45774 Based on interviews and record reviews, the facility failed to ensure one of four sampled patient ’ s (Patient 1) gallbladder (a small, pear-shaped organ in the upper right abdomen beneath the liver that stores and concentrates bile[greenish-yellow fluid produced by the liver, stored, and concentrated in the gallbladder] to aid in fat digestion) specimen (sample) was retrieved before the surgical site wound closure post robotic-assisted laparoscopic cholecystectomy (a robotic-assisted, minimally invasive procedure to remove the gallbladder through small abdominal incisions). This deficient practice resulted in Patient ’ s 1 surgery site reopening and prolonging anesthesia (medication that provide sedation during surgical procedures) exposure. It has the potential to cause an increased risk of bleeding, bile leakage (a serious post-surgical complication where bile escapes from the bile ducts into the abdominal cavity, causing intense pain, fever, nausea, and jaundice [yellowish color of the skin]) and infection. Findings: During a review of Patient 1 ’ s “Operative Report,” dated 6/13/2025, indicated that Patient 1 was an 82-year-old man who was seen in Surgical Doctor ’ s (SD1) office complaining of signs and symptoms of acute (sudden) and chronic (long-lasting condition) cholecystitis (inflammation of the gallbladder) and was recommended for surgical treatment. A post robotic-assisted laparoscopic cholecystectomy (a robotic-assisted, minimally invasive procedure to remove the gallbladder through small abdominal incisions) was performed. The gallbladder specimen (sample) was sent to pathology (a laboratory that analyzes clinical specimen), no immediate apparent complications after surgery, and Patient 1 was extubated (removal of a breathing tube from a patient ’ s airway) and was transferred to recovery room (a specialized area where patients are taken after surgery) in stable condition. An addendum was added by SD1 dated 7/1/2025, it indicated that a specimen (sample) was left in situ (a Latin phrase meaning an organ has been left in its original place or natural position) upon initial closure of skin by the RNFA (Registered Nurse First Assist). After both SD1 and RNFA left the operating room. The circulating nurse (a nurse who manages the non-sterile, logistical [things are plan or organize], and safety aspects of the operating room) reminded SD1 of the oversight. SD1 immediately re-entered the room and assessed that all necessary laparoscopic (minimally invasive) instruments were still sterile (free of living microorganisms, bacteria, and viruses) and the anesthesiologist (doctor who manage patient during surgical procedures) had not awakened and extubated Patient 1. SD1 and RNFA scrubbed (cleaning) back in and removed the gallbladder without incident through the prior incisions. During an interview on 2/17/2026 at 04:00 PM with Operating Room Manager (ORM), ORM stated, Patient 1 had a robotic-assisted laparoscopic cholecystectomy last 6/13/2025, the surgery involved a removal of the gallbladder and the surgery team forgot to remove it. The RNFA had already completed skin closure, and the surgeon had left the room. The circulating nurse realized that there was no gallbladder specimen collected and informed SD1. Patient 1 was still on the operating room table under anesthesia. SD1 had to scrubbed back in and remove the gallbladder. ORM added that the facility deemed it as a “retain object” incident. It was later found out that the case debrief (a structured, post-procedure huddle designed to improve patient safety, team communication, and workflow efficiency) was not completed. A case debrief must be completed prior to the surgeon stepping out of the operating room. SD1 should not have left the waiting room without completing a case debrief. During an interview on 2/20/2026 at 02:00 PM with Surgical Doctor (SD1), SD1 stated, he had left the task of completing the gallbladder removal and skin closure to RNFA and had left the OR (operating room) to do his surgical dictation (the immediate, post-procedure recording of operative details into medical records to ensure accuracy and compliance). He was later informed by the circulating nurse that there was no gallbladder specimen collected. He reentered the operating room and together with RNFA, retrieved Patient 1 ’ s gallbladder through the prior incision. The incision had to be re-opened since it was previously closed by the RNFA. During a review of the facility ’ s policy & procedure (P&P) titled “Universal Protocol,” last reviewed 08/07/2025, indicated the following: Post Procedure Debrief - A post procedure debrief should be performed prior to the proceduralist (the doctor who performed the procedure) leaving the procedural area. Procedural Safety Checklist Boards should be used to guide the post procedure debrief. 1.As applicable, the following information will be confirmed during the post debrief: a. Verification of procedure performed b. Verification of post op diagnosis c. Verification of sponge, sharp, and instrument count status d. Verification of specimens e. Review any instrument/equipment concerns f. Review patient recovery/management concerns g.Verification of wound classification h. Verification of blood loss (EBL/QBL) with proceduralist and anesthesiologist i. Verification that guidewire(s) have been removed and are intact j. Verification that loose items, i.e., blades, pens, caps, scratchers, etc. are removed and intact.”

“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: 50632 Based on interviews and record review, the facility failed to provide an appropriate stabilization for one of 21 sampled patients (Patient 1) when Patient 1 presented to the Emergency Department (ED - the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment. This deficient practice resulted in the facility failing to provide further medical examination with a consulting general surgeon, in order to stabilize patient with emergency surgery to potentially stop the internal bleeding. (Refer to A-2407) Findings: A review of Patient 1 ’ s face sheet (a document that provides a quick overview of key information about a person), dated 5/25/2025, indicated patient was admitted to the emergency department (ED – emergency room providing 24/7 unscheduled medical care to patients with urgent or life-threatening conditions) at 4:38 p.m., for ectopic pregnancy (a pregnancy that develops outside of the uterus, which is not viable and requires medical treatment). A review of Patient 1 ’ s Emergency Department (ED) Triage Nursing Notes and Nursing Flowsheet, dated 5/25/2025, indicated: Patient arrived at 12:26 p.m. At 12:33 p.m., triage vital signs were blood pressure (BP) of 103 /58 millimeters of mercury (mmHg), heart rate (HR) was 99 beats per minute (bpm), respiratory rate (RR) was 22 breaths per minute (bpm), temperature was not obtained, oxygen (O2) saturation was 100% on room air, and pain was the worse pain ever with a score of 10 out of 10. Patient was classified with an Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care to prioritize patients for treatment, ensuring that those with the most urgent needs are seen first) of 2 – which is emergent(medical condition present an immediate threat to life, limb(arm or leg)or eyesight, that requiring prompt and potentially life-saving intervention). A review of Patient 1 ’ s pregnancy test, dated 5/25/2025, indicated a human chorionic gonadotropin (hCG – a hormone produced by the placenta during pregnancy with levels measured in the blood or urine to confirm pregnancy) level of 4367 mIU/ml. A review of Patient 1 ’ s Transvaginal ultrasound, dated 5/25/2025, indicated a live ectopic pregnancy at an estimated gestational age of five weeks and 4 days, with complex fluid seen in the pelvis – consistent with ruptured ectopic gestation, which was reported to Emergency Department Physician 1 (ED 1). A review of Patient 1 ’ s physician orders dated 5/25/2025, indicated: norepinephrine 4 mcg per minute IV without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ’ s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg. Red blood cells (RBC ’ s) two units to be given right away (STAT) and massive transfusion protocol. Two (2) units of RBC ’ s STAT and one (1) unit of fresh frozen plasma (FFP – a blood product containing various clotting factor and other plasma proteins to treat bleeding disorders) STAT. One (1) unit of platelets (blood product that plays a crucial role in blood clotting and stopping bleeding) at 2:53pm. Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm. Labs to check for anemia at 3:55pm. A review of Patient 1 ’ s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated: From 2:04 p.m. to 2:26 p.m., patient received 500 milliliters (ml) of RBC ’ s. From 3:02 p.m. to 3:21 p.m., patient received 2 units of RBC ’ s. Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm. From 3:45 p.m. to 3:51 p.m., patient received 1 unit of platelets. At 3:48 p.m., patient received 1 unit of FFP. On 6/26/2025, at 8:35 a.m., interview with Nursing Services Director of Emergency Department (NSED) and Emergency Department Educator (EDE), EDE stated At 4:19 p.m., patient ’ s hemoglobin (Hgb – a protein component in the RBC that carries oxygen from the lungs to the tissues) was 6.4 (normally 12-17.5 grams per deciliter) and hematocrit (the percentage of volume of red cells in the blood) was 19.9 (normally 36-44%). And the Patient received IV transfusion (the process of transferring blood or blood components into the blood stream to replace blood or blood products lost due to severe bleeding) summary, dated 5/25/2025, EDE stated the following blood products were administered to the patient: RBC 278 milliliters (ml – one-thousandth of a liter), Platelets 334 ml, RBC 500 ml x 4. And ED 1 did not order any consultations for general surgery. A review of Patient 1 ’ s vital signs (measurable physiological indicators that reflect a person ’ s basic bodily functions including temperature, pulse rate, respiratory rate, blood pressure (BP), oxygen saturation) dated 5/25/2025, indicated: 12:32 p.m., BP was 100/58, HR was 99, RR was 18, O2 saturation was 100% on room air. At 12:50 p.m., BP was lower at 88/54, HR was 100, RR was 20, O2 saturation was 100% on room air. At 1:00 p.m., BP was lower at 86/50, HR was 80, RR was 22, O2 saturation was 100% on room air, and temperature was 97.2 degrees Fahrenheit. At 1:35 p.m., BP was 98/74, HR was 86, RR was 22, O2 saturation was 100% on oxygen by nasal cannula (a medical device that provides supplemental oxygen therapy) at 2 liters per minute (lpm). 1:45 p.m., BP was lower at 66/42, HR was 78, RR was 17, O2 saturation was 99% on oxygen by nasal cannula at 2 lpm. 2:44 p.m., BP was 94/53. 3:17 p.m., BP was 107/74. 8. 3:36 p.m., BP was 127/74. 9. 3:51 p.m., BP was 113/56. 10. 4:19 p.m. BP 108/56, HR 93, O2 saturation 99% on nasal cannula at 2 lpm, temperature 97.7 degrees Fahrenheit On 6/26/2025, at 3:34 PM, during an interview with the Chief of the Emergency Department (CED), the CED stated a patient is not considered to be stable if they are on a norepinephrine drip (medication used to increase blood pressure) during transfer. The CED stated, regarding Patient 1, he had called several different doctors at the surrounding facilities, but they would not accept the patient due to the physical distance of transport. The CED stated he understood that without first receiving acceptance from the receiving facility, the transferring facility would be at fault for sending a patient to a facility with no capacity to accept the patient. Concurrently, during review of Patient 1 ’ s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated norepinephrine 4 mcg per minute IV was ordered and administered without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ’ s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg. On 6/26/2025, at 4:01 PM, during an interview with the Emergency Department Physician 1 (ED 1), the ED 1 stated, to treat a ruptured (breaking of vessel or membrane) ectopic pregnancy (can be life threatening; a pregnancy that occurs outside the uterus and cannot be carried to term) he would need to stabilize the patient by keeping the blood pressure in normal range and by stopping the bleeding. The ED 1 stated, this medical condition would require surgical intervention, which the patient would have to be transferred out from the facility to another facility that had the capability of treating such condition. On 6/27/2025, at 10:54 AM, during an interview with the Chief of General Surgery (CGS), the CGS stated, generally, a general surgeon should be able to handle a patient that comes into the emergency room and is bleeding. The DGS stated that the facility ’ s general surgeon should be competent enough to stop a patient from bleeding. The CGS also stated with a patient who is unstable and has a ruptured ectopic pregnancy, a general surgeon is compelled (force to do something) to intervene (to step in) the best they can for that patient at the facility in an attempt to salvage (to rescue) the patient. A review of Patient 1 ’ s Emergency Department (ED) Physician record, dated 5/25/2025, indicated: Arrived by private vehicle to the ED with complaint of abdominal pain with nausea and vomiting, vaginal bleeding heavier than usual, and worsening pain. Active problems included abnormal pelvic ultrasound. Physical examination with diffused abdominal tenderness. Transvaginal ultrasound (a common and safe imaging technique used in early stages of pregnancy to visualize the pelvic organs, including the uterus, ovaries and cervix, to confirm early pregnancy and to monitor for potential complications) indicated a mass noted in the right area beside the uterus which was consistent with a live ectopic pregnancy (a pregnancy that occurs outside the uterus and that cannot be carried to term with an embryo identified, which can be life threatening). Consulting services for obstetrics and gynecology (OB/GYN - medical doctor specializing in both obstetrics for pregnancy and gynecology for female reproductive health) were contacted from other facilities, with intent for transfer to a facility capable of stabilizing and treating patient with patient unstable for discharge. General surgeon was not consulted for this patient. Massive transfusion protocol initiated for hemorrhagic shock (a critical condition where severe blood loss leads to inadequate oxygen and nutrient delivery to the body – potentially causing organ damage or death), due to ruptured ectopic pregnancy (a serious life-threatening condition where a fertilized egg implanted outside the uterus and ruptured, leading to internal bleeding and shock, requiring immediate medical intervention, including surgery). Intravenous (IV - into a vein) medications given, included norepinephrine (medication used to increase blood pressure) 4 micrograms (mcg – a unit of mass – one millionth of a gram) per minute, normal saline boluses. IV blood products given included fresh frozen plasma (FFP – a blood product used to treat bleeding disorders), platelets (thrombocytes – blood cells to improve patient ’ s ability to clot blood), and packed red blood cells (RBC - blood cells to increase a patient ’ s oxygen carrying capacity and treat blood loss). Patient will be transferred by 9-1-1 to another facility due to medical necessity with inherent risks and benefits of transfer discussed with patient and family. Disposition – patient care transferred to another facility for higher acuity of care. On 6/27/2025, at 2:15 PM, during an interview with the General Surgeon (GS), the GS stated, if there was no other way to transfer a patient with a ruptured ectopic pregnancy out of the facility to another receiving facility, he, as a general surgeon, would have decided to pack the abdomen as a means of stabilizing (secure) the patient for transportation. The GS stated he would have opened the abdomen (the belly area) and placed packs to tamponade (the surgical use of a plug of absorbent material) the bleeding and had the patient transferred to a trauma facility with the abdomen left open. The GS also stated he was not notified for consultation (meeting) regarding Patient 1 ’ s case on 5/25/2025, when he was scheduled for general surgery. A review of facility ’ s Emergency Department Physician Call Schedule, dated May 2025, GS was scheduled for general surgery on 5/25/2025. A review of Patient 1 ’ s Assessment Forms (calls and communication for the patient), dated 5/25/2025, indicated the following: At 12:54 p.m., Code Sepsis paged. 2:51 p.m., potential receiving facility indicated patient was too critical to transfer out. 3:04 p.m., massive blood transfusion was overhead paged. 3:28 p.m., potential receiving facility indicated patient is too critical to transfer. 3:51 p.m., patient was being 9-1-1 transferred out. Transfer to another facility at 4:19 p.m. with a diagnosis of hemorrhagic shock and ruptured ectopic pregnancy. A review of facility ’ s Emergency Department (ED) Triage and Medical Screening Guidelines, dated 12/2024, indicated the following: Triage is the process of collecting pertinent information about patients who are seeking emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity-designation system. Facility uses a Five-Level scale called Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care; used to prioritize patients for treatment, ensuring that those with the most urgen needs are seen first) and references the most updated version of the Emergency Nurses Association (ENA – an accredited organization providing nursing professionals continuing development by the American Nurses Credentialing Center ’ s Commision on accreditation). Patients arriving to the ED will be triaged by an ESI triage-trained ED registered nurse (RN) to determine the patient ’ s ESI level, after the ED triage RN performed the initial assessment after obtaining the five elements: chief complaint Allergies vital signs – measurable physiological indicators that reflect a person ’ s basic bodily functions to provide essential information about the person ’ s health status and to help identify potential medical conditions, including temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation Pain level Height and weight 4. ED triage RN will consider the five elements and will assign the ESI level based on the decision points of the ENA criteria. 5. ESI level 1 and 2 are conditions which may result in loss of life or limb, if not treated immediately, including cardiac arrest (sudden unexpected loss of heart function, breathing, and consciousness), shock, gun-shot wounds, imminent delivery of a newborn. 6. ESI level 3 are conditions that require care, but will not generally cause loss of life, permanent or severe impairment, if untreated for one to three hours, including vomiting, diarrhea, childhood fever, vaginal bleeding in the first three months of pregnancy with stable vital signs and minimal bleeding. 7. All patients, who come to the ED and are ill or injured, are entitled to a medical screening examination (MSE – the initial assessment performed in an ED to determine if a patient has an emergency medical condition), regardless of insurance status, including a general and focused assessment based on the patient ’ s symptoms by a qualified medical professional, continuous monitoring until stabilized, and treatment until stabilized. 8. Pregnant patients with suspected ectopic pregnancy (a pregnancy that develops outside of the woman ’ s uterus and requires medical intervention to prevent serious complications, including internal bleeding which is potentially life-threatening). A review of facility ’ s Transfer of Patients – EMTALA policy, dated 3/18/2025, indicated the following: Emergency department (ED) triages patients to the most appropriate area within the department for medical screening or based on medical/age-based criteria to another department for medical screening. Medical Screening Examination (MSE) is the process requiring determining, with reasonable clinical confidence, whether an emergency medical condition (EMC) exists or a woman is in labor, which is documented in the patient ’ s medical record, by a physician or qualified medical person, with additional screening and treatment performed to stabilize the emergency medical condition. Stable for transfer – a patient is stable for transfer if the treating physician attending to the patient had determined that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient ’ s medical condition and any reasonably foreseeable complication of that condition. Stabilize – providing medical treatment of the patient ’ s condition necessary to assure that no material deterioration of the condition is likely to result from or occur during transfer of the patient from a facility, including a woman in labor. Transfer – movement of a patient to another facility at the direction of any person employed by the facility to a higher level of care. All transfers will be documented on a Transfer form with physician ’ s evaluation of patient ’ s condition at the time of transfer, signature of transferring physician, name of accepting physician for patient to be transferred to, informed consent by the patient/family (after being informed of the reasons for transfer and risks/benefits of transfer) with patient ’ s signature. A review of facility ’ s Massive Blood Transfusion policy, dated 3/18/2025, indicated the following: Purpose – to provide blood/blood components for massively transfused patients in the emergency department, operating room, and intensive care unit. To manage patients at risk of bleeding for blood component replacement during the bleeding episode with replacement of patient ’ s entire blood volume within a 24-hour period. Activation with the attending physician ordering massive transfusion protocol by a telephone call to the blood bank, after initial laboratory testing, including type and screen.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50632 Based on interviews and record review, the facility failed to provide an appropriate stabilization for one of 21 sampled patients (Patient 1) when Patient 1 presented to the Emergency Department (ED - the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment. This deficient practice resulted in the facility failing to provide further medical examination with a consulting general surgeon, in order to stabilize patient with emergency surgery to potentially stop the internal bleeding. Findings: A review of Patient 1 ’ s face sheet (a document that provides a quick overview of key information about a person), dated 5/25/2025, indicated patient was admitted to the emergency department (ED – emergency room providing 24/7 unscheduled medical care to patients with urgent or life-threatening conditions) at 4:38 p.m., for ectopic pregnancy (a pregnancy that develops outside of the uterus, which is not viable and requires medical treatment). A review of Patient 1 ’ s Emergency Department (ED) Triage Nursing Notes and Nursing Flowsheet, dated 5/25/2025, indicated: Patient arrived at 12:26 p.m. At 12:33 p.m., triage vital signs were blood pressure (BP) of 103 /58 millimeters of mercury (mmHg), heart rate (HR) was 99 beats per minute (bpm), respiratory rate (RR) was 22 breaths per minute (bpm), temperature was not obtained, oxygen (O2) saturation was 100% on room air, and pain was the worse pain ever with a score of 10 out of 10. Patient was classified with an Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care to prioritize patients for treatment, ensuring that those with the most urgent needs are seen first) of 2 – which is emergent(medical condition present an immediate threat to life, limb(arm or leg)or eyesight, that requiring prompt and potentially life-saving intervention). A review of Patient 1 ’ s pregnancy test, dated 5/25/2025, indicated a human chorionic gonadotropin (hCG – a hormone produced by the placenta during pregnancy with levels measured in the blood or urine to confirm pregnancy) level of 4367 mIU/ml. A review of Patient 1 ’ s Transvaginal ultrasound, dated 5/25/2025, indicated a live ectopic pregnancy at an estimated gestational age of five weeks and 4 days, with complex fluid seen in the pelvis – consistent with ruptured ectopic gestation, which was reported to Emergency Department Physician 1 (ED 1). A review of Patient 1 ’ s physician orders dated 5/25/2025, indicated: norepinephrine 4 mcg per minute IV without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ’ s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg. Red blood cells (RBC ’ s) two units to be given right away (STAT) and massive transfusion protocol. Two (2) units of RBC ’ s STAT and one (1) unit of fresh frozen plasma (FFP – a blood product containing various clotting factor and other plasma proteins to treat bleeding disorders) STAT. One (1) unit of platelets (blood product that plays a crucial role in blood clotting and stopping bleeding) at 2:53pm. Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm. Labs to check for anemia at 3:55pm. A review of Patient 1 ’ s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated: From 2:04 p.m. to 2:26 p.m., patient received 500 milliliters (ml) of RBC ’ s. From 3:02 p.m. to 3:21 p.m., patient received 2 units of RBC ’ s. Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm. From 3:45 p.m. to 3:51 p.m., patient received 1 unit of platelets. At 3:48 p.m., patient received 1 unit of FFP. On 6/26/2025, at 8:35 a.m., interview with Nursing Services Director of Emergency Department (NSED) and Emergency Department Educator (EDE), EDE stated At 4:19 p.m., patient ’ s hemoglobin (Hgb – a protein component in the RBC that carries oxygen from the lungs to the tissues) was 6.4 (normally 12-17.5 grams per deciliter) and hematocrit (the percentage of volume of red cells in the blood) was 19.9 (normally 36-44%). And the Patient received IV transfusion (the process of transferring blood or blood components into the blood stream to replace blood or blood products lost due to severe bleeding) summary, dated 5/25/2025, EDE stated the following blood products were administered to the patient: RBC 278 milliliters (ml – one-thousandth of a liter), Platelets 334 ml, RBC 500 ml x 4. And ED 1 did not order any consultations for general surgery. A review of Patient 1 ’ s vital signs (measurable physiological indicators that reflect a person ’ s basic bodily functions including temperature, pulse rate, respiratory rate, blood pressure (BP), oxygen saturation) dated 5/25/2025, indicated: 12:32 p.m., BP was 100/58, HR was 99, RR was 18, O2 saturation was 100% on room air. At 12:50 p.m., BP was lower at 88/54, HR was 100, RR was 20, O2 saturation was 100% on room air. At 1:00 p.m., BP was lower at 86/50, HR was 80, RR was 22, O2 saturation was 100% on room air, and temperature was 97.2 degrees Fahrenheit. At 1:35 p.m., BP was 98/74, HR was 86, RR was 22, O2 saturation was 100% on oxygen by nasal cannula (a medical device that provides supplemental oxygen therapy) at 2 liters per minute (lpm). 1:45 p.m., BP was lower at 66/42, HR was 78, RR was 17, O2 saturation was 99% on oxygen by nasal cannula at 2 lpm. 2:44 p.m., BP was 94/53. 3:17 p.m., BP was 107/74. 8. 3:36 p.m., BP was 127/74. 9. 3:51 p.m., BP was 113/56. 10. 4:19 p.m. BP 108/56, HR 93, O2 saturation 99% on nasal cannula at 2 lpm, temperature 97.7 degrees Fahrenheit On 6/26/2025, at 3:34 PM, during an interview with the Chief of the Emergency Department (CED), the CED stated a patient is not considered to be stable if they are on a norepinephrine drip (medication used to increase blood pressure) during transfer. The CED stated, regarding Patient 1, he had called several different doctors at the surrounding facilities, but they would not accept the patient due to the physical distance of transport. The CED stated he understood that without first receiving acceptance from the receiving facility, the transferring facility would be at fault for sending a patient to a facility with no capacity to accept the patient. Concurrently, during review of Patient 1 ’ s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated norepinephrine 4 mcg per minute IV was ordered and administered without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ’ s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg. On 6/26/2025, at 4:01 PM, during an interview with the Emergency Department Physician 1 (ED 1), the ED 1 stated, to treat a ruptured (breaking of vessel or membrane) ectopic pregnancy (can be life threatening; a pregnancy that occurs outside the uterus and cannot be carried to term) he would need to stabilize the patient by keeping the blood pressure in normal range and by stopping the bleeding. The ED 1 stated, this medical condition would require surgical intervention, which the patient would have to be transferred out from the facility to another facility that had the capability of treating such condition. On 6/27/2025, at 10:54 AM, during an interview with the Chief of General Surgery (CGS), the CGS stated, generally, a general surgeon should be able to handle a patient that comes into the emergency room and is bleeding. The DGS stated that the facility ’ s general surgeon should be competent enough to stop a patient from bleeding. The CGS also stated with a patient who is unstable and has a ruptured ectopic pregnancy, a general surgeon is compelled (force to do something) to intervene (to step in) the best they can for that patient at the facility in an attempt to salvage (to rescue) the patient. A review of Patient 1 ’ s Emergency Department (ED) Physician record, dated 5/25/2025, indicated: Arrived by private vehicle to the ED with complaint of abdominal pain with nausea and vomiting, vaginal bleeding heavier than usual, and worsening pain. Active problems included abnormal pelvic ultrasound. Physical examination with diffused abdominal tenderness. Transvaginal ultrasound (a common and safe imaging technique used in early stages of pregnancy to visualize the pelvic organs, including the uterus, ovaries and cervix, to confirm early pregnancy and to monitor for potential complications) indicated a mass noted in the right area beside the uterus which was consistent with a live ectopic pregnancy (a pregnancy that occurs outside the uterus and that cannot be carried to term with an embryo identified, which can be life threatening). Consulting services for obstetrics and gynecology (OB/GYN - medical doctor specializing in both obstetrics for pregnancy and gynecology for female reproductive health) were contacted from other facilities, with intent for transfer to a facility capable of stabilizing and treating patient with patient unstable for discharge. General surgeon was not consulted for this patient. Massive transfusion protocol initiated for hemorrhagic shock (a critical condition where severe blood loss leads to inadequate oxygen and nutrient delivery to the body – potentially causing organ damage or death), due to ruptured ectopic pregnancy (a serious life-threatening condition where a fertilized egg implanted outside the uterus and ruptured, leading to internal bleeding and shock, requiring immediate medical intervention, including surgery). Intravenous (IV - into a vein) medications given, included norepinephrine (medication used to increase blood pressure) 4 micrograms (mcg – a unit of mass – one millionth of a gram) per minute, normal saline boluses. IV blood products given included fresh frozen plasma (FFP – a blood product used to treat bleeding disorders), platelets (thrombocytes – blood cells to improve patient ’ s ability to clot blood), and packed red blood cells (RBC - blood cells to increase a patient ’ s oxygen carrying capacity and treat blood loss). Patient will be transferred by 9-1-1 to another facility due to medical necessity with inherent risks and benefits of transfer discussed with patient and family. Disposition – patient care transferred to another facility for higher acuity of care. On 6/27/2025, at 2:15 PM, during an interview with the General Surgeon (GS), the GS stated, if there was no other way to transfer a patient with a ruptured ectopic pregnancy out of the facility to another receiving facility, he, as a general surgeon, would have decided to pack the abdomen as a means of stabilizing (secure) the patient for transportation. The GS stated he would have opened the abdomen (the belly area) and placed packs to tamponade (the surgical use of a plug of absorbent material) the bleeding and had the patient transferred to a trauma facility with the abdomen left open. The GS also stated he was not notified for consultation (meeting) regarding Patient 1 ’ s case on 5/25/2025, when he was scheduled for general surgery. A review of facility ’ s Emergency Department Physician Call Schedule, dated May 2025, GS was scheduled for general surgery on 5/25/2025. A review of Patient 1 ’ s Assessment Forms (calls and communication for the patient), dated 5/25/2025, indicated the following: At 12:54 p.m., Code Sepsis paged. 2:51 p.m., potential receiving facility indicated patient was too critical to transfer out. 3:04 p.m., massive blood transfusion was overhead paged. 3:28 p.m., potential receiving facility indicated patient is too critical to transfer. 3:51 p.m., patient was being 9-1-1 transferred out. Transfer to another facility at 4:19 p.m. with a diagnosis of hemorrhagic shock and ruptured ectopic pregnancy. A review of facility ’ s Emergency Department (ED) Triage and Medical Screening Guidelines, dated 12/2024, indicated the following: Triage is the process of collecting pertinent information about patients who are seeking emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity-designation system. Facility uses a Five-Level scale called Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care; used to prioritize patients for treatment, ensuring that those with the most urgen needs are seen first) and references the most updated version of the Emergency Nurses Association (ENA – an accredited organization providing nursing professionals continuing development by the American Nurses Credentialing Center ’ s Commision on accreditation). Patients arriving to the ED will be triaged by an ESI triage-trained ED registered nurse (RN) to determine the patient ’ s ESI level, after the ED triage RN performed the initial assessment after obtaining the five elements: chief complaint Allergies vital signs – measurable physiological indicators that reflect a person ’ s basic bodily functions to provide essential information about the person ’ s health status and to help identify potential medical conditions, including temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation Pain level Height and weight 4. ED triage RN will consider the five elements and will assign the ESI level based on the decision points of the ENA criteria. 5. ESI level 1 and 2 are conditions which may result in loss of life or limb, if not treated immediately, including cardiac arrest (sudden unexpected loss of heart function, breathing, and consciousness), shock, gun-shot wounds, imminent delivery of a newborn. 6. ESI level 3 are conditions that require care, but will not generally cause loss of life, permanent or severe impairment, if untreated for one to three hours, including vomiting, diarrhea, childhood fever, vaginal bleeding in the first three months of pregnancy with stable vital signs and minimal bleeding. 7. All patients, who come to the ED and are ill or injured, are entitled to a medical screening examination (MSE – the initial assessment performed in an ED to determine if a patient has an emergency medical condition), regardless of insurance status, including a general and focused assessment based on the patient ’ s symptoms by a qualified medical professional, continuous monitoring until stabilized, and treatment until stabilized. 8. Pregnant patients with suspected ectopic pregnancy (a pregnancy that develops outside of the woman ’ s uterus and requires medical intervention to prevent serious complications, including internal bleeding which is potentially life-threatening). A review of facility ’ s Transfer of Patients – EMTALA policy, dated 3/18/2025, indicated the following: Emergency department (ED) triages patients to the most appropriate area within the department for medical screening or based on medical/age-based criteria to another department for medical screening. Medical Screening Examination (MSE) is the process requiring determining, with reasonable clinical confidence, whether an emergency medical condition (EMC) exists or a woman is in labor, which is documented in the patient ’ s medical record, by a physician or qualified medical person, with additional screening and treatment performed to stabilize the emergency medical condition. Stable for transfer – a patient is stable for transfer if the treating physician attending to the patient had determined that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient ’ s medical condition and any reasonably foreseeable complication of that condition. Stabilize – providing medical treatment of the patient ’ s condition necessary to assure that no material deterioration of the condition is likely to result from or occur during transfer of the patient from a facility, including a woman in labor. Transfer – movement of a patient to another facility at the direction of any person employed by the facility to a higher level of care. All transfers will be documented on a Transfer form with physician ’ s evaluation of patient ’ s condition at the time of transfer, signature of transferring physician, name of accepting physician for patient to be transferred to, informed consent by the patient/family (after being informed of the reasons for transfer and risks/benefits of transfer) with patient ’ s signature. A review of facility ’ s Massive Blood Transfusion policy, dated 3/18/2025, indicated the following: Purpose – to provide blood/blood components for massively transfused patients in the emergency department, operating room, and intensive care unit. To manage patients at risk of bleeding for blood component replacement during the bleeding episode with replacement of patient ’ s entire blood volume within a 24-hour period. Activation with the attending physician ordering massive transfusion protocol by a telephone call to the blood bank, after initial laboratory testing, including type and screen.”