El Camino Health

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46939 Based on interview and record review, Facility A failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: 1. Facility A transferred Patient 1 on 4/28/25 to Facility B, without exhausting all of its capabilities to resolve Patient 1’s EMC of having a Foreign Body (FB-an object inside the body that is not normally seen in the body) before transferring. This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1’s emergent medical condition, and had the potential to negatively affect Patient 1’s health in delaying treatment. Findings: 1. During a review of Patient 1’s “ED Provider Note” dated 4/27/25, by Medical Doctor (MD) A, at 11:20 pm, note indicated, “Chief Complaint Patient presents with Abdominal Pain General abd [abdominal] pain and rectal pain after eating breakfast this AM. + nausea [with nausea]. . .Describes abdominal pain as intermittent [comes and goes], cramping sensation, 10/10 intensity, with associated nausea. Reports diaphoresis [excessive sweating], chills, and rectal pain causing difficulty sitting. . .CT [computed tomography a type a scan using x-rays to create cross section of internal body structures] abdomen and pelvis with IV contrast performed, reported by Radiology, showing 1.9cm linear radio-opaque [object that is seen on x-ray imaging] density [measure of how dark an object appears on scan] Regional [in location to] the anus [The opening of the rectum to the outside of the body] correlation for foreign body. . .I attempted to perform anoscopy [procedure used to examine the anus. It involves the insertion of a short, hollow, lighted tube called an anoscope to visualize the area] . . .but patient was not tolerable to this exam. . .I consulted the on-call general surgeon, [MD B]”. During a review of Patient 1’s “CT Abdomen and Pelvis” dated 4/28/25, exam indicated, “Findings: Bowel: 1.9cm linear radiodensity regional to the anus”. During an interview on 7/7/25, at 2:32 p.m., with MD A, MD A stated, he was the emergency department provider for Patient 1 on 4/27/25. MD A stated, he attempted to perform the anoscopy to see the foreign body in Patient 1, but Patient 1 was unable to tolerate the procedure. MD A stated, he then consulted the general surgeon who had just left the hospital and came back to see Patient 1. MD A stated, MD B told him to transfer the patient to Facility B. MD A stated, he can do an anoscopy exam under procedural sedation [technique used to help patients relax during medical procedures. It involves administering medication that can range from minimal to deep sedation, reducing pain, and anxiety] but deferred to MD B’s decision. During a review of Patient 1’s “General Surgery Consult Note”, dated 4/29/25, by MD B, at 2:40 am, note indicated, “I d/w [discussed with] her in presence of her nurse [Nurse C]. . .[MD A] tried to do an endoscope [anoscopy] and it was unsuccessful too. . .I would suggest to perform vaginal exam and also consult to check her vagina. If there is no FB at her vagina. We can transfer to [Facility B] to have a colorectal surgeon with EUS [Endoscopic Ultrasound- a medical device that combines endoscopy and ultrasound to visualize the digestive tract and surrounding organs, aiding in diagnosis and treatment] to be able to find the FB”. During an interview on 7/7/25, at 12:51 p.m., with MD B, MD B stated, “CT showed foreign body there was a concern in would in the perianal [the area of skin surrounding the anus] to the rectum and [Patient 1] has a lot of pain, we couldn’t do any rectal exam. I told her we need some type of colorectal [refers to the colon (large intestine) and rectum] surgery and we need EUS to look the FB”. MD B stated, he has performed numerous exams under anesthesia for removal of foreign bodies in the rectum/anus. MD B stated, “We have to put the scope in. . .the EUS and take a look in the rectum, if something penetrated in the area I need an US [ultrasound] to see the area, and then figure out how to take it out. I don’t have the ability to do that”. During a review of MD B’s “Clinical Privileges” (Clinical privileges are the permissions granted to healthcare professionals to provide specific medical services within a particular healthcare facility) Dated 2024-2026 indicated, MD B was granted privileges for “General Surgery. . . Core privileges for General Surgery include the ability to admit, evaluate, diagnose, consult, and provide pre[before]-, intra-[during], and postoperative [after surgery] care and perform surgical procedures for patients of all ages to correct or treat various conditions” During a review of facility ‘s on call list dated 4/27/25-4/28/25 indicated, the on-call colorectal surgeon was MD D. During an interview on 7/8/25, at 12:00 p.m., with MD C, MD C stated, he was the on call Gastroenterology surgeon [specializes in surgical procedures of the digestive system] on 4/27/25-4/28/25. MD C stated, he was not consulted regarding any foreign body cases. MD C, his specialty is available to assist the general surgeon on cases of foreign body they may need help with. MD C stated, if a foreign body penetrated into soft tissues it would be hard to perform an endoscopy, sometimes the general surgeon will call us. MD C stated, they can sedate the patient to assist with the procedure. During an interview on 7/8/25, at 9:12 a.m., with MD D, MD D stated, he was a gastroenterology surgeon. MD D stated, the facility here does have an endoscopic ultrasound. During an interview on 7/8/25, at 9:50 a.m., with Chief of General Surgery (CGS), CGS stated, both MD A, and MD B were unable to visualize the foreign body during their anoscopy exam due to patient discomfort. CGS stated, the next steps could have been to offer procedural sedation, or do an exam under anesthesia. CGS stated, he read the CT scan and the assumption would have been that the foreign body is in the anus. CGS stated, it is in the scope of practice as a general surgeon to perform an exam under anesthesia to look for the foreign body. During an interview on 7/1/25, at 11:28 a.m., with MD E, MD E stated, he is an emergency department physician at Facility A. MD E stated, if a patient is not able to tolerate an anoscopy procedure, “you don’t want to delay care”. It could be completed in the OR [operating room]. You can do procedural sedation also. MD F stated, the next step if the patient cannot tolerate the anoscopy would be to do the procedure under sedation or in the OR. During a review of Patient 1’s “Emergency Transfer Notification” dated 4/28/25, at 0506 a.m., document indicated, “Physician Authorization 2. Reason for Transfer Need for higher level of care than provided at [Facility A]”. During a review of a recorded phone call between MD B and MD F dated 4/28/25, phone call indicated, a physician to physician phone call occurred to explain the reason for the transfer of Patient 1 from Facility A to Facility B. MD F stated, he was a general surgeon at Facility B and needed clarification of why the transfer was necessary. MD F stated, if we accepted the patient (Patient 1) “we would just put the patient under general anesthesia and take a look”. MD F stated, “the problem is I don’t have the experience for the EUS and I don’t want to something I cannot do that [sic] I never did this”. MD F stated, “an exam under anesthesia [is a medical procedure where a patient undergoes an examination while under anesthesia to allow for a more thorough and comfortable assessment] is a standard general surgery operation, I’m just trying to understand, we would not take them [Patient 1] for an ultrasound, we would just take them to the OR [operating room] and just put them under general anesthesia”. MD B stated, “The point is the foreign body is not just the anus”. MD F stated, “So we would just take the patient to the OR and look under anesthesia, this is a very standard general surgery operation, so I’m just wondering why on a recorded line why you as a general surgeon feel like you’re unable to do this operation”. MD B stated, “Yeah I told them because we did an anoscope to take a look at that and it goes through the vagina and I’m not sure from the just anoscope I don’t have anything to do that [sic] I need somebody with access if they cannot find it they can get the EUS to see where it is there. If its in the anus I can go and find that a lot of foreign body I have removed from the anus but this is not inside the of the anus this is something inside the perineal [he area of the body between the anus and the external genitalia] area and we don’t know where is that [sic] “. MD F stated, “So as a general surgeon you feel you’re not able to handle this perianal”. MD B stated, “No I can’t”, if this is inside the anus I can. . .we don’t know which part of the tissue it is”. MD F stated, “Ok, we’ll take this patient”. The recorded phone call indicated, MD B left the line, while MD F spoke with Staff Member (SM) G. MD F stated, we can find out if this is an EMTALA violation or not once the patient gets here. SM G stated, “I’ve heard some other surgeons say, I’m sorry you’re a general surgeon if you’re board certified you should be able to take care of this”. During an interview on 7/8/25 at 1p.m., with MD F, MD F stated, he was a general surgeon at Facility B. MD F stated, his facility got a request for transfer of Patient 1 so for a foreign body in the anal area. MD F stated, he requested to speak with the transferring surgeon to ask why they were not able to treat the patient. MD F stated, in his clinical opinion, as a surgeon for Patient 1’s case you would not need an endoscopic ultrasound. MD F stated, if a patient is not able to tolerate an anoscopy procedure the next step would be to perform an exam under anesthesia and any board certified general surgeon is able to perform this procedure. During a review of Patient 1’s “Operative Report” dated 4/28/25 at 4:48 p.m., Report indicated, “”Procedure: Rectal exam under anesthesia, removal of foreign body. . .findings: 2cm chicken bone approximately 3 cm from the anal verge [end of the anal canal and the point where stool exits the body]”. During an interview with Patient 1 on 7/16/25, at 106 p.m., Patient 1 stated, she went to Facility A’s Emergency Department with severe 10/10 pain in her rectum and abdomen. “To be honest it was the worst experience of my life”. Patient 1 stated, MD A attempted to look inside my behind to see, but it was too painful, so he called the surgeon (MD B). Patient 1 stated, the surgeon (MD B) could not do the procedure either because it was too painful, I’ve been through childbirth and this was worse. Patient 1 stated, MD B left the room and didn’t say anything to me after the attempt. Patient 1 stated, the ED Doctor (MD A) came back in and told her “I’m going to be honest with you he [MD B] said to send you home, but we need to take care of your emergency, if you leave you will just come back in a few hours, so I’m going to call the ambulance and have you sent to [Facility B]”. Patient 1 stated, the facility never offered to give her sedation or to perform surgery to find out what was causing her pain. Patient 1 stated, “[MD A] told me the reason I’m sending you to [Facility B] is because the surgeon doesn’t want to deal with you”. During a review of the facility’s Policy and Procedure (P&P) titled, “Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)”, dated 2025 the P&P indicated, “It is the policy of [Facility A] to comply with state and federal laws regarding EMTALA in accordance with the policy below. . .D. Patient who have an EMC 1. When a Physician or Qualified Medical Professional determines that the patient has an EMC the hospital shall: a within the capability of the staff and facilities, provide further medical examination and treatment as required to stabilize the patients EMC”.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 46939 Based on interview and record review the facility (Facility A) failed to provide necessary stabilizing treatment to one of 20 sampled patients (Patient 1) with an emergency medical condition (EMC-a health condition or situation that needs immediate medical attention) within the capabilities of the staff and facilities available when: 1. Facility A transferred Patient 1 on 4/28/25 to Facility B, without exhausting all of its capabilities to resolve Patient 1’s EMC of having a Foreign Body (FB-an object inside the body that is not normally seen in the body) before transferring. This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1’s emergent medical condition, and had the potential to negatively affect Patient 1’s health in delaying treatment. Findings: 1. During a review of Patient 1’s “ED Provider Note” dated 4/27/25, by Medical Doctor (MD) A, at 11:20 pm, note indicated, “Chief Complaint Patient presents with Abdominal Pain General abd [abdominal] pain and rectal pain after eating breakfast this AM. + nausea [with nausea]. . .Describes abdominal pain as intermittent [comes and goes], cramping sensation, 10/10 intensity, with associated nausea. Reports diaphoresis [excessive sweating], chills, and rectal pain causing difficulty sitting. . .CