Sierra View Medical Center

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 45654 Based on interview and record review the facility failed to ensure Medical Doctor (MD) 1 documented a comprehensive procedural note following insertion of a Right Femoral Tri flow dialysis catheter (triple lumen catheter (CTLC- a temporary vascular [vein] access [central line] device inserted directly into a large vein [neck, chest, or groin] for short term use) for one of one sampled patient (Patient 16). This failure had the potential for unmonitored medical complications, delayed identification of adverse events, and compromised continuity of care. Findings: During a review of Patient 16’s “Facesheet [FS],” undated, the FS indicated Patient 16 was admitted to the facility on 6/8/26. During a review of Patient 16’s “Order Detail (OD),” dated 6/9/26 at 12:29 p.m., the OD indicated Patient 16 was on hemodialysis (dialysis - a life-sustaining medical treatment that filters waste, toxins, and excess fluid from your blood). During a review of Patient 16’s “Care Assessment (CA),” dated 6/9/26 at 1:43 p.m., the CA indicated “Patient Central Line Catheter Type, Dialysis.” During a review of Patient 16’s “OD,” dated 6/10/26 at 2:21 p.m., the OD indicated Patient 16 was on hemodialysis. During a review of Patient 16’s “OD,” dated 6/11/26 at 7:13 a.m., the OD indicated Patient 16 was on hemodialysis. During a review of Patient 16’s “Care Assessment [CA],” dated 6/17/26, the “CA” indicated, “Central Line Insertion. . .Date of insertion attempt 6/9/26 at 1:45 p.m. . .Central Line Location Femoral (vein) Right. . . Central Name of Central Line Inserter MD 1. . .Catheter Type Dialysis Non Tunneled. During a concurrent interview and record review on 6/16/26 at 2:43 p.m. with Registered Nurse (RN) 3, Patient 16’s electronic medical record (EMR) was reviewed. RN 3 stated she was unable to provide physician [MD 1] documentation regarding Patient 16’s Right Femoral Tri flow dialysis catheter insertion procedure completed on 6/9/26. During a review of the facility’s P&P titled “Physician Medical Record Documentation & [and] Dictation Requirements,” (undated), the P&P indicated, “Operative/Procedural Report Immediate Operative Note (Handwritten or Electronic) Must be entered immediately following surgery before the patient leaves the PACU [post anesthesia care unit-patient is monitored following surgery/procedure] or procedure suite. . . Final Operative Report must be dictated or completed within 24 hours of the surgery or invasive [medical procedure that enters the body, usually by cutting or puncturing the skin] procedure.”

“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: 32946 The facility failed to meet the regulatory requirements for the Conditions of Participation: CFR 482.23 Nursing Services as evidence by the following: 1. Based on interview and record review, the facility failed to develop and implement a person-centered care plan (CP - a written, individualized plan that outlines a person’s health conditions, needs, and goals, along with specific steps for the staff to follow) for two of 30 sampled patients (Patient 12 and Patient 13). For Patient 12 and Patient 13, the facility failed to develop a care plan for pain. This failure had the potential for staff to be unaware of the condition and the steps to follow to alleviate the pain Patient 12 and Patient 13 were experiencing. (Refer to A-0396) 2. Based on interview and record review, the facility failed to ensure the facility’s Policy and Procedure (P&P) titled, “CENTRAL VENOUS CATHETER [central line is a long flexible hollow tube inserted into a large vein such as in the groin and threaded into a major vein just above the heart], CARE AND MAINTENANCE OF,” and Instructions for Use (IFU - are mandatory, detailed, and often FDA [food and drug administration]-regulated documents providing step-by-step guidance for safely using medical devices) for the Tri-CT Triple Lumen catheter (CTLC - a temporary vascular [vein] access device inserted directly into a large vein [neck, chest, or groin] for short-term use) were followed when Registered Nurse (RN) 1 failed to apply pressure for 10 to 15 minutes to the CTLC femoral exit site (groin area where the catheter emerges from the body after being inserted into the femoral vein) after the removal of the CTLC; failed to ensure the patient was positioned correctly during and after the CTLC was removed; failed to ensure the patient was monitored every 15 minutes for bleeding for 60 minutes; and failed to ensure a qualified staff removed the CTLC. These failures resulted in Patient 1’s catastrophic blood loss (severe, rapid and uncontrollable bleeding) and subsequent death on 2/18/26 at 1:41 p.m. (Refer to A-0398) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the provision of quality nursing care in compliance with the Condition of Participation for Nursing Services.”

“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: 44134 Based on interview and record review, the facility failed to develop and implement a person-centered care plan (CP - a written, individualized plan that outlines a person’s health conditions, needs, and goals, along with specific steps for the staff to follow) for two of 30 sampled patients (Patient 12 and Patient 13). For Patient 12 and Patient 13, the facility failed to develop a care plan for pain. This failure had the potential for staff to be unaware of the condition and the steps to follow to alleviate the pain Patient 12 and Patient 13 were experiencing. Findings: During a review of Patient 12’s “Facesheet [FS],” undated, the FS indicated Patient 12 was admitted to the facility on 3/20/26. During a review of Patient 12’s “Pain Assessment [PA],” undated, the PA indicated on 3/22/26 at 10 p.m. Patient 12 reported a numeric pain score (tool used to measure patient’s pain intensity, pain is rated from zero to 10, no pain [0], mild pain [1-4], moderate pain [5-6], severe pain [7-10]) of 7 to his right foot and on 3/23/26 at 2 p.m. During a concurrent interview and record review on 3/25/26 at 12:06 p.m. with Registered Nurse (RN) 2, Patient 12’s CPs were reviewed within the electronic medical record (EMR). RN 2 stated she was unable to provide a CP which addressed Patient 12’s pain. RN 2 stated a CP should have been developed and implemented to address Patient 12’s reported pain. During a review of Patient 13’s FS, undated, the FS indicated Patient 13 was admitted to the facility on 3/14/26. During a review of Patient 13’s PA, undated, the PA, indicated Patient 13 reported the following numeric pain scores: 3/18/26 at 12 p.m. back pain score of 10 3/18/26 at 8 p.m. back pain score of 2 3/19/26 at 12 a.m. back pain score of 4 3/19/26 at 8 a.m. back pain score of 10 3/19/26 at 12 p.m. back pain score of 10 3/19/26 at 4 p.m. back pain score of 10 3/20/26 at 5 a.m. back pain score of 10 3/20/26 at 9 p.m. back pain score of 8. During a concurrent interview and record review on 3/25/26 at 2:07 p.m. with RN 2, Patient 13’s CPs were reviewed within the EMR. RN 2 stated she was unable to provide a CP which addressed Patient 13’s pain. RN 2 stated a CP should have been developed and implemented which addressed Patient 13’s reported pain. During a review of the facility’s policy and procedure (P&P) titled, “Standards Of Nursing Practice Medical/Surgical,” (undated), the P&P indicated, “The following standards were developed to direct nursing activities so that each patient’s health deficits can be corrected in a continuous progression toward optimum health. . .A. Individualized, goal-directed nursing care is provided to a patient through the use of the nursing process. . .D. A Multi-disciplinary Care Plan is started within the first eight (8) hours of admission and becomes part of the permanent medical record. . .2. The goals are based on nursing assessment and nursing diagnosis. . .5. The plan includes measures that restore, maintain, or promote the patient’s well-being. 6. The plan includes at least the following areas: a. Physiological Needs; b. Psycho-social aspects/spiritual needs; c. Environmental factors; d. Patient/family education. . .7. The plan is reviewed and revised PRN [as needed] every 24 hours, or more often as the needs of the patient change.””

“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: 32946 Based on interview and record review, the facility failed to ensure the facility’s Policy and Procedure (P&P) titled, “CENTRAL VENOUS CATHETER [central line is a long flexible hollow tube inserted into a large vein such as in the groin and threaded into a major vein just above the heart], CARE AND MAINENANCE OF,” and Instructions for Use (IFU - are mandatory, detailed, and often FDA [food and drug administration]-regulated documents providing step-by-step guidance for safely using medical devices) for the Tri-CT Triple Lumen catheter (CTLC - a temporary vascular [vein] access device inserted directly into a large vein [neck, chest, or groin] for short-term use) were followed when Registered Nurse (RN) 1 failed to apply pressure for 10 to 15 minutes to the CTLC femoral exit site (groin area where the catheter emerges from the body after being inserted into the femoral vein) after the removal of the CTLC; failed to ensure the patient was positioned correctly during and after the CTLC was removed; failed to ensure the patient was monitored every 15 minutes for bleeding for 60 minutes; and failed to ensure a qualified staff removed the CTLC. These failures resulted in Patient 1’s catastrophic blood loss (severe, rapid and uncontrollable bleeding) and subsequent death on 2/18/26 at 1:41 p.m. Findings: During a review of Patient 1’s “Facesheet [FS],” undated, the “FS” indicated Patient 1 was admitted to the facility on 2/10/26 and expired on 2/18/26. During a review of Patient 1’s “History and Physical Report [H&P],” dated 2/10/26, the H&P indicated Patient 1 was a 73-year-old female with a medical history that included congestive heart failure (CHF - the heart pumps blood inefficiently to the body and fluids can build up in the lungs), coronary heart disease (a condition by where the arteries are narrowed or blocked), and possible chronic obstructive pulmonary disease (lung disease). Patient 1 presented to the Emergency Department (ED) with recurrent shortness of breath on exertion. The “Assessment & [and] Plan. . .patient’s condition likely worsening of symptom related to CHF exacerbation [worsening].” Code status indicated the patient was a full code (patient wants all possible life-saving measures used to revive them if their breathing or heart stops). During a review of Patient 1’s “CONSENT TO SURGERY SPECIAL DIAGNOSTIC/THERAPEUTIC PROCEDURE [consent],” dated 2/10/26, the consent indicated, “your doctors have recommended the following operation or procedure: Vas-Cath Tri-Flow line insertion. . . name of practitioner (s) who is/are performing and/or assisting with the procedure or administration of medical treatment: Physician’s name (Medical Doctor [MD 1]), Dated 2/10/26 at 10:22 p.m.” and signed by Patient 1’s family member (FM). During a review of Patient 1’s “Operative Report [OPR],” dated 2/10/26, the OPR indicated, “Central Line Placement Right Femoral Indication(s): other (hemodialysis [treatment for advanced kidney failure that filters waste, toxins, and excess fluid from the blood].” The procedure performed by Medical Doctor (MD 1). During a review of Patient 1’s “Order Details [OD],” dated 2/18/26, the OD indicated, “DC [discontinue] Central line [CTLC] NOW.” During an interview on 3/23/26 at 1:40 p.m. with RN 1, RN 1 stated she had never removed a femoral central venous catheter (CTLC). During an interview on 3/23/26 at 1:45 p.m. with RN 1, RN 1 stated she took a suture removal kit, gauze, clear adhesive dressing and a sandbag (used to apply pressure) to Patient 1’s room. RN 1 stated Patient 1 had an “AvaSure TeleSitter [a remote patient observation system used for safety by monitoring patients at risk of falling, self-harm, or elopement using continuous, audio and video technology],” for patient safety. During a review of Patient 1’s “Nurse Note [NN],” dated 2/18/26 (late entry created at 3:42 p.m. for 12:15 p.m.), the NN indicated, “1215 [12:15 p.m.] triflo [CTLC] to right femoral [vein] removed. Pressure applied for 5 minutes, Tegaderm ( transparent, sterile, waterproof film dressings) applied over. No signs of bleeding at this time. Applied sand bag over dressing as additional precaution even though there was no active bleeding at this time. Educated patient to leave site alone. Set 20-minute timer to reassess patient and when the timer went off, I was in another room. As soon as I came out, Avasure [TeleSitter] called around 12:45 [p.m.] stating patient looks like she spilt [sic] juice but then she moved the blanket and it looked more like blood. At this point, I was walking to Charge nurse, [RN 3], was at the nurse’s station when I was at patient’s door, so I called for her attention for help, RRT [rapid response team] called immediately and applied pressure. At this point patient was responsive, pale and lethargic. Patient coded [heart stopped] 12:52 p.m.. See code sheet.” No other documentation in the NN that the patient was monitored every 15 minutes after the removal of the CTLC. During an interview on 3/23/26 at 1:50 p.m. with RN 1, RN 1 stated Patient 1 was laying on her back during the removal of the CTLC from the right femoral vein. RN 1 stated she removed the CTLC site dressing, cleaned with alcohol swab then removed the CTLC while the patient was instructed to exhale. RN 1 stated she applied sterile four- inch by four-inch gauze pad and applied firm pressure with her fingertips to the CTLC exit site for five minutes. RN 1 stated she did not lift the gauze to check for bleeding prior to applying a clear dressing over the gauze and then placed the sandbag on the right leg CTLC exit site. RN 1 stated she set a timer for 20 minutes. RN 1 stated the 20 minute timer was alarming when she received a call from the telesitter staff member. RN 1 stated the telesitter informed her Patient 1 had what was thought to be juice, but when Patient 1 moved the blanket and it looked like blood. RN 1 stated she ran to Patient 1’s room and called for assistance from the charge nurse and requested a code rapid (emergency code) to be called. RN 1 stated the patient had a PureWick catheter (an external urine management system designed to wick away urine into a canister away from the body using low-pressure suction) in place and the PureWick canister had blood in it. RN 1 stated Patient 1 was pale and mumbling when she entered the room. RN 1 stated she had not assessed the CTLC exit site since it was removed by her. During a review of “CODE BLUE FORM [CBF],” dated 2/18/26, the “CBF” indicated the Code Blue was initiated at 12:53 p.m. Code Blue ended and time of death at 1:41 p.m. During an interview on 3/23/26 at 3:23 p.m. with Director of Medical/Surgical/Telemetry unit (DMST), DMST stated CTLC are new and nurses can remove them. DMST stated the CTLC has a large bore (size of catheter tube that is inserted into the vein) which required 15-20 minutes of pressure to be held on the exit site after the CTLC was removed. DMST stated she would have called the physician and possibly requested platelets (blood cell that help form clots to stop bleeding) or have the CTLC removed by the interventional radiologist (IR-doctor who performs image-guided, minimally invasive surgical procedures) in the Intensive Care Unit (ICU is a specialized department which provides intensive monitoring, advanced life support for patients with severe life-threatening injuries or illnesses). During an interview on 3/24/26 at 9:22 a.m. with MD 1, MD 1 stated, A tri flow catheter (CTLC) is used for dialysis and has a large lumen (size of tube) catheter which increases the risk of bleeding when removed. MD 1 stated removal of the CTLC should be a sterile procedure and pressure should be applied to the CTLC exit site for 15-20 minutes and the area should have been monitored once pressure was removed. During an interview on 3/24/26 at 9:26 a.m. with MD 2, MD 2 stated he would have IR remove bigger central lines. MD 2 stated Resident physicians would have an attending supervisor during the placement and removal of a CTLC. MD 2 stated he would have the patient go to IR for removal of the CTLC. During an interview on 3/24/26 at 1 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she had returned from lunch and was scanning through the telesitter screens when she saw a spot on Patient 1’s blanket. CNA 1 stated she called a CNA to check on Patient 1 because she did not know if it was spilled juice or blood, but the CNA was busy. CNA 1 stated she called RN 1 to ask RN 1 to check on Patient 1 because the spot was getting larger. CNA 1 stated she saw Patient 1 moving her arms, and when the blanket was moved she was able to see the area. CNA 1 stated the patient was not flat in bed. CNA 1 stated she was not told to monitor for bleeding after a central line removal. During an interview on 3/25/26 at 11:36 a.m. with CNA 2, CNA 2 stated Patient 1 was calm and was not calling for help when she saw her on the telesitter screen. CNA 2 stated she went to lunch about 15 minutes after RN 1 left Patient 1’s room following the removal of the CTLC. During an interview on 3/25/26 at 1:16 p.m. with RN 1, RN 1 stated she put Patient 1’s bed at 45 degrees while holding pressure on the CTLC exit site after the removal. RN 1 stated she did not remove the gauze that she applied pressure with to assess the site or to see how much blood was on the gauze. RN 1 stated Patient 1’s bed was at a 45-degree angle when she left the room. During a review of the facility’s P&P titled, “CENTRAL VENOUS CATHETER, CARE AND MAINENANCE OF,” undated, the P&P indicated, “Purpose: To Provide standardized guidelines for continuous and intermittent central venous therapy, to minimize the incidence of catheter-related complications and to provide guidelines for removal of central venous catheter. . .TRAINING AND COMPENENCY NURSING 1. All RNs will be educated on central line management. . .2. RN competency on central line management and infection prevention will be validated initially on hire and annually thereafter. . . REMOVAL. . .d. Place the patient in supine or low semi-fowlers position [lying on back with the head of the bed elevated at 15 to 30 degree angle]. Al. slowly remove catheter while patient is holding breath, bearing down, or exhaling and apply immediate pressure to exit site with a 4X4 gauze dressing, holding until hemostats (blood clotting) occurs. . .n. Keep patient in supine position for 30 minutes, monitoring every 15 minutes for bleeding. . .O. Following removal of a femoral line, the patient must be monitored for 60 minutes. After 30 minutes, there is no bleeding or oozing, patients may flex hip and ambulate.” During an review of the IFU titled, “TRIO-CT TRIPLE LUMEN CATHETER HEMODIALYSIS [a treatment to cleanse the blood of waste and extra fluids artificially through a machine when the kidney(s) have failed], APHERESIS [the removal of blood plasma [the pale-yellow, liquid component of blood], AND INFUSION [a medical treatment that delivers fluids, medication, or nutrients directly into the body], INSTRUCTIONS FOR USE. The IFU indicated, “Indication for use: “The Trio-CT Triple Lumen Catheter is indicated for use in attaining short-term [less than 30 days] vascular [body’s network of blood vessels] access for hemodialysis and apheresis...INFECTION:. . .Sterile technique should always be strictly adhered to. . .CATHETER REMOVAL Warning Only a physician familiar with appropriate techniques should attempt the following procedures. Caution: Always review hospital or unit protocol potential complications and their treatment, warnings, and precautions prior to catheter removal. NOTE: The patient should be in a modified Trendelenburg position [patient lies flat with their legs elevated, usually at a 30-degree angle, while the head remains level with the body. It is used to increase venous return to the heart and boost cerebral blood flow] . . . 1. Cut sutures from suture wing (device used to secure stitch to a patient’s skin). Follow hospital protocol for removal of skin sutures 2. Withdraw catheter through the exit site. 3. Apply pressure to exit site for approximately 10-15 minutes or until bleeding stops. 4. Apply dressing in manner to promote optimal healing WARRANTY ...Use of this product should be in accordance with instructions provided and as directed by a prescribing physician.””

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 44134 Based on interview and record review, the facility failed to ensure informed consent (IC, a process in which a healthcare provider educates a patient about the surgery and the risks, benefits, and alternatives) was obtained prior to the placement of a central line (CL, a flexible tube inserted into a large vein) for two of 30 sampled patients (Patient 6, Patient 26). This failure resulted in several patients not being offered the opportunity to make informed decision based on risks, benefits and alternatives of the procedure. Findings: 1. During a review of Patient 6’s “Operative Report [OR],” dated 12/2/25, the OR indicated, Patient 6 had a central line placement to the left femoral vein (a large vein, located in the upper thigh that carries blood back toward the heart). During a concurrent interview and record review on 3/24/26 at 3:04 p.m. with Registered Nurse (RN) 2, Patient 6’s Electronic Medical Record (eMAR - electronic health record), (undated), was reviewed. Patient 6’s eMAR indicated, Patient 6 did not have an IC prior to the placement of the CL on 12/2/25. RN 2 stated she was unable to find an IC for Patient 6’s CL placement on 12/2/25. During an interview on 3/24/26 at 3:08 p.m. with Director of Medical/Surgical (DMS), DMS stated Patient 6 should have had an IC obtained prior to the CL placement. 32946 2. During a concurrent interview and record review on 3/25/26 at 10:33 a.m. with RN 5, Resident 26’s eMAR was reviewed, Patient 26’s OR dated 4/20/25 was reviewed. The OR indicated, “JCL” right femoral, indication(s): shock and poor, or inadequate peripheral venous access (a flexible tube inserted into small veins).” RN 5 was unable to provide documented evidence that consent for treatment was obtained for Patient 26’s placement of a “Right Femoral line.” During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Catheters, Care and Maintenance Of,” (undated), the P&P indicated, “1. Insertion of a central venous catheter requires signed informed consent.” During a review of the facility’s P&P titled, “Consent/Informed Consent,” (undated), the P&P indicated, “B. Informed Consent. . .Informed consent must be obtained for procedures that are “complex” in that they involve material risks and are not commonly understood. Specifically informed consent must be obtained for: a. All major or minor surgery which involves entry into the body either through an incision or through the use of natural openings. There must be a valid consent for each procedure or operation. . .e. For the insertion of central lines. . .including those inserted at bedside. . .NOTE: If there is a doubt as to whether a procedure requires informed consent, it is appropriate for the physician to obtain one.””

“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: 51540 Based on interview and record review the facility failed to follow its policy & procedure (P&P) titled, “Stroke Alert and Acute Care Stroke Management: Emergency Department and Inpatient Units,” for one patient (Patient 1), when Patient 1 was identified to have left-sided weakness, and a stroke alert was not called in a timely manner by Registered Nurse (RN) 1. This failure resulted in delayed identification and treatment of Patient 1’s deteriorating (worsening) condition and the potential to result in Patient 1’s death. Findings: During a review of Patient 1’s “Emergency Room Note (ERN),” dated 3/13/25 at 2:19 p.m., the “ERN” indicated “70 year old male with past medical history significant for previous stroke 10/2021 and vascular dementia [a type of dementia caused by problems with the blood supply to the brain] presents to the Emergency Department accompanied by his [Family Member (FM)] sent by [Neurologist- doctor who specializes in brain and nerve function] for abnormal MRI [Magnetic Resonance Imaging - a kind of x-ray]. . .Symptoms of altered mental status [a change in a person’s usual mental function, including changes in awareness and behavior], face numbness, and slurred speech. . .NEUROLOGICAL: Patient appears confused, nonsensical speech [speech that is difficult to understand] . . .Plan: “admit acute care w/in [within] hospital. . .Clinical impression: Acute cerebrovascular accident [CVA- also known as a stroke, is a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells and potential neurological damage].” During a review of Patient 1’s “MRI of the Brain (MRI),” dated 3/13/25, the “MRI” indicated “HISTORY: Headaches, dizziness, right-sided numbness and weakness, right-sided vision loss x [for] 3 days. IMPRESSION 1. Proximal occlusion [blockage in the large blood vessels in the neck or base of the brain] of the left posterior [behind] cerebral artery [the blood vessels that supply oxygen and nutrients to the brain] resulting in ischemia [shortage of blood and oxygen supply] of most of the remaining left occipital [the visual processing center of the brain] and posterior medial [middle] temporal lobes [a section of the brain that is involved in processing hearing information, memory, and language] as well as portions of the left thalamus [part of the brain for sensory and motor information] and internal capsules [ two structures located within the brain for communicating sensory and motor information]. . .this case was discussed with the emergency room [sic] at 2:08 PM 3/13/25, and patient [Patient 1] was taken to the emergency room by radiology staff at 2:10 p.m.” During a review of Patient 1’s “National Institutes of Health Stroke Scale (NIHSS- a tool used to quickly assess the severity of stroke in patients),” dated 3/13/25, the “NIHSS” indicated, “Level of consciousness: Alert, Orientation: Answers Nether Correctly, Responds to Commands: Performs both correctly, Visual fields Partial Hemianopia [a condition where there’s a loss of vision in half of your visual field], Facial Movement Normal, Left Arm Motor Function No Drift, Right Arm Motor Function No Drift, Left Leg Motor Function No Drift, Limb Ataxia [poor muscle control] absent, Sensory Mild to moderate, Language Mild to moderate aphasia [loss of ability to understand or express speech, caused by brain damage], NIH Stroke Score 7 [The scale ranges from 0 to 42, with a higher score indicating greater neurological deficits. A score of 0 means there are no stroke symptoms, while a score of 21 or higher indicates a severe stroke. 0-4: Minor stroke or no stroke symptoms. 5-15: Moderate stroke. 16-20: Moderate to severe stroke. 21-42: Severe stroke] NIH Stroke Level: Moderate Stroke.” During an interview on 5/19/25 at 2:30 p.m. with RN 1, RN 1 stated signs and symptoms (s/s) of a stroke include arm weakness. RN 1 stated if a patient has any of these s/s RN 1 would call a rapid response [RRT- a specialized group of healthcare professionals, including nurses and respiratory therapists, who are trained to intervene quickly and prevent a patient’s medical condition from deteriorating into a serious emergency], complete a neurological assessment (conditions that affect the brain), complete a physical assessment (checks your body to determine if you do or do not have a physical problem) and document the findings. RN 1 stated a RRT should have been called for Patient 1. During a review of Patient 1’s “Neurological Assessment (NA),” dated 3/19/25 at 5:00 p.m., the “NA” indicated, “Bilateral Leg -Strength Slight Weakness Left Arm- Strength Slight W Right arm -Strength Slight Weakness.” During a review of Patient 1’s “NA,” dated 3/19/25 at 9:00 p.m., the NA indicated, “Left Arm -Strength Flaccid. Right Arm-Strength Slight weakness. . .Facial Symmetry Left Side Droop. . .Stroke -New Onset Signs and Symptoms of Stroke Yes.” During a concurrent interview and record review on 5/20/25 at 3:03 p.m. with Director of Nursing (DON), Patient 1’s “Nurse Note (NN),” dated 3/19/25 at 6:35 p.m. by RN 1 was reviewed. The NN indicated, “I [RN 1] was notified by patient’s [Patient 1’s] wife that patient was not moving left extremities. Upon assessment patient left extremities [arm and leg] appeared flaccid [loose and hanging-unable to move].” DON stated when Patient 1 was not moving his left arm and leg, RN 1 needed to call a stroke alert immediately. DON stated RN 1 needed to complete an assessment and notify the physician. During a concurrent interview and record review on 5/20/25 at 3:30 p.m. with DON, Patient 1’s “NN,” dated 3/19/25 at 7:14 p.m. by RN 1 (approximately 39 minutes after COC was documented), the NN indicated, “Notified [medical doctor] that patient left upper and lower extremity were remaining flaccid, [medical doctor] to see patient at bedside.” DON stated RN 1 needed to call a stroke alert before notifying the physician. During a review of Patient 1’s “Event Note (EN),” dated 3/20/25, the “EN” indicated, “At 7 PM a rapid response was called as the patient was noticed to have flaccid paralysis of the left upper extremity. . . He [Patient 1] was noticed that he can move all his right side of the body however noticed to have severe weakness on his left upper extremity, left lower extremity there is some movement however not against gravity. For that reason, a stroke alert was initiated and patient was sent to CT [Computed Tomography - a type of x-ray] scan for the brain and head and neck CT. . .” During a concurrent interview and record review on 5/20/25 at 3:35 p.m. with RN 1, Patient 1’s electronic medical record (EMR) was reviewed. RN 1 stated there was no documentation of interventions or physical assessment completed for Patient 1 after the notification of left sided upper and lower extremities remaining flaccid (3/19/25 at 6:35 p.m.) and before the physician was notified (3/19/25 at 7:14 p.m.). RN 1 stated a stroke alert should have been called as these are signs of a stroke, and the physician notified. During a concurrent interview and record review on 5/21/25 at 8:55 a.m. with Stroke and Sepsis Coordinator (SSC), Patient 1’s “NN,” dated 3/19/25 at 6:35 p.m. and Patient 1’s “NN,” dated 3/19/25 at 7:14 p.m. were reviewed. The NN at 6:35 p.m. indicated Patient 1 was not moving the left extremities. The NN at 7:14 p.m. indicated RN 1 notified the Medical Doctor (MD) 2 of Patient 1’s COC. SSC stated the 39-minute delay of notifying the MD was not appropriate. SSC stated RN 1 was expected to immediately call a stroke alert or immediately call the physician when Patient 1 had signs of stroke. SSC stated their policy is to activate a stroke alert within ten minutes of symptoms. During a concurrent interview and record review on 5/21/25 at 9:05 a.m. with SSC, Patient 1’s “NIHSS,” dated 3/19/25 at 7:24 p.m. was reviewed. The NIHSS indicated, “Not Alert Obtunded [reduced level of alertness], Orientation Answers Neither Correctly, Responds to Commands Performs neither correctly, Visual fields Complete Hemianopia, Facial Movement Complete Paralysis, Left Arm Motor Function No Movement, Right Arm Motor Function No Drift, Left Leg Motor Function: No Effort Against Gravity, Limb Ataxia Present in one limb, Language Severe aphasia, NIH Stroke Score 23 [The scale ranges from 0 to 42, with a higher score indicating greater neurological deficits. A score of 0 means there are no stroke symptoms, while a score of 21 or higher indicates a severe stroke. 0-4: Minor stroke or no stroke symptoms. 5-15: Moderate stroke. 16-20: Moderate to severe stroke. 21-42: Severe stroke] NIH Stroke Level: Severe Stroke.” SSC stated an increase of three or more points of the NIHSS score indicated a significant change in symptoms of stroke for Patient 1. During an interview on 5/21/25 at 9:12 a.m. with Registered Nurse (RN) 2, RN 2 stated shift began at 6:45 p.m. and RN 2 received hand off report from RN 1 at Patient 1’s bedside with FM. RN 2 stated FM said during report Patient 1 was having left-sided weakness and unable to move the left side earlier that day. RN 2 questioned RN 1 about Patient 1’s COC and if MD had been notified. RN 2 stated RN 1 reported the MD had rounded on Patient 1 but was not sure if the MD was aware of the weakness to Patient 1’s left side. RN 2 stated she instructed RN 1 to immediately call the MD. RN 2 stated MD came to Patient 1’s bedside, completed a quick assessment and immediately called a stroke alert. RN 2 stated when Patient 1’s COC was identified, interventions, including calling a rapid response should have been started immediately and the MD should have been notified. During a review of Patient 1’s “NN,” dated 3/19/25 at 7:15 p.m. (by RN 2), the NN indicated, “report received from [RN 1]. New onset left sided weakness noted. LWK [last well know] at 3:18 p.m. [MD] called to bedside for change in neurological status by [RN 1]. 7:20 p.m. [MD] at bedside. Initiated stroke alert. RRT [rapid response team] called for stroke alert. 8:00 p.m. pt [Patient 1] send down to CT brain. . .” During a review of the “Rapid Response Intervention (RRI),” dated 3/19/25 at 7:20 p.m. the RRI indicated, “The rapid response was called on 3/19/25 at 7:20 p.m. [approximately 45 minutes after Patient 1’s symptoms of stroke]. . .Situation: acute change in conscious [being awake]; background: new onset left sided weakness; rapid response assessment: pt [Patient 1] with eyes closed, left side flaccid, non-verbal, does not follow commands, movement to right side-reaching out. . .” During a review of Patient 1’s “CT,” dated 3/19/25, the CT indicated “. . .acute [sudden] subacute [a condition between acute and chronic] large infarct [an area of tissue that has died due to a lack of blood supply] . . .” During a review of Patient 1’s “EN,” dated 3/20/25, the EN indicated, “Teleneuologist was consulted. . .contacted the transfer nurse for possible interventional neurologist consultation, I [MD 2] was connected with an interventional neurologist, she reviewed the images and reported that the patient at high risk of hemorrhagic [bleeding] conversion if embolectomy [a medical procedure that surgically removes a blockage in a blood vessel caused by a clot or other foreign material] was done. Furthermore, the long-term benefits and recovery for the patient is not guaranteed due to severity of the stroke and the acuity of radiologic changes. . .” During a review of the hospital’s policy and procedure (P&P) titled, “Rapid Response Team Adult & Pediatric,” undated the P&P indicated, “Purpose: the goal of the rapid response team is to address the recognition of and response to an unexpected deterioration in a patient’s condition. . .notwithstanding the RN’s overall concern for changes in the patient’s condition, he/she can activate the team based on the following criteria. . .Neurological Factors to Consider:. . .New motor/sensory function changes. . . notwithstanding the RN’s overall concern for changes in the patient’s condition, he/she can activate the team based on the following criteria a) staff or patient/family member concerned about the patient. . .” During a review of the hospital’s “P&P” titled, “Interdisciplinary Patient Assessment and Reassessment,” undated the P&P indicated, “Reassessment: a) the patient will be reassessed: when there is a significant change in condition. . .b) Documentation of the reassessment will be located on the unit specific intervention flowsheet. c) Reassessments are completed by RN’s ...” During a review of the hospital’s P&P titled, “Stroke Alert and Acute Care Stroke Management: Emergency Department and Inpatient Units,” undated the P&P indicated, “This policy will also outline the procedure for implementing current evidence-based practice for the management and care of the patient presenting with signs and symptoms of acute stroke and to implement clinical practice guidelines to further reduce the morbidity and mortality associated with stroke these guidelines support the primary principles and detailed aspects of successful stroke systems of care. . . Policy: In recognition of the Stroke Chain of Survival, the SVMC stroke program strives to provide early recognition and appropriate treatment throughout the patients length of stay (LOS). To further the care continuum referral to appropriate post-acute care takes place. 1. Detection: Early recognition. . .D. Stroke Unit (Telemetry) RN or Medical Surgical RN performs and documents the NIHSS upon admission to the unit, with any change in condition, or as prescribed. Reports any change in condition to the attending provider. Performs neuro checks and vital signs as prescribed, and/or as needed. Is responsible for general nursing care of the stroke/TIA/stroke alert patient. . .””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36543 0043 Based on interview, and record review, the Governing Body (GB) failed to effectively govern the activities, conduct and processes of the medical staff to provide safe and quality care to all patients as evidenced by: 1. The GB failed to follow the “Bylaws of the Board of Directors” when: a. The Chief of Staff did not initiate an investigation into allegations regarding one of one Medical Staff (MD 1) sexually abused sedated patients during endoscopy (examination of digestive tract using a lighted tube with a camera) examinations. This failure had the potential MD 1 to sexually abuse future patients. (Refer A044) b. The Chief of Staff did not initiate an investigation into allegations one of one Medical Staff (MD 1) created a hostile work environment. This failure resulted in staff ceasing to report MD 1’s behavior due to lack of faith in the reporting process, sexual harassment, and fear of retaliation. (Refer A044) c. The Chief of Staff did not ensure one of one Medical Staff (MD 1) sedated patients were provided safe, respectful care during endoscopy examinations. This failure had the potential to result in violation of patient rights to a safe and respectful healthcare. (Refer A044) d. Medical Staff were not required to complete training in patient safety measures. This failure had the potential for Medical Staff to be unaware of patient safety issues. (Refer A044) 2. Based on observation, interview and record review, the Governing Body failed to ensure Medical Staff was accountable to the GB when: a. The Medical Staff Bylaws did not have an explicit statement indicating the medical staff is accountable to the GB. This failure resulted in a lack of leadership and oversights by the governing body. (Refer A049) b. GB did not initiate an investigation into allegations of abuse by one of one medical staff (MD 1) towards 10 of 10 sedated patients (Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, and Patient 20) during endoscopic procedures. These failures resulted in allegations of abuse to not be investigated and the potential for continued abuse. (Refer A049) 3. One of one Medical Staff (MD 1) did not follow the hospital’s “Code of Conduct” to exhibit professional behavior and ensure a non-offensive work environment This failure resulted in staff to cease reporting unprofessional conduct and a hostile work environment. (Refer A083) 4. Hospital policy and procedures titled “Patient Rights and Responsibilities,” “Code of Conduct,” and “Restraint Use - Medical/Surgical and Behavioral Restraint” were followed for 12 of 30 sampled patients (Patient 5, Patient 6, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, and Patient 20). This failure resulted in patient rights violations. (Refer A115) The cumulative effect of these systemic practices resulted in the hospital’s inability to deliver care in compliance with the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36543 Based on interview and record review, the hospital failed to follow the hospital’s policy and procedures (P&P) titled, “Patient Rights and Responsibilities” and “Code of Conduct” for 11 of 11 patients (Patient 5, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19 and Patient 20) and “Restraint Use - Medical/Surgical and Behavioral Restraint,” for one of three sampled patients (Patient 6) when: 1. One of five sampled patients (Patient 5) was not provided pain medication in a timely manner.This failure resulted in Patient 5 suffering severe pain and not receiving pain medication for approximately five hours. (Refer A-144) 2. One of two sampled surgeons (Medical Doctor MD1) inserted up to two ounces (oz) of lubricant (lube) into four of four sampled patient’s (Patient 14, Patient 15, Patient 16, and Patient 19) mouth through the bite block (device to keep mouth open and protect the scope) during an upper endoscopy (EGD, examination of the digestive tract using an endoscope [scope, flexible tube with a light and camera]). This failure had the potential for patients to swallow and aspirate (breathe into lungs) the lube. (Refer A-144) 3. One of two sampled surgeons (MD 1) covered the face of four of four sampled patient’s (Patient 14, Patient 15, Patient 16, and Patient 19) during an upper endoscopy EGD. This failure had the potential for nursing staff to not be able to visually assess patient’s comfort level, sedation level, and oxygenation. (Refer A-144) 4. One of two sampled surgeons (MD 1) used seven of seven patients’ buttocks (Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, Patient 18, and Patient 20) as a table to hold up to two ounces of lubricant during a lower endoscopy (colonoscopy - flexible tube with light and camera used to examine the colon, lower intestines) This failure resulted in MD 1 not respecting patients’ dignity. (Refer A-144) 5. One of two sampled surgeons (MD 1) rapidly pushed the colonoscope in and out of the seven of seven patients’ (Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, Patient 18, and Patient 20) rectum. This failure had the potential for patients to feel violated. (Refer A-144) 6. One of two sampled surgeons (MD 1) did not follow the American Society for Gastroenterologist (ASGE) guidelines which indicated frequency and justification for repeat endoscopic exams for seven of seven patients (Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, Patient 18, and Patient 20). This failure had the potential to place patients at risk for surgical complications. (Refer A-144) 7. One of one sampled managers (FORM) did not forward complaints of potential sexual abuse to the Compliance Officer (CO). This failure resulted in continued potential sexual abuse of sedated patients and sexual harassment of operating room (OR) personnel. (Refer A-145) 8. A medical restraint (devices or methods used to limit a patient’s movement or behavior) order was written for one of three sampled patients (Patient 6). This failure resulted in Patient 6 to not be assessed and monitored every 15 minutes and the potential to result in injury to Patient 6. (Refer A-175) 9. Medical Staff did not ensure all physicians and other licensed independent practitioner (LIP) training on restraint application and the implementation of seclusion was documented. This had the potential to affect patients requiring restraints. (Refer A-176) The cumulative effect of these systemic practices resulted in the hospital’s inability to deliver care in compliance with the Condition of Participation for Patient Rights.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 36543 Based on interview and record review the Governing Body (GB) failed to follow the Bylaws of the Board of Directors, when: 1. The Chief of Staff did not initiate an investigation into allegations regarding one of one Medical Staff (MD 1) sexually abused sedated patients during endoscopy (examination of digestive tract using a lighted tube with a camera) examinations. This failure had the potential MD 1 to sexually abuse future patients. 2. The Chief of Staff did not initiate an investigation into allegations one of one Medical Staff (MD 1) created a hostile work environment. This failure resulted in staff ceasing to report MD 1’s behavior due to lack of faith in the process, sexual harassment, and fear of retaliation. 3. The Chief of Staff did not initiate an investigation into allegations one of one Medical Staff (MD 1) created a hostile work environment. This failure resulted in staff ceasing to report MD 1’s behavior due to lack of faith in the process, sexual harassment, and fear of retaliation. 4. Medical Staff were not required to complete training in patient safety measures. This failure had the potential for Medical Staff to be unaware of patient safety issues. Findings: 1. During a concurrent interview and record review on 12/18/24 at 12:15 p.m., with the Chief of Staff (COS), the Medical Staff Rules and Regulations Reference 1004 (MSRR), dated 5/28/19, were reviewed. COS stated Nothing can be taken lightly when it comes to patient safety. COS stated, the Medical Staff Coordinator brought the allegations against MD 1 regarding ten patients who had procedures on 12/3/24. COS stated he called MD 1 to ensure MD 1 was aware of the allegations. COS stated MD 1 was not suspended upon COS learning of the sexual abuse allegation. The MSRR indicated “Subject: Rules and Regulations relating to Patient Care” the MSRR indicated “Responsibility: Medical Staff.” the MSRR indicated “In instances of suspected patient abuse and/or neglect, the procedures as outlined in state and federal regulations will be followed. COS stated, “How I perceived it is the doctor needed to be aware of the allegation. I am not the judge and jury of whether it did or did not occur.” COS stated from the information provided to him, one person made the allegation. COS stated he did not do an investigation. COS stated, he just notified MD 1 since it was a written concern. COS stated my interpretation of the CMS guidelines is that if COS suspended MD 1, that COS was making an accusation and being judge and jury. COS stated reporting allegations of sexual abuse towards patient would absolutely be needed, but he was concerned about making an accusation and felt like he was saying the sexual abuse happened. COS stated, he asked MD 4 to review the allegations and MD 4 said the allegations indicated odd behavior and techniques. COS stated he would wait for the hospital Administration to bring their investigation results to him. COS stated, the hospital administration would do an investigation, Administration would not have the authority to discipline MD 1. COS stated Medical Staff, COS, and the Board was responsible for disciplining MD 1. During an interview on 12/19/24 at 8:42 a.m. with Medical Staff Coordinator (MSC), MSC stated COS informed MD 1 of the complaint, without dates, nothing to indicate any particular staff had complained. MSC stated COS made MD 1 aware of the allegations. MSC stated she did not recall if COS asked MD 1 any questions. During an interview on 12/20/24 at 9:03 with Compliance Officer (CO), CO stated during the Administration investigation, Administration requested CO’s assistance during the interviews. CO stated around 11 staff were interviewed. CO stated during the interviews staff said MD 1s techniques were weird (strange and unusual), the staff felt uncomfortable, and grossed out. Staff said they felt there was a sexual aspect to MD 1’s techniques. CO stated she was not aware of any requests from Medical Staff to release copies of the interview transcripts. 2. During an interview on 12/17/24 at 8:55 a.m., with Registered Nurse (RN) 5, RN 5 stated MD 1 could be hostile with staff. MD 1 would yell and blame staff. MD 1 was not very nice at times. MD 1 made inappropriate comments to nursing staff such as staff needs to get more endoscopy cases scheduled, asked what their hours were, what were the nurse’s job duties. RN 5 stated there was an incident when MD 1 called the Former Operating Room (OR) Director (FORD)’s voice mail, and MD 1 was speaking so loudly, the patient in the next room could hear. During an interview on 12/17/24 at 9:15 a.m. with unit clerk (UC), UC stated recently after FORD left, MD 1 said FORD was uneducated and not able to run the OR. UC stated, FORD had started as a unit clerk, returned to school for a nursing degree, eventually became manager and then director. UC 1 stated, MD 1 continued to bad-mouth FORD. During an interview on 12/17/24 at 9:24 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated there had a couple of incidents with MD 1 regarding how MD 1 spoke to patients. CNA 1 stated they sent a Datix - (facility reporting system, informs boss, manager, director and up to leaders). CNA 1 stated “Everyone’s’ demeanor changes when [MD 1] enters the hospital,” due to the way MD 1 speaks about workers, belittles the staff, says staff do not do their job correctly. CNA 1 stated at times MD 1 spoke rudely to the staff. CNA 1 stated “tries to keep distance.” During an interview on 12/17/24, at 12:50 p.m., with RN 3, RN 3 stated when nurses asked why MD 1 did certain things, MD got upset and said his standards were different. Most of staff stay quiet due to fear of retaliation from MD 1. RN 3 stated MD 1 sounds upset, aggressive, and very defensive. RN 3 stated staff reported MD 1’s actions prior to this current incident. RN 3 stated they reported concerns to the Charge Nurse, and the Charge Nurse informed them the concerns had gone up the chain-of-command. RN 3 stated they was not aware of outcomes, there was no change in MD 1’s behaviors. The day this incident was reported was a long day and enough was enough. During an interview on 12/17/24, at 1:41 p.m., with RN 7, RN 7 stated on multiple occasions, near the beginning of 2024, MD 1 questioned them about medications in Pyxis (automated medication dispensing machine), what was in there, questions about crash cart, and what abilities did they have. RN 7 stated MD 1’s questions made them feel unsafe. RN 7 stated, sometime female staff need to use the male locker room. Several staff observed urine in the sink after MD 1 used the locker room. During an interview on 12/17/24 at 2:47 p.m., with Endoscopy Technician (ET) 4, ET 4 stated, there was an incident when a male tech used the restroom. MD 1 used the restroom after the tech. The tech returned to the restroom after MD 1 exited and there was urine-colored fluid in the sink. ET 4 stated, pictures were sent to the administration. ET 4 stated MD 1 made this a hostile workplace. The work environment was hostile, and uncomfortable. During an interview on 12/17/24 at 3:20 p.m., with RN 2, RN 2 stated, MD 1 had created a hostile work environment for some staff. During an interview on 12/18/24 at 8:46 a.m., with Compliance Officer (CO), CO stated compliance related incidents for MD 1 included disruptive behavior, rudeness to staff and bullying behavior. CO stated Medical Staff incidents went through the Medical Staff Process. CO stated, during interviews conducted with endoscopy staff, Endoscopy staff informed her MD 1 urinated on bathroom sinks. CO stated MD 1 had a trend of disruptive behaviors. During an interview on 12/18/24 at 12:15 p.m., with the COS, COS stated there had been other complaints regarding MD 1’s behavior in the past. COS stated Medical Staff received reports about MD 1’s behavior, and then there would be a period without reports of MD 1’s behavior. COS stated, when there was a period without reports of MD 1’s behaviors, COS assumed all was good. COS was not aware the nursing staff were being told the concerns were sent to Medical Staff, however, because nursing staff did not see any changes in MD 1;’s behaviors, the nursing staff felt there was no point in complaining. COS stated the Bylaws state that providers need to be professional and respectful. COS stated the Code of Conduct also addresses behavior. During an interview on 12/19/24, 9:31 a.m., with RN 4, RN 4 stated it was hard to approach MD 1. RN 4 stated they did not know how to approach MD 1. RN 4 stated MD 1 was a powerful man. RN 4 stated they were afraid to approach MD 1. RN 4 stated they were uncomfortable to be around MD 1 and to work in OR with MD 1. During an interview on 12/19/24 at 11:13 a.m. with ET 2, ET 2 stated “[MD 1] talked down to staff.” ET 2 stated they had spoken with former manager and FORD, the former manager and FORD responded they would speak with MD 1, but the former manager and FORD did not pursue the complaint or move the complaint forward. During an interview on 12/19/24 at 11:46 a.m., with ET 3, ET 3 stated they “worked frequently with MD 1.” ET 3 stated coworkers had warned them to be careful and mindful of what was said, “because you never know.” ET 3 stated they were careful asking MD 1 questions. ET 3 stated they felt uncomfortable with MD 1. ET 3 stated, Staff was warned when MD 1 was scheduled. Nurses submitted requests not to be in OR with MD 1. ET 3 stated, MD 1 has had these behaviors since the ET 3 started a few years ago. ET 3 stated they had verbally reported MD 1’s behavior to Charge Nurse and Manager. ET 3 stated they were “afraid to submit a written report because [MD 1] is on the Board of Directors.” ET 3 stated they had heard there had been several complaints about MD 1’s behaviors, but MD 1 was still at the hospital. ET 3 stated they were concerned MD 1 would retaliate. During an interview on 12/19/24 at 12:12 p.m. with ET 1, ET 1 stated they informed other staff they were uncomfortable working with MD 1. ET 1 stated they heard MD 1 was on the hospital Board of Directors. ET 1 stated they were scared of MD 1. ET 1 stated coworkers told them MD 1 was on the hospital Board, therefore the Board would not do anything about MD 1’s behaviors. ET 1 stated they wanted to say something, but they were discouraged based on what other staff said. During an interview on 12/19/24 at 2:17 p.m., with Former OR Manager (FORM) FORM stated, MD 1 could be unprofessional. MD 1 could raise his voice, make comments about poor management skills, such as you are not doing your job right. FORM stated, MD 1 would specially make comments when he did not get his way, such as staffing issues, and changing block times. FOR stated MD 1 created a hostile environment for staff by raising his voice, being demanding, and rude. During an interview on 12/20/24 at 8:32 a.m. with RN 9, RN 9 stated MD 1’s demeanor towards staff was not respectful for example, during a colonoscopy biopsy, the endoscopy technician put specimen cup on bed, and it spilled. MD 1 lost it. MD 1 was verbally abusive to the endoscopy technician. During an interview on 12/20/24 at 8:49 a.m., with RN 9, RN 9 stated it was difficult to communicate with MD 1, staff were afraid of MD 1 because they did not know how MD 1 would respond. During an interview on 12/20/24 at 9:03 with Compliance Officer (CO), CO stated the nurse was to be the sedated patient’s advocate. CO stated during the Administration investigation, Administration requested CO’s assistance during the interviews. CO stated around 11 staff were interviewed. CO stated during the interviews staff said MD 1s techniques were weird, the staff felt uncomfortable, grossed out and just Ewwww. Staff said they felt there was a sexual aspect to MD 1’s techniques. During a review of the Medical Board of California’s website the article titled “Accusations of Sexual Misconduct or Harassment against Physicians” excerpt dated July 1994 Action Report, the article indicated “Sexual misconduct can be defined as unwelcome behavior of a sexual nature which can take several courses ...creating a hostile work environment because of some conduct or harassment of a sexual nature is also illegal and unethical ...” 3. During an interview on 12/19/24 at 8:42 a.m. with Medical Staff Coordinator (MSC), MSC stated during the hospital’s threat assessment meeting on 12/6/24, MSC informed the threat assessment team she had verbally informed COS of the situation. MSC stated she felt COS did not understand the seriousness of the incident. MSC stated, following the threat assessment meeting, a second meeting was held in the Chief Executive Officer’s office with COS and other hospital leadership to discuss the severity of the allegations and the need to meet with MD 1. MSC stated a clean written report was prepared for COS and provided to him later that day. During an interview on 12/18/24 at 12:15 p.m., with the COS, COS stated he perceived the allegation report as MD 1 needed to be aware of the allegations. COS stated he was not the judge and jury of whether the allegations occurred. COS stated he was not in a position to judge the procedures and techniques used in a colonoscopy. COS stated he did not suspend MD 1 during the hospital’s investigation. During a review of the Bylaws of the Board of Directors, undated, the Bylaws indicated “8.4.4 Board Procedure: In satisfying its responsibilities, hereunder, the Board shall exercise functions of an administrative nature and of a judicial nature, as provided herein...” During a review of the Bylaws of the Board of Directors, undated, the Bylaws indicated “8.5.7 Whenever a Practitioner’s conduct requires immediate action to be taken to reduce a substantial likelihood of imminent impairment of the life, health or safety of any patient, prospective patient or any other person, the Board or the Chief Executive officer may summarily suspend the Medical Staff membership status or all or any portion of the clinical privileges of such Practitioner; provided, however, that the Board or the Chief Executive Officer, before the suspension, makes reasonable attempts to contact the governing body of the Medical Staff (the “Medical Executive Committee”)...” During a review of the Medical Staff Rules and Regulations (R&R) Reference 1004, dated 5/28/19, the R&R indicated, “In instances of suspected patient abuse and/or neglect, the procedures as outlined in state and federal regulations will be followed.” During a review of Appendix A section 483.12(c) (3) the regulation indicated “In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ... (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.” 4. During an interview on 12/19/24 at 8:42 a.m., with MSC, MSC stated the Hospital did not provide formal training for physicians on abuse. MSC stated according to the bylaws, MDs were expected to follow all hospital Policies and Procedures (P&P). MSC stated she did not track physician training. MSC stated, she did not know why MD 1 would be asking for training certificate on abuse. During an interview on 12/20/24 at 2:25 p.m. with MSC, Appendix A (federal regulations for general acute care hospitals) A0176 was reviewed. MSC stated she was not aware if Medical Staff provided restraint training. MSC stated all physicians are required to follow all facility P&Ps. MSC stated communication goes to med staff to department chair to individual MDs. MSC does not get read receipts or Doc-U-Sign acknowledgements from e-mails. MSC does not track if MDs take required training such as restraints. During a review of the facility “Code of Conduct” dated 12/5/23, the Code of Conduct indicated “[hospital] maintains an ongoing, proactive patient safety program for the identification of risk to patient safety...” During a review of the facility “Code of Conduct” dated 12/5/23, the Code of Conduct indicated “Medical Staff: Healthcare services like those owned and operated by [hospital] are a collaboration between Hospital Staff and Medical Staff members. As in any collaboration, each party has important roles and responsibilities that they must adhere to...The Identification and Management of Disruptive Behavior policy establishes that [hospital] has an environment that requires all individuals, employees, physicians...to conduct themselves in a professional and cooperative manner within the facility and to define the behaviors that: Interfere with high quality patient care. Disrupt the orderly administration of [hospital] Disrupt the orderly of the independent Medical Staff. Affects the abilities of others to do their jobs. Creates a hostile work environment of others to do their jobs...””

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 36543 Based on observation, interview and record review, the Governing Body (GB) failed to ensure Medical Staff was accountable to the GB when: 1. The Medical Staff Bylaws did not have an explicit statement indicating the medical staff is accountable to the GB. 2. GB did not initiate an investigation into allegations of abuse by one of one medical staff (MD 1) towards 10 of 10 sedated patients (Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, and Patient 20) during endoscopic procedures. These failures resulted in a lack of leadership and oversight by the governing body. Findings: 1. During a concurrent interview and record review on 12/20/24 at 2:25 pm with Medical Staff Coordinator (MSC), the Bylaws of the Board of Directors, undated, and the Medical Staff Bylaws, dated 5/24/22, were reviewed. MSC stated she was not aware of a statement in the Bylaws that specifically indicated the medical staff was accountable to the GB. The Bylaws of the Board of Directors indicated 2.2 Purposes and Powers. The District is organized for the purposes described in the Local Health Care District Law and shall have and may exercise such powers in the furtherance of its purposes...4.1 General Powers. The Board is the governing body of the District. All District Powers shall be exercised by or under the direction of the Board. The Board is authorized to make appropriate delegations of its powers and authority to officers and employees...” MSC stated the Medical Staff Bylaws indicated “These bylaws provide the professional and legal structure for medical staff operations, organized medical staff relations with the board of directors, relations with applicants to and members of the medical staff. The organized medical staff both enforce and complies with these medical staff bylaws. 2. During a review of the Facility Reported Incident (FRI) dated 12/9/24, the FRI indicated on 12/3/24 staff member expressed concern about a physician’s conduct during endoscopy (EGD, examination of the food path from the throat through the stomach to the first part of the intestine) and colonoscopy (examination of the body waste path, small intestine, large intestine, rectum and anus) procedures (low risk surgery).The FRI indicated staff were present during procedures and observed physician behaviors which staff interpreted to be sexual in nature towards the unconscious patient. The facility interviewed other staff who corroborated the account provided. The FRI indicated the hospital Medical Staff was notified and the Chief of Staff (COS) would interview the surgeon (Medical Staff [MD] 1) and advise the Medical Executive Committee who would advise the next steps. During an interview on 12/18/24 at 12:17 p.m., with Chief of Medical Staff (COS), the COS stated “Nothing can be taken lightly when it relates to patient safety. COS stated Medical Staff Coordinator (MSC) brought the allegations regarding MD 1’s behavior towards ten patients on 12/3/24, to his attention. COS stated, he called MD 1 to ensure MD 1 was aware of the allegations. COS stated beyond that, COS was unable to make it (the complaint) more than just an accusation. COS stated he did not suspend MD 1 while an investigation into the allegations was conducted. COS stated he did not discuss the allegations with a gastrointestinal physician (doctor specializing in the diseases and treatment of the digestive system). COS stated he did not conduct an investigation into the allegations of abuse. COS stated his primary concern was to ensure patients received safe care. During a review of MD 1’s surgical schedule dated 12/3/24, the surgical schedule indicated MD 1 performed 11 procedures on 10 patients (Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, and Patient 20). During a review of the facility “Code of Conduct” dated 12/5/23, the Code of Conduct indicated “[hospital] maintains an ongoing, proactive patient safety program for the identification of risk to patient safety...” During a review of the Bylaws of the Board of Directors, undated, the Bylaws indicated “8.4.4 Board Procedure: In satisfying its responsibilities, hereunder, the Board shall exercise functions of an administrative nature and of a judicial nature, as provided herein...” During a review of the Bylaws of the Board of Directors, undated, the Bylaws indicated “8.5.7 Whenever a Practitioner’s conduct requires immediate action to be taken to reduce a substantial likelihood of imminent impairment of the life, health or safety of any patient, prospective patient or any other person, the Board or the Chief Executive officer may summarily suspend the Medical Staff membership status or all or any portion of the clinical privileges of such Practitioner; provided, however, that the Board or the Chief Executive Officer, before the suspension, makes reasonable attempts to contact the governing body of the Medical Staff (the “Medical Executive Committee”)...””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 36543 Based on interview and record review, the hospital failed to ensure one of one Medical Staff (MD 1) followed the hospital’s “Code of Conduct” to exhibit professional behavior and ensure a non-offensive work environment This failure resulted in staff to cease reporting unprofessional conduct and a hostile work environment. Findings: During an interview on 12/17/24 at 8:51 a.m. with Registered Nurse (RN 8) RN 8 stated sometimes, MD 1 made inappropriate comments such as his Hispanic patients being charity cases and nurses made too much money. RN 8 stated MD 1 had made these comments for years. RN 8 stated in the past they had notified the operating room (OR) manager, but they did not know if MD 1 had any disciplinary action. During an interview on 12/17/24 at 8:55 a.m. RN 5, RN 5 stated MD 1 can be hostile with staff, he would yell and blame staff for things. MD 1 was not very nice at times and made inappropriate comments. RN 5 stated one nursing staff informed them that MD 1 said nurses needed to sedate for endoscopy cases, nurses were paid too much, and the staff needs to get more endoscopy cases scheduled over here. RN 5 stated MD 1 would ask nurses what their hours and job duties were. RN 5 stated, the hostile environment affected the Former Operating Room (OR) Director (FORD). RN 5 recounted three incidents. During the first incident, MD 1 called the FORD’s voice mail, MD 1 was so loud, the patient in the next room could hear. During the second incident, MD 1 wanted patient to go home with Huber (specialty needle, often used for chemotherapy) needle in place without writing an order, Nursing staff informed MD 1 it was not in their policy to discharge a patient with a Huber needle in place. Nursing staff called the manager and instructed nursing, MD 1 needed to write the order for patient discharge with the Huber needle in place. RN 5 stated, MD 1 did not like nurses questioning him. During the third incident, the patient came in for a Laparoscopic Nissan fundoplication (surgery for reflux, heartburn). The patient told the nurse, MD 1 said everything was done through the throat, without incisions (cuts). The nurse educated patient that small incisions are typically made during the surgery. The patient was upset because he thought everything was through the throat without incisions. The patient canceled the surgery. MD 1 was upset that nurses educated the patient differently than he had in his office. During an interview on 12/17/24 at 9:15 a.m. with Unit Clerk (UC), UC stated after FORD left, MD 1 made comments regarding FORDs qualifications, such as, FORD was uneducated and not able to run the OR. UC stated, FORD had worked their way up from UC, they returned to school for a nursing license, became OR Manager, and eventually OR Director. UC stated MD 1 continued to bad-mouth FORD. UC stated they had observed MD 1 attitude towards people if MD 1 did not get his way. During an interview on 12/17/24 at 9:24 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 had a couple of incidents with MD 1 regarding how MD 1 spoke to patients. CNA 1 sent a Datix (informs boss, manager, director and up to leaders). CNA 1 stated everyone’s demeanor changed when MD 1 entered the hospital. CNA 1 stated staff did not like to work with MD 1 due to way MD 1 spoke about staff, belittled staff, said staff did not do their job correctly. CNA 1 stated at times, MD 1 was rude when speaking to staff, CNA 1 stated it felt like MD 1 thought he was above everybody else. CNA 1 stated a couple of months ago, a non-English speaking patient had questions about the surgery when they brought the patient back to pre-op. CNA 1 stated they informed MD 1 that the patient had questions. CNA 1 stated Patient had been informed at MD 1’s office that the surgery would be a laparoscopic (surgery performed through small incisions with very small tools inserted, typically a shorter recovery time) procedure, but nursing staff informed him it was an open (traditional surgery with large incision) procedure. CNA 1 stated the patient became distraught because of how MD 1 spoke to him. CNA 1 stated MD 1 told the patient there would be a charge for canceling the surgery. CNA 1 stated the patient said MD 1 gave misinformation and now he was upset. MD refused to get an interpreter in. During an interview on 12/17/24, at 12:50 p.m. with RN 3, RN 3 stated when staff asked MD 1 why he did something a certain way, MD 1 would get upset. MD 1 said his standards were different. RN 3 stated, most staff stay quiet around MD 1 due to fear of retaliation. RN 3 stated MD 1 sounds upset and very aggressive. RN 3 stated MD 1 was very defensive. RN 3 stated staff had reported MD 1’s actions previously. RN 3 stated they reported MD 1’s behaviors to the Charge Nurse, who told them the complaint had gone up the chain of command. RN 3 stated they were not aware of any outcomes (disciplinary action), but MD 1’s behavior had not changed. RN 3 stated they were worried about retaliation. During an interview on 12/17/24 at 1:41 p.m. with RN 7, RN 7 stated when they first started, there were multiple occasions when MD 1 questioned them about what medications were in the Pyxis (automated medication dispensing device), what was in the crash (emergency supply) cart and their abilities. RN 7 stated MD 1 would not let them observe the face of patients during an upper endoscopy (EGD, examination of the upper digestive tract using a flexible tube with a light and camera). RN 7 stated they reported MD 1’s behavior to the Charge Nurse and former OR Manager near the beginning of 2024. RN 7 stated nursing staff was afraid of MD 1; nursing staff feel they have a lot to lose while advocating for their patients. RN 7 stated MD 1 was a powerful man, he would retaliate against staff. RN 7 stated other staff have told them if they follow MD 1 into the restroom in the men’s locker, they see a urine-colored liquid in the sink. During an interview on 12/17/24 at 3:20 p.m. with RN 2, RN 2 stated MD 1 had created a hostile work environment for some staff. During an interview on 12/18/24 at 8:46 a.m. with Compliance Officer (CO), CO stated incidents regarding MD 1’s disruptive behavior went through the Medical Staff Process. CO stated MD 1 had a history of being rude to staff and exhibiting bullying behaviors. CO stated, MD 1 had a trend of disruptive behaviors. During a concurrent interview and record review on 12/18/24 at 12:12 p.m. with Chief of Staff (COS), the Facility Code of Conduct was reviewed. COS stated there had been other complaints regarding MD 1’s behavior in the past. COS stated in the past, there were reports of MD 1’s behavior, and then there would be a period without complaints. COS stated, “at that point [no continuing complaints] he [COS] assumes all is good.” COS stated the Bylaws stated providers need to have professional, respectful behaviors, the Code of Conduct as well. COS stated allegations of operating room behavior goes to the (surgical) department chair, but the current allegation came through the hospital administration, due to the seriousness of the allegation. During an interview on 12/19/24, 9:31 a.m. with RN 4, RN 4 stated it was hard to approach MD 1. RN 4 stated they did not know how to approach MD 1. RN 4 stated MD 1 was a powerful man, and they were afraid to approach MD 1. During an interview on 12/19/24 at 11:46 a.m., with ET 3, ET 3 stated, they had been warned to be careful and mind what they said to MD 1, because “you never know.” ET 3 stated they felt uncomfortable with MD 1, and they were careful when asking MD 1 questions. ET 3 stated they had made verbal reports to the manager and director. ET 3 stated they were afraid to submit a written report, because MD 1 was on the Board of Directors. ET 1 stated coworkers told them because MD 1 was on the Board of Directors, the Board would not do anything about the complaint. ET 3 stated, they wanted to say something but was discouraged based on what coworkers said. During an interview on 12/19/24 at 12:35 p.m. with RN 6, RN 6 stated on their second day at the hospital they needed orders from MD 1, instead of giving them the orders they needed, MD 1 asked how much money they made? and MD 1 said you nurses make too much money. RN 6 stated, it was difficult when the person you were speaking with was on the Board. During an interview on 12/19/24 at 2:17 p.m., with Former OR Manager (FORM), FORM stated staff complains about working with MD 1. FORM stated MD 1 was always trying to get into other people’s business. FORM stated she told staff to tell MD 1 “I do not want to have this conversation.” FORM stated MD 1 can be unprofessional. MD 1 would raise his voice, make comments about poor management skills or you are not doing your job right. MD 1 would make these types of comments especially when MD 1 did not get his way on staffing issues or time blocks. MD 1 created a hostile environment for staff with raising his voice, being demanding and rude. During a review of the facility “Code of Conduct” dated 12/5/23, the Code of Conduct indicated the following: “[hospital] strives to provide a safe and productive work environment. The work environment must be free from discrimination and harassment...[hospital] does not tolerate sexual advances, actions comments, or any other conduct in the workplace that creates an intimidating or otherwise offensive environment. If you believe that you are subject to such conduct, bring such activity to the attention of the Organization...Some other activities that are prohibited because they clearly are not appropriate are: Threats...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47444 Based on interview and record review, the hospital failed to ensure the patient’s right to comfort, dignified, respectable, and safe care was protected for 11 of 11 patients (Patient 5, Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, and Patient 20) when: 1. One of five sampled patients (Patient 5) was not provided pain medication in a timely manner. This failure resulted in Patient 5 suffering severe pain and not receiving pain medication for approximately five hours. 2. One of two sampled surgeons (MD 1) inserted up to two ounces (oz) of lubricant (lube) into four of four sampled patient’s (Patient 14, Patient 15, Patient 16, and Patient 19) mouth through the bite block (device to keep mouth open and protect the scope) during an upper endoscopy (EGD, examination of the digestive tract using an endoscope [scope, flexible tube with a light and camera]). This failure had the potential for patients to swallow and aspirate (breathe into lungs) the lube resulting in harm or death. 3. One of two sampled surgeons (MD 1) covered the face of four of four sampled patient’s (Patient 14, Patient 15, Patient 16, and Patient 19) during their EGDs. This failure had the potential for nursing staff to not be able to visually assess patient’s comfort level, sedation level and oxygenation lube resulting in harm or death. 4. One of two sampled surgeons (MD 1) used seven of seven patients’ buttocks (Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, Patient 18, and Patient 20) as a table to hold up to two ounces of lube during a lower endoscopy (colonoscopy). This failure resulted in MD 1 not respecting patients’ dignity. 5. One of two sampled surgeons (MD 1) rapidly pushed the colonoscope (endoscope, used to examine the colon, lower intestines) in and out of the seven of seven patients’ (Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, Patient 18, and Patient 20) rectum. This failure had the potential for patients to feel violated. 6. One of two sampled surgeons (MD 1) did not follow the American Society for Gastroenterologist (ASGE) to repeat endoscopic exams. This failure had the potential to place patients at risk for surgical complications. Findings: 1. During a review of Patient 5’s “Triage Assessment (TA),” dated 12/16/24 at 2:17 a.m., the TA indicated Patient 5 reported left side abdominal pain and reported a pain level of 9 (Numeric pain scale - 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain). Patient 5 had taken Norco (medication used to treat severe pain) at 11 p.m. prior to coming to the emergency department (ED). During a concurrent interview and record review on 12/20/24 at 10:12 a.m. with RN 1, Patient 5’s medical record (MR) was reviewed. The MR indicated Patient 5 was seen by triage RN 10 on 12/16/24 at 2:16 a.m. then returned to the waiting room. At 5:54 a.m. Patient 5 was brought to an ED room. RN 1 stated there was no documentation that Patient 5 received pain medication between 2:16 a.m. and 7:34 a.m. on 12/16/24. During a concurrent interview and record review on 12/20/24 at 2:52 p.m. with RN 11, Patient 5’s “MR,” was reviewed. The MR indicated RN 11 completed a Gastrointestinal Assessment on 12/16/24 at 6:55 a.m. RN 11 stated she gave Patient 5 an antinausea medication, but nothing for pain. RN 11 stated she asked Patient 5 if he was having pain and he immediately vomited. RN 11 stated at that point she prioritized the antinausea medication and did not give patient 5 pain medication. During a review of Patient 5’s “Patient Order Summary (POS).” dated 12/16/24 at 7:09 a.m., the POS indicated physician ordered Morphine Sulfate (pain medication used to treat moderate to severe pain) 4mg (milligrams) for Patient 5. This was the first documented physicians order for pain medication. During a review of Patient 5’s “MAR [Medication Administration Record] Documentation (MAR),” dated 12/16/24 at 7:34 a.m., the MAR indicated Patient 5 received Morphine Sulfate (pain medication) for a pain level of 10, approximately five hours after arriving at the ED. During a concurrent interview and record review on 12/20/24 at 3:13 p.m. with Emergency Department Manager (EDM), Patient 5’s “MR,” was reviewed. The MR indicated Patient 5 reported a pain level of 9 during the triage assessment. The MR indicated no pain medication was ordered until 7:09 a.m. and the medication was given at 7:34 a.m. for a pain level of 10. EDM stated the expectation was for the triage nurse to notify the charge nurse or physician of Patient 5’s pain level of 9. EDM stated the expectation is for the triage nurse to make a nurses note when the physician or charge nurse was notified of Patient 5’s pain level of 9. EDM stated there was no nurses note which indicated the physician or charge nurse was notified of Patient 5’s pain level. EDM stated there were pain medication options that could have been offered to Patient 5. EDM stated Patient 5 should not have had to wait for five hours before being given pain medication. During an interview on 12/20/24 at 4:02 p.m. with RN 10, RN 10 stated she assessed Patient 5 on 12/1/24 in the triage area. RN 10 stated she could tell Patient 5 was in pain and she informed the charge nurse. RN 10 stated if a patient is having severe pain, pain medication can be given to the patient in the waiting area. During a review of the hospital’s policy and procedure (P&P) titled, “Pain Management,” (undated), the P&P indicated, “Definitions: 1. 0-10 Pain Scale (numeric scale) - Pain scale used for children older than 7 years of age and for adults who can understand abstract numbers (10-point scale) . . . 6. Severe pain - Value of 7-10 on the numeric scale. . . Policy: A. Optimal management of pain is a primary goal of patient care and is crucial to quality patient care.” During a review of the hospital’s P&P titled, “Patient Rights and Responsibilities,” (undated), the P&P indicated, “Patient Rights. . . 9. Reasonable responses to any reasonable requests made for service.” 36543 2. During an interview on 12/17/24 at 11 a.m., with MD 2, MD 2 stated they had not heard of anyone putting lube in sedated patient’s mouth. MD 2 stated putting lube in the mouth of a sedated patient would put the patient at risk for aspiration. During an interview on 12/17/24, at 12:50 p.m., with Registered Nurse (RN) 3, RN 3 stated the tube of lube that was used during the procedure was about five inches long. RN 3 stated MD 1 squirts a large amount of lube into the patient’s mouth through the bite block. RN 3 stated putting that much lube in the patient’s mouth was a risk for patient aspiration. RN 3 stated they used the suction to remove the excess lube from the patient’s mouth prior to the start of the procedure. RN 3 stated no other doctor added lube to the patient’s mouth for an upper endoscopy. RN 3 stated other doctors put the lube on a gauze square (4X4) and wipe the lube onto the scope’s tube. During an interview on 12/17/24 at 1:41 p.m. with RN 7, RN 7 stated MD 1 squirts a lot of lubes into the sedated patient’s mouth, then inserts the scope. RN 7 stated patients are only mildly sedated and often gag. RN 7 stated, other doctors put lube on gauze and then apply the lube to the scope. During an interview on 12/17/24 at 4 p.m. with MD 3, MD 3 stated it was not desirable nor acceptable to put lube into the patient’s mouth. MD 3 stated very little lube was needed on the scope for insertion into the patient’s mouth during an endoscopy procedure. MD 3 stated over lubricating could put the patient at risk. MD 3 stated the lube was difficult to swallow, could be aspirated into the lungs, and the lube did not taste good. MD 3 stated any excessive medications, including lube, need to be thought through for best possible practices. During an interview on 12/18/24, at 12:17 p.m., with Chief of Staff (COS), COS stated, he performed bronchoscopies (procedure to look directly at the airways in the lungs using a thin, lighted tube [bronchoscope]) and EGDs. COS stated, he did not see any need to squirt an entire tube of lube through the bite block into the sedated patient’s mouth. COS stated, “I normally use the lido [lidocaine, numbing medication] spray and test gag reflex, I don’t know what the purpose would be for the whole tube of lube.” COS stated sedated patients would be at risk for aspiration with a large amount of lube in the stomach. During an interview on 12/19/24, 9:31 a.m. with RN 4, RN 4 stated MD 1 squirts lube into the patient’s mouth through the bite block and uses that lube to lube the scope. RN 1 stated the patient had a higher risk of aspiration with this technique, so they kept the suction close by. RN 4 stated, they were not sure how much lube, MD 1 squirted into the patient’s mouth. RN 4 stated MD 1 squirted a significant amount into the patient’s mouth, but less than the entire tube. RN 4 stated, they stood at the head of bed and exercised extra cautions such as suctioning excess lube out of the patient’s mouth with MD 1. During an interview on 12/19/24 at 11:13 am with Endoscopy Technician (ET) 2, ET 2 stated they had many years experience working in endoscopy. ET 2 stated MD 1 puts lube in the patient’s mouth through the bite block and the lube drips down the patient face. ET 2 stated they told the nurse the patient could aspirate. ET 2 stated MD 1 used almost the entire 2-ounce tube in the bite block. During an interview on 12/19/24 at 11:46 a.m., with ET 3, ET 3 stated MD 1 squirts almost all the two (2) ounce tube of lube into the patient’s mouth through the bite block. ET 3 stated they were concerned because a sedated patient swallowing the lube was a safety issue. ET 3 stated squirting lube into the patient’s mouth was not right, no other doctor squirted the lube into the patient’s mouth. ET 3 stated, other doctors put a small amount of lube on the tip of the scope. ET 3 stated sometimes, the patient was uncomfortable and gagged. During an interview on 12/19/24 at 12:12 with ET 1, ET 1 stated MD 1 squirted the entire tube (2 ounces) of lube in the patient’s mouth. ET 1 stated, every other MD used the smallest amount of lube. ET 1 stated they were concerned the sedated patient would aspirate the lube, due to the amount of lube used by MD 1. ET 1 asked if the patient cannot drink a small sip of water before the procedure, what would happen with this thick goo in the mouth? During a review of Patient 15’s Operative Report (OpReport) dated 12/3/24, the OpReport listed Benzocaine (numbing medication) spray under Medications. During a review of Patient 15’s Procedural Sedation Flow Sheet (PSFS), dated 12/3/24, the PSFS indicated Benzocaine spray was administered at 12:33 p.m. During a review of Patient 19’s OpReport, dated 12/3/24, the OpReport listed Benzocaine spray under Medications. During a review of Patient 19’s PSFS, dated 12/3/24, the PSFS indicated Benzocaine spray was administered (no time noted). During a review of WebMD (online health information source ) the articled “Benzocaine 20 % Mucosal Spray - Uses, Side Effects and More” undated, indicated “Benzocaine spray is used to numb the lining of the mouth and throat before certain medical procedures (such as intubation)...It is a local anesthetic that starts to numb the lining of the mouth and throat 15 to 30 seconds after application and lasts about 15 minutes...This medication numbs the mouth and throat. This effect may make swallowing difficult and increase your risk of choking or swallowing the wrong way. Do not eat or chew gum for 1 hour after this product is used or until your mouth/throat is no longer numb...” During a review of the facility provided “Safety Data Sheet Sterile Lubricating Jelly (SDS),” undated, the SDS indicated, “Section 4. First-Aid Measures. . . Ingestion: If swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water. Do not induce vomiting unless directed to do so by a physician. Never give anything by mouth to an unconscious person. If vomiting occurs spontaneously, keep head below hips to prevent aspiration of liquid into lungs. . . Section 11. Toxicological Information. . . Acute Toxicity: Ingestion May be harmful if swallowed.” 3. During an interview on 12/17/24, at 1:41 p.m., with RN 7, RN 7 stated when working with MD 1 in room, during EGD, MD 1 puts a towel over the patient’s eyes. During an interview on 12/17/24 at 2:47 p.m., with ET 4, ET 4 stated, before starting an EGD, MD 1 asks the ET for a washcloth and MD 1 covered everything on the patient’s face but the mouth. ET 4 stated they were concerned as the RN could not see changes in patient’s skin tone. ET 4 stated MD 1 would not let the nurse look at the patient’s face. ET 4 stated, MD 1 would just tell the nurse the patient was fine, sometimes MD 1 might lift a corner of the washcloth, but not typically. ET 4 stated if a nurse wanted to see the patient’s face, MD 1 would insist the patient is fine. ET 4 stated attempts had been made to remove washcloth at times, but MD 1 replaced the washcloth back onto the patient’s face. During an interview on 12/17/24 at 3:20 pm with RN 2, RN 2 stated, they did not typically work with MD 1. RN 2 stated during an EGD they moved to hold the patient’s head and they noticed a towel was covering most of the patient’s face. RN 2 stated they were concerned. RN 2 stated they did not like to not be able to see the sedated patient’s face during the procedure. RN 2 stated, they tried to remove towel from the patient’s face but, the ET told them, MD 1 liked the patient’s face covered. RN 2 stated, as a nurse they liked to see the patient’s face, to ensure the patient did not have symptoms of distress, a seizure, or inadequate oxygenation. RN 2 stated when the patient’s face was covered, they would be unable to determine if patient was cyanotic or had aspirated. During an interview on 12/17/24 at 4 p.m. with MD 3, MD 3 stated it was not acceptable to cover a patient’s face. MD 3 stated covering the patient’s face was disrespectful, only the faces of dead people were covered. MD 3 stated there was no need to cover the face. MD 3 stated one needed to see color of lips, skin, nose, how was the patient doing, if there is pain. MD 3 stated if you cover the face a lot of important observations could be missed. MD 3 stated the patient’s face was an important observation tool and covering the face compromises the safety of patient. During an interview on 12/18/24, at 12:17 p.m., with COS, COS stated he would not cover the face of a patient during an EGD. COS stated, “There isn’t any need to [cover the patient’s face], being able to observe the patient’s face is part of my assessment.” During an interview on 12/19/24, 9:31 a.m. with RN 4, RN 4 stated MD 1 covered the patient’s eyes during the EGD procedure. RN 4 stated they had never seen another doctor cover patient’s eyes during an EGD. During an interview on 12/19/24 at 11:46 a.m., with ET 3, ET 3 stated MD 1 covered every patient face/eye area during EGD procedures. ET 3 stated this practice was also a safety issue as the nurse was not able to assess the patient completely when they could not see the patient’s eyes. ET 3 stated MD 1 would not allow the towel to be removed from the patient’s face during an EGD. During an interview on 12/19/24 at 12:35 p.m. RN 6 RN 6 stated, RN 6 stated they had been uncomfortable with MD 1’s techniques for a while. RN 6 stated, during an EGD procedure, MD 1 wanted the patient’s face covered with a towel. RN 6 stated they want to see that the patient’s face was pink, wants to see the items going in - i.e., dilators (stretches narrow areas of esophagus, food tube), that the dilator is going in the right place. RN 6 stated most doctors just use a little lube; they suction out the excess lube from the patient’s mouth to prevent aspiration. During a review of Patient 15’s OpReport, dated 12/3/24, the OpReport listed Benzocaine (numbing medication) spray under Medications. During a review of Patient 15’s Procedural Sedation Flow Sheet (PSFS), dated 12/3/24, the PSFS indicated Benzocaine spray was administered at 12:33 p.m. During a review of Patient 19’s OpReport, dated 12/3/24, the OpReport listed Benzocaine spray under Medications. During a review of Patient 19’s PSFS, dated 12/3/24, the PSFS indicated Benzocaine spray was administered (no time noted). During a review of WebMD (online site) the articled “Benzocaine 20 % Mucosal Spray - Uses, Side Effects and More” undated, indicated “This medication has rarely caused a very serious (possibly fatal) blood disorder (methemoglobinemia). This effect is more likely if you have breathing problems, certain diseases of the blood, or if you smoke (see also Precautions section). The symptoms of this disorder may occur within minutes to a couple of hours after using this medication. Stop using this medication and get medical help right away if you develop any symptoms of methemoglobinemia, including: pale/bluish/gray skin, unusual tiredness, shortness of breath...” During a review of the peer reviewed journal Gastrointestinal Endoscopy, dated 1/28/14, the article titled “Guidelines for Safety in the Gastrointestinal Endoscopy Unit” the article indicated, “Minimal monitoring requirements include electronic assessment of blood pressure, respiratory rate, heart rate, and pulse oximetry (measures percentage of oxygen in the blood) combined with visual monitoring of the patient’s level of consciousness and discomfort. During a review of the peer reviewed journal Gastroenterology, Volume 143, issue 1, dated 7/2012, the article titled “Multisociety Sedation Curriculum for Gastrointestinal Endoscopy” the article indicated “As a basic component of monitoring, pulse oximetry has become a standard of care in endoscopy units around the world. Yet, pulse oximetry may not adequately reflect hypoventilation [low air exchange], apnea [stop breathing], impending hemodynamic instability [abnormal or unstable blood pressure], or vasoconstrictive shock [insufficient oxygen-carrying blood to tissues] ...The most common serious and life-threatening complications related to sedation are respiratory in etiology [cause]. Of these, the most serious is aspiration because its consequences may be impossible to correct or prevent once substantial aspiration has occurred. Even minor episodes of aspiration may result in prolonged coughing, bronchospasm [tightening and narrowing of airways], or pulmonary [lung] infections. Thus, avoidance of pulmonary aspiration is critical for safe endoscopic practice ... Cardiovascular complications are less commonly life-threatening during endoscopy, and, when life threatening, they most often follow a period of inadequate ventilation [air exchange] and hypoxemia [low oxygen] ... It is the responsibility of the nurse to monitor the patient’s vital signs, comfort, and clinical status. In addition, an individual other than the physician performing the endoscopy, such as a nurse, needs to possess the skills necessary to recognize and intervene in the event that adverse events occur during the endoscopic procedure... The combination of observation and electronic monitoring provides a thorough method of patient assessment ... It is important to monitor the level of consciousness of the patient ...” During a review of the hospital policy and procedure (P&P) titled “Procedural Sedation” undated, the P&P indicated “Throughout the administration of the agent(s) [sedation medication] and during the procedure...Every 5 [five] minutes throughout the procedure and for at least 15 minutes after the last dose of medication, the patient will be monitored, and the following will be documented:...e. Level of consciousness f. Response to verbal commands...During the procedure...the RN will verbally notify the physician of any signs or symptoms of adverse reaction or physiologic compromise. These include, but are not limited to...Diaphoresis [excessive sweating due to underlying health condition or a medication] f. Inability to arouse the patient g. The need to maintain the patient’s airway mechanically h. Any other untoward or unexpected patient responses...” 4. During an interview on 12/17/24 at 11 a.m., with MD 2, MD 2 stated there was no medical need to apply lube to patient buttocks during a colonoscopy. During an interview on 12/17/24 at 3:20 p.m. with RN 2, RN 2 stated the colonoscopy procedure with MD 1 was different than with other doctors. RN 2 stated they felt uncomfortable with MD 1’s colonoscopy techniques. RN 2 stated MD 1 squirts the lube on the patient’s buttocks and then used that lube to apply the lube to the scope. RN 2 stated MD 1 does apply the lube on a 4x4, and then onto the scope, like other doctors. During an interview on 12/17/24 at 4 p.m. with MD 3, MD 3 stated doctors need to be respectful of the sedated patient’s body during procedures. During an interview on 12/19/24, 9:31 a.m. with RN 4, RN 4 stated they had sedated for MD 1 and had observed MD 1’s concerning behaviors for a few years. RN 4 stated MD 1 squirted the lube onto the patient’s buttocks and then lubed the scope with the lube from the buttocks. RN 4 stated “It [squirting lube onto the patient’s buttock and allowing the lube to run down the patient’s buttocks] is a violation of patient privacy.” During an interview on 12/19/24 at 11:13 am with ET 2, ET 2 stated they had many years’ experiences in endoscopy. ET 2 stated MD 1 put the lube on the patient’s buttocks - the entire 2-ounce tube, then used the lube from the buttocks for his finger for the digital rectal exam (check for tumors, polyps, or other abnormalities at the anal opening) and finally the lube on the patient’s buttocks was used to lube the scope. ET 2 stated they had never seen this done; most MDs only use a small amount of lube. 5. During an interview on 12/17/24 at 11 a.m., with MD 2, MD 2 stated during a colonoscopy, there was no reason to quickly push and pull the scope in and out of the rectum multiple times During an interview on 12/17/24, at 12:50 p.m., with RN 3, RN 3 stated they felt like sexual abuse occurred during colonoscopies. RN 3 stated, MD 1’s colonoscopy technique made them very uncomfortable, and they wanted to run away. RN3 stated they felt like patients needed a hug because MD 1 was taking advantage of them. RN 3 stated, they were very uncomfortable when MD 1 would rapidly push in and pull out the scope in the patient’s colon. RN 3 stated they had not seen other doctors use this technique. RN 3 stated during orientation, their preceptor told them this was “just his [MD 1] style.” During an interview on 12/17/24 at 1:41 p.m. with RN 7, RN 7 stated during colonoscopies, staff noticed MD 1 had a fast repetitive in and out technique on all patients during their colonoscopy. RN 7 stated, MD 1 had the surgical table at hip level making the action seem very sexual. RN 7 stated, no other doctor does the fast in and out; other doctors only withdraw and then go back in but not like MD 1. RN 7 stated they would not like an exam like this done on them. During an interview on 12/17/24 at 2:47 p.m., with ET 4, ET 4 stated “Feels personally uncomfortable” with MD 1. ET 4 stated MD 1 was “Humping” the bed. ET 4 stated MD 1’s technique with the scope, the fast in and out action at the beginning of the colonoscopy procedure, made them feel uncomfortable. ET 4 stated, “has worked with many other GI [gastrointestinal, digestive disease] doctors and no other doctor does that.” ET 4 stated “had worked in other facilities and had never seen similar techniques.” ET 4 stated has worked as an ET for a few years. During an interview on 12/17/24 at 3:20 p.m. with RN 2, RN 2 stated the procedure with MD 1 was different, RN 2 stated they felt uncomfortable. MD 1 puts lube on patient’s buttocks and then applies that lube to the scope. MD 1 does not use lube on a 4x4 gauze like other doctors. RN 2 stated most doctors go slowly through the colon, but MD 1 goes fast in and out with about nine to twelve inches of the scope. RN 2 stated while watching the video screen during this pushing and pulling action, it did not appear MD 1 was able to advance the scope. RN 2 stated MD 1’s colonoscopy techniques were nasty, inappropriate, gross, and violated the patient’s rights. RN 2 stated MD 1 was taking advantage of the female patients. During an interview on 12/17/24 at 4 p.m. with MD 3, MD 3 stated the hospital follows the American Society for Gastrointestinal Endoscopy (ASGE) standards. MD 3 stated going in and out quickly would be an indication of improper training. MD 3 stated, the physician should not be ramming the scope in through the (anus) small orifice (opening). That action could damage the sphincter (muscle to close opening). MD 3 stated This fast scope action was not good practice and should be stopped. The fast in and out action does not allow the scope to advance. MD 3 stated physicians must be respectful to the other person’s body. Physicians should have compassion, and respect. During an interview on 12/19/24, 9:31 a.m. with RN 4, RN 4 stated during the past two years, they had sedated for MD 1 and has observed concerning behaviors during colonoscopy procedures. RN 4 stated they had been aware of MD 1’s behaviors since they started working in endoscopy. RN 4 stated they spoke to the former charge nurse (FCRN) and was told that was just MD 1’s style. RN 4 stated, MD 1 would get frustrated when he was not able to advance the scope during a colonoscopy and pushed and pulled the scope in and out fast. RN 4 stated they were concerned MD 1 would perforate (put a hole through) the patient’s colon. RN 4 stated “it is a violation of patient privacy.” RN 4 stated they were very uncomfortable with MD 1’s techniques and behaviors. RN 4 stated, “would not like to be a patient on the table and treated like that.” RN 4 stated they dread going into MD 1’s surgeries and have to witness MD 1’s behaviors. RN 4 stated, MD 1’s techniques may be harmful. “It is just not right. It is a violation of patient privacy, a sexual violation, like when lubricating the scope in the patient anus.” Other doctors lube the scope, and then enter the patient’s anus. RN 4 stated it was uncomfortable to be around MD 1 and work in Operating Room (OR) with MD 1. During an interview on 12/19/24 at 11:13 am with ET 2, ET 2 stated they had many years’ experiences in endoscopy. ET 2 stated they had not seen MD 1’s particular techniques used by other doctors. ET 2 stated they stood next to MD 1 during the procedures. ET 2 stated usually the doctors want the table at waist high. MD 1 wants the table at the lowest position, about hip level. ET 2 stated they observed MD 1’s back and forth hip action with every patient having a colonoscopy that day (12/3/24). ET 2 stated MD 1 had a weird thrust - bump the gurney while putting scope in and out. ET 2 stated they told the nurses it was wrong. ET 2 stated they perceived it as a sexual action. ET 2 stated the colon could be perforated with the fast scope movement and scraping the wall of the colon with the scope. During an interview on 12/19/24 at 3:57 p.m. with MD 1, MD 1 stated he puts the lube on the patient’s right buttock and the lube dripped onto scope as the scope advanced. MD 1 stated he picks up jelly (lube) with his fingers and does the digital rectal exam. MD 1 stated he did not consider placing the lube on the patient’s buttocks disrespectful. During a review of the American College of Surgeons Statements on Principles, dated 4/12/16, the Statements on Principles indicated, “The ethical practice of medicine establishes and ensures an environment in which patients, staff, colleagues, students, residents, and all other individuals are treated with respect...” During a review of the hospital’s Patient Bill of Rights, undated, the Bill of Rights indicated, “13. Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse.” During a review of the facility “Code of Conduct” dated 12/5/23, the Code of Conduct indicated “[hospital] maintains an ongoing, proactive patient safety program for the identification of risk to patient safety...” During a review of the American Society for Gastroenterologists (ASGE) peer reviewed magazine GIE, Volume 98, Issue, dated October 2023 the article titled, American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations indicated “This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopies...This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework...Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI.” The article graphic showed the patient’s rectum at the physician’s waist height.” 6. During a concurrent interview and record review n 12/18/24 at 11:17 a.m. with Senior Data Analyst (SDA) Patient 11, Patient 12, Patient 13, Patient 14, Patient 17, and Patient 20’s Operation report (OpReport), dated 12/3/24 were reviewed. Patient 11’s OpReport indicated Patient 11 was a 65-year-old female and this was Patient 11’s first colonoscopy. The OpReport indicated the quality of the bowel preparation (clearing of feces in the large intestine) was adequate. The OpReport indicated no specimens were taken (no evidence of suspicious growths or cancer). The OpReport indicated “Recommendation Repeat colonoscopy in 5 years for surveillance.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk ...” SDA stated Patient 11’s OpReport indicated this was the patients first colonoscopy and MD 1 advised a repeat colonoscopy in 5 years. No specimens collected. Patient 12’s OpReport indicated Patient 12 was a 66-year-old female. The OpReport indicated the quality of the bowel preparation was excellent. The OpReport indicated no specimens were taken. The OpReport indicated “Recommendation Repeat colonoscopy in 5 years for screening purposes.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk ...” SDA stated Patient 11’s OpReport indicated this was the patients first colonoscopy and MD 1 advised a repeat colonoscopy in 5 years. No specimens collected. Patient 13’s Op Report dated 12/3/24, indicated Patient 13 was a 47-year-old female. The OpReport indicated the quality of the bowel preparation was excellent. The OpReport indicated no specimens were taken. The OpReport indicated “Recommendation Repeat colonoscopy in 5 weeks for screening purposes.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk.” SDA stated Patient 13’s OpReport indicated this was the patient’s first colonoscopy, repeat colonoscopy in 5 weeks No specimens collected. SDA stated, that (time frame) is a little sooner (than other repeat colonoscopies). Patient 14’s OpReport, dated 12/3/24, indicated Patient 14 was a 59-year-old female. The OpReport indicated the quality of the bowel preparation was excellent. The OpReport indicated no specimens were taken. The OpReport indicated “Recommendation Repeat colonoscopy in 5 years for screening purposes.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk ...” SDA stated Patient 14’s OpReport indicated this was the patients first colonoscopy and MD 1 advised a repeat colonoscopy in 5 years. No specimens collected. During a record review of Patient 17’s OpReport, dated 12/3/24, the OpReport indicated Patient 17 was a 57-year-old female. The OpReport indicated the quality of the bowel preparation was excellent. The OpReport indicated no specimens were taken. The OpReport indicated “Recommendation Repeat colonoscopy in 5 weeks for screening purposes.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk ...” SDA stated Patient 17’s OpReport indicated this was the patient’s first colonoscopy, repeat colon in 5 weeks No specimens collected. During a record review of Patient 20’s OpReport, dated 12/3/24, the OpReport indicated Patient 20 was a 70-year-old female. The OpReport indicated the quality of the bowel preparation was excellent. The OpReport indicated no specimens were taken. The OpReport indicated “Recommendation Repeat colonoscopy in 5 years for surveillance.” The OpReport indicated “Procedure Code(s): G0121 Colorectal cancer screening: colonoscopy on individual not meeting criteria for high risk.” During an interview on 12/19/24 at 3:57 p.m. with MD 1, MD 1 stated the two patients with a recommendation for a repeat colonoscopy was at five weeks was a mistake. MD 1 stated, these six patients had diabetes and therefore were at a higher risk for colon cancer than nondiabetic patients. During a review of the ASGE document titled “Colorectal Cancer Screening” undated, indicated “Are You at Average-Risk People 45 and older*: Without prior colorectal cancer or polyps; Without any of the factors that define high-risk screening *Per recommendations from the United States Multi-Society Task Force on Colorectal Cancer and United States Preventive Services Task Force...Are You at High-risk? Family history of colorectal cancer or precancerous polyps in a first degree relative diagnosed before age 60, Multiple first-degree relatives with colorectal cancer or precancerous polyps, Family history of inherited colorectal cancer syndrome, Previous diagnosis of ulcerative colitis or Crohn’s disease.” The document did not indicate people with diabetes as a High-Risk Factor or people with diabetes should be screened more frequently for colon cancer. During a review of the Centers for Disease Control and Prevention (CDC, national health agency) document titled “Screening for Colorectal Cancer” dated 10/17/24, the document indicated for people who do not have an increased risk of colorectal cancer a colonoscopy should occur every 10 years. The document did not indicate people with diabetes as a High-Risk Factor or people with diabetes should be screened more frequently for colon cancer. During a review of the U.S. (United States) Preventive Services Task Force (USPSTF, authorized by the U.S. Congress for the Agency for Healthcare Research and Quality (AHRQ) to convene the task force comprised of independent, volunteer panel of national experts in prevention and evidenced-based medicine to make evidence-based recommendations) document titled Colorectal Cancer: Screening” dated 5/18/21, the document indicated “Colonoscopy screening every 10 years.” USPSTF document did not indicate people with diabetes were a high risk for colon cancer nor people with diabetes should have a colon cancer screening more frequently. The USPSTF document indicated “Overall findings indicated increasing risk of bleeding and perforation with increasing age. Bowel preparation for colonoscopy...may lead to dehydration or electrolyte imbalances, particularly in older adults...” During a review of the U.S. Multi-Society Task Force on Colorectal Cancer (MSTF) article titled “Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer” dated 6/6/17, the article did not indicate people with diabetes were a high risk for colon cancer or should be screened more frequently for colon cancer. During a review of the National Cancer Institute (official U.S. government website) document titled Colorectal Cancer, dated 10/29/24, the document indicated “Experts recommend screening colonoscopy every 10 years for people at average risk.” During a review of the American Cancer Society document titled “Colorectal Cancer Early Detection, Diagnosis, and Staging” dated 1/29/24, the document indicated “Regular screening can even prevent colorectal cancer. A polyp can take as many as 10 to 15 years to develop into cancer... American Cancer Society Guideline for Colorectal Cancer Screening The American Cancer Society has developed colorectal cancer screening guidelines for people at average risk as well people at high risk for colorectal cancer...For people at average risk...Visual (structural) exams of the colon and rectum Colonoscopy every 10 years...For screening, people are considered to be at average risk if they do not have: A personal history of colorectal cancer or certain types of polyps, A family history of colorectal cancer, A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC), A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer.” The American Cancer Society document did not indicate people with diabetes as a High-Risk Factor or people with diabetes should be screened more frequently for colon cancer.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36543 Based on interview and record review, the hospital failed to ensure one of one sampled operating room [OR] manager (Former Operating Room Manager - FORM) followed the hospital’s policy and procedure titled “Code of Conduct when complaints of potential sexual abuse were reported to the Compliance Officer (CO). This failure resulted in the continued sexual abuse/violation of sedated patients and sexual harassment of operating room (OR) personnel by MD 1. During an interview on 12/17/24 at 12:50 p.m. with RN 3, RN 3 stated staff had reported Medical Staff (MD) 1’s actions in the past to the FORM. RN 3 stated they had reported incidents to the Charge RN and was informed the complaint had gone up the chain of command. RN 3 stated they were not aware of the outcome, but there was no change of MD 1 behaviors. During an interview on 12/17/24 at 1:41 p.m. with RN 7, RN 7 stated in early 2024, they had reported incidents regarding MD 1’s behavior during procedures to the Charge RN and FORM. During an interview on 12/19/24, at 9:31 a.m. with RN 4, RN 4 stated MD 1’s behavior and treatment of patients in the procedure room made staff feel uncomfortable. RN 4 stated they had spoken to the Charge RN and FORM regarding observations of concerning behaviors by MD 1 during procedures but was told “that was MD 1’s style.” During an interview on 12/19/24 at 11:46 a.m. with ET 3, ET 3 stated the Charge RN and FORM were aware of staff concerns and they had verbally reported concerns to both Charge RN and FORM. During an interview on 12/19/24 at 2:17 p.m. with FORM, FORM stated Staff complained about having to work with MD 1. FORM stated many of the staff had expressed concerns about MD 1’s behaviors. FORM stated MD 1’s behaviors the staff complained about were “just MD 1’s style.” During an interview on 12/20/24 at 9:03 a.m., with Compliance Officer (CO), CO stated during investigation interviews with approximately 11 OR staff, the OR staff stated they felt weird, uncomfortable, grossed out and just eww (disgusting) when working with MD 1. CO stated some OR staff felt MD 1 had a sexual aspect to his technique. CO stated staff informed her of their concerns that were reported to the FORM, but FORM said that it was just MD 1’s technique. CO stated the staffs’ concerns did not go anywhere. CO stated when she interviewed FORM regarding the issues with MD 1, FORM said that was her assessment was based on her experience with MD 1. COS stated mandated reporters need to report allegations at the time of the alleged incident. COS stated FORM should have reported the incident up the chain of command right then and not made her own assessment and to not report. During a review of the hospital’s “Code of Conduct,” dated 12/5/23, the Code of Conduct indicated, “Policy: It is the responsibility of every [hospital] staff member...Medical Staff member and Board member to act in a manner that is consistent with [hospital’s] policies and procedures, Values and this Code of Conduct...Duty to report: There may come a time when you are made aware of a known or suspected violation of law, the Code of Conduct, or a [hospital] policy. If you become aware of any questionable activities made by staff...that appear to violate applicable laws, rules, regulations, conditions of participation, policy, or this Code of Conduct, you have a duty to report the incident. Failure to report a violation is a serious violation in itself and may result in disciplinary action. You can report incidents via: Your Supervisor The Compliance Privacy Officer...Internal Investigations: Violation of the Code of Conduct, failure to comply with applicable federal or state laws, and other types of misconduct threaten {hospital’s] status as a reliable and honest provider...prompt steps to investigate the conduct in question will be initiated ...Retaliation: All levels of leadership have a responsibility to create an atmosphere that facilitates open and honest discussion around issues that may negatively impact the organization.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47444 Based on interview and record review, the hospital failed to ensure the type of restraint ordered for one of three sampled patients (Patient 6) met the patient’s individual behavioral needs. This failure resulted in Patient 6 to not be assessed and monitored based on his behavior needs which had the potential for patient harm. Findings: During a review of Patient 6’s “Emergency Department Note (EDN),” dated 11/3/24, the EDN indicated Patient 6 was brought to the ED for erratic behavior. The EDN indicated Patient 6 had a history of schizophrenia (mental illness that affects a person’s thoughts, feelings, and behaviors) and bipolar (mental illness that causes severe mood swings) disorder. During a review of Patient 6’s “View Order Details (VOD),” dated 11/3/24 at 11:24 p.m., the VOD indicated, “4 HR [four hour] Behavioral Restraints [physical or mechanical device used to restrict a person’s movement, to manage violent or aggressive behavior, limiting their ability to move freely to control potentially harmful actions] Q [every] 15M [minutes]. . . Clinical Justification for Behavioral Restraints: Highly Agitated, Physically Assaultive. . . 4 Point [wrist and ankles] Soft Restraint (a padded device placed on the wrist or ankle to limit patients movement), Bilateral [both sides].” During a review of Patient 6’s “Care Assessments 4 HR Behavioral Restraint (CABR),” dated 11/3/24 through 11/4/24, the CABR indicated Patient 6 was assessed for circulation and signs of injury every 15 minutes. The CABR indicated assessment was done on 11/3/24 at 11:25 p.m., 11:39 p.m., 11:54 p.m., and 11/4/24 at 12:09 a.m., 12:15 a.m., 12:30 a.m., 12:45 a.m., 1 a.m., and 1:15 a.m. During a review of Patient 6’s “VOD,” dated 11/4/24 at 1:26 a.m., the VOD indicated, “24 HR Medical Restraints [restricts ability to remove medical devices] Q [every] 2 HR. . . Clinical Justification for Medical Restraints [Restricts movement to assist with the provision of medical or surgical care]: Unable to Comply Safe/Ins [instructions].” During a review of Patient 6’s “Care Assessments 24 HR Medical Restraint (CAMR),” dated 11/4/24, the CAMR indicated Patient 6 was assessed for circulation and signs of injury on 11/4/24 at 1:29 a.m., 2 a.m., 4 a.m., 5:58 a.m., and 6:58 a.m. (instead of every 15 minutes required for behavioral restraints). During a concurrent interview and record review on 12/20/24 at 3:30 p.m. with Emergency Department Manager (EDM), Patient 6’s “VOD,” dated 11/4/24 at 1:26 a.m. was reviewed. The VOD indicated, “24 HR Medical Restraints. EDM stated Patient 6 should have remained on behavioral restraints due to Patient 6’s violent behavior, aggressiveness toward self and others, hitting, kicking, threatening, combativeness and non-compliance. EDM stated Patient 6’s behavior required more frequent monitoring and assessments. EDM stated the documentation showed Patient 6 was assessed every two hours (medical restraint criteria) but due to his behaviors, behavioral restraints should have continued. EDM stated Patient 6 should have been assessed every 15 minutes for circulation (blood flow to the hands and feet) in the restrained extremities and monitored more frequently than every two hours to ensure the patient was safe and circulation was not compromised. During an interview on 12/20/24 at 4:07 p.m. with RN 10, RN 10 stated violent patient in behavioral restraints needed to be assessed every 15 minutes for circulation in extremities, skin condition, respirations, hydration, ensure the patients safety, and reassess the behavior. RN 10 stated a physician should not order medical restraints for patients with behaviors as the patient needed to be monitored more frequently and kept safe. RN 10 stated the physician should not have ordered medical restraints for Patient 6 due to his aggressive behaviors toward staff and himself. The type of behavior exhibited by Patient 6 required more frequent monitoring and assessments. During a review of the hospital’s policy and procedure (P&P) titled, “Restraint Use - Medical/Surgical and Behavioral Restraint,” (undated), the P&P indicated, “Medical/Surgical restraint means restricting a patient’s movement to assist with the provision of medical or surgical care...10. Patient Monitoring Monitor restrained patients as often as necessary to ensure safety and dignity and to attend to comfort needs. Patients will be observed at least every two (2) hours to ensure that restraint remains necessary, that restraining devices remain safely applied, and that the patient remains as comfortable as possible. Patients will be observed at least every two (2) hours to ensure that restraint remains necessary... Such monitoring will be documented every 2 hours...Behavior Restraint is the restriction of patient movement in response to severely aggressive, destructive, violent, or suicidal behaviors that place the patient or others in imminent danger. . . 9. Patient Monitoring Patient will be placed in ICU where staff will continuously observe patient in behavioral restraint. Such monitoring will be documented at least every 15 minutes.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 36543 Based on interview and record review the facility failed to ensure all physicians and other licensed independent practitioner (LIP) training on restraint (devices or methods used to limit a patient’s movement or access to their body) application and the implementation of seclusion was documented. This failure had the potential to affect any patient who required the use of restraints or seclusion in a universe of 76 in-patients and all emergency department patients. Findings: During a review of the hospital Policy and Procedure (P&P) titled “Restrain Use - Medical/Surgical and Behavioral Restraint” undated, the P&P indicated “Staff Education: 1. During the initial orientation period, all levels of staff who have direct patient care responsibilities are oriented to this policy and procedure and trained in the proper and safe application and use of restraints...3. During a concurrent interview and record review on 12/20/24 at 2:25 p.m. with Medical Staff Coordinator (MSC), the State Operations Manual Appendix A Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals (federal regulations for general acute care hospitals), dated 7/21/23, regulation A0176 was reviewed. MSC stated she was not aware if Medical Staff provided restraint training. MSC stated all physicians are required to follow all facility P&Ps. MSC stated she did not track if MDs take required training such as restraints. During a concurrent interview and record review on 12/20/24 at 3:30 p.m. with Emergency Department Manager (EDM), Patient 6’s medical record (MR), dated 11/3/24 through 11/4/24, was reviewed. The MR indicated a Registered Nurse (RN) received a verbal order from a physician for use of medical restraints. EDM stated based on the reason for use of restraints (Patient 6’s violent behavior) the physician order should have been for behavioral restraints. EDM stated the restraints are being used for behavior and the patient needs to be assessed for circulation (blood flow to the hands and feet) in the extremities and ensure the patient is safe. During an interview on 12/20/24 at 4:07 p.m. with Registered Nurse (RN) 10, RN 10 stated use of behavioral restraints for violent patient needed to be assessed every 15 minutes for circulation in extremities, skin condition, respirations, hydration, ensure the patients safety, and reassess the behavior. RN 10 stated a physician should not order medical restraints for patients with behaviors as the patient needed to be monitored more frequently and kept safe. During a review of the hospital’s policy and procedure (P&P) titled, “Restraint Use - Medical/Surgical and Behavioral Restraint,” (undated), the P&P indicated, “Medical/Surgical restraint means restricting a patient’s movement to assist with the provision of medical or surgical care...10. Patient Monitoring Monitor restrained patients as often as necessary to ensure safety and dignity and to attend to comfort needs. Patients will be observed at least every two (2) hours to ensure that restraint remains necessary, that restraining devices remain safely applied, and that the patient remains as comfortable as possible. Patients will be observed at least every two (2) hours to ensure that restraint remains necessary... Such monitoring will be documented every 2 hours... Behavior Restraint is the restriction of patient movement in response to severely aggressive, destructive, violent, or suicidal behaviors that place the patient or others in imminent danger. . . 9. Patient Monitoring Patient will be placed in ICU where staff will continuously observe patient in behavioral restraint. Such monitoring will be documented at least every 15 minutes.””

“MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(2) [The bylaws must:] (2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) This Standard is not met as evidenced by: 47444 Based on interview and record review, medical staff failed to ensure one of two sampled physicians (MD 1), specializing in General Surgery had complete and clearly defined privileges (authorization by the hospital to perform specific surgical procedures) prior to performing surgical procedure. This failure had the potential for adverse surgical outcomes, surgical complications, and death. Findings: During a concurrent interview and record review on 12/18/24 at 9:50 a.m. with Medical Staff Coordinator (MSC) Medical Doctor (MD) 1’s “Delineation of Privileges (DOP- a process where a medical staff evaluates and recommends which specific patient care services a practitioner can provide within an institution),” dated 12/16/24 was reviewed. The DOP indicated MD 1 had privileges for Transoral Esophagogastric Fundoplication (TIF - a minimally invasive [no incisions] procedure to treat gastroesophageal reflux disease [GERD - a digestive disorder that occurs when stomach contents flow back into the esophagus]). The DOP did not indicate privileges for Laparoscopic Nissen Fundoplication (LNF - a surgical procedure [requiring incisions] to treat GERD). The DOP indicated a list of “core privileges” for Laparoscopy (a surgery with small incisions into the abdomen) which did not include LNF. MSC stated she thought the TIF and LNF were the same procedure. MSC stated the list of privileges for MD 1 did not include LNF. During a record review on 12/18/24 at 3:13 p.m. MD 1’s “Privilege Delineation Form General Surgery (PDF),” dated 3/14/24 was reviewed. The PDF indicated MD 1 requested and was granted privileges for TIF. The PDF did not indicate MD 1 requested or was granted privileges for LNF. 36543 During an interview on 12/18/24 at 3:52 p.m., with the Chief of Surgery (MD 5), MD 5 stated, there are different types of hernias so a physician may be competent in one type of hernia repair but not necessarily another type of hernia repair. MD 5 stated, the Medical staff needs to revisit core privilege list to update should be specific. During an interview on 12/18/24 at 4:10 p.m., with MD 5, MD 5 stated the Medical Staff should have separate privileges to indicate what type of hernia repair, not just hernia. During a review of Medical Staff Bylaws, dated 5/24/22, the Bylaws indicated, “Article V Clinical Privileges 5.1 Exercise of Privileges Except as otherwise provided in these bylaws, a member providing clinical services at this hospital shall be entitled to exercise only those clinical privileges specifically granted. Said privileges and services must be hospital specific, within.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 42344 Based on interview and record review, the hospital failed to ensure four of four sampled patients’ (Patient 11, Patient 12, Patient 13, and Patient 1) information regarding status of patient stabilization, reason for transfer, and /or risks and benefits were accurately documented prior to transfer from the hospital’s Emergency Department (ED) or Labor and Delivery Unit to other hospitals. This failure had the potential for patients or their representatives to not have sufficient information to make informed decisions prior to consenting to being transferred to other hospitals. Findings: During a review of Patient 11’s medical record, the “Emergency Room Note” (ERN) dated 9/2/23 indicated Patient 11 was a five year old male, with a history of asthma (chronic lung disease which can cause coughing, wheezing, shortness of breath and chest tightness), arrived at the hospital’s ED on 9/2/23 at 12:44 p.m. with his father, with complaints of “dyspnea [difficulty breathing]” and “cough” for “4 days.” The ERN indicated Patient 11 developed an “increased respiratory rate” and would be admitted and transferred to a children’s hospital for a higher level of care. During a concurrent interview and record review on 12/4/23 at 1:50 p.m. with Director of IT/Informatics (DII), Patient 11’s “Physician Transfer Certification (PTC),” dated 9/2/23 at 10:31 p.m. was reviewed. The PTC indicated, Physician 1 did not check “yes” or “no” to certify if Patient 11 was “Stabilized for Transfer.” Physician 1 did not complete the “Summary of Specific Medical Reason for Transfer” and did not indicate which “Risks” and “Benefits” applied to Patient 11’s transfer to another hospital. DII stated the “Physician Transfer Certification” was not completed. During a review of Patient 12’s medical record, the ERN dated 9/4/23 at 1:28 a.m. indicated Patient 12 was brought to the hospital’s ED via ambulance with complaints of “difficulty breathing.” The “[Hospital] Imaging Report Signed” dated 9/4/23 indicated Patient 12 had a computerized tomography (CT) scan (combines series of X-ray images taken from different angles of the body to provide more-detailed information than a conventional X-ray) of the chest, abdomen, and pelvis. The CT scan results indicated Patient 12 had biliary tract obstruction (system which stores and transfer bile from the liver, pancreas, and gallbladder) and narrowing of arteries in the digestive tract. The ERN dated 9/4/23 at 2:50 p.m. indicated Patient 12 was going to be transferred to another hospital to undergo an Endoscopic retrograde cholangiopancreatography (ERCP- procedure used to identify the presence of stones, tumors, or narrowing in the biliary and pancreatic ducts). During a concurrent interview and record review on 12/4/23 at 1:53 p.m. with DII, Patient 12’s “PTC,” dated 9/4/23 at 5:30 p.m. was reviewed. The PTC indicated, Physician 2 did not specify which “Risks” and “Benefits” applied to Patient 12’s transfer to another hospital. DII stated no boxes were checked and the form (PTC) was not completed properly. During a review of Patient 13’s medical record, the “[Hospital] Imaging Report Signed (IRS),” dated 9/4/23 at 10:08 PM, indicated Patient 13 had a “Gunshot injury with comminuted [bone is broken into more than two pieces] fracture of the right hip at the level of the lesser trochanter [upper part of leg bone where muscle attached to the bone], suspicious for fracture extending through the right femoral neck [area connecting long shaft of leg bone to head of leg bone].” The ERN dated 9/4/23 indicated Patient 13 sustained a gunshot wound to his right hip which resulted in a fractured (broken) pelvis and would be admitted and transferred to another hospital for a higher level of care. During a concurrent interview and record review on 12/4/23 at 2:01 p.m. with DII, Patient 13’s “PTC,” dated 9/4/23 at 11 p.m. was reviewed. The PTC indicated, Physician 3 did not specify which “Risks” and “Benefits” applied to Patient 12’s transfer to another hospital. DII stated the form (PTC) was not completed properly. During a review of Patient 1’s medical record, the “History and Physical Report” (H&P) dated 11/5/23 indicated Patient 1 was 34 weeks pregnant (40 weeks is full term, less than 37 weeks is premature), leaking amniotic fluid (water which surrounds fetus in the womb), and the fetus had gastroschisis (birth defect where a hole in the abdominal wall allows the baby’s intestines to extend outside of the baby’s body). The “OB Assessment & Plan” section of the H&P indicated, “Admit to labor & delivery” and transfer to another hospital. The “Details Notes Log” dated 11/5/23 at 8:50 p.m. indicated Patient 1 was “Transfer/Discharge: To Other Facility- Per stretcher/Cart- Per Ambulance- Per Helicopter.” During a concurrent interview and record review on 12/4/23 at 4:15 p.m. with Informatics Nurse (IN), Patient 1’s “PTC,” dated 11/5/23 at 7:20 p.m. was reviewed. The PTC indicated Physician 4 did not complete the “Summary of Specific Medical Reason for Transfer” and did not indicate which “Risks” and “Benefits” applied to Patient 1’s transfer to another hospital. IN stated the “PTC” form was incomplete. During a review of the hospital’s policy and procedure (P&P) titled “EMTALA - Interfacility transfers, MSE, Emergency Care and Stabilization” undated, the P&P indicated, “Procedure: Interfacility Transfer Procedure (EMTALA Patient) . . . B. Form # 009462 ‘Physician Transfer Certification” will be completed. A. Document if the individual is stabilized for transfer; b. Specify the medical reason for transfer (ex: specialty services not available at [hospital]) c. Document the risks and benefits of transfer and explain them to the individual or their representative in layman’s terms.””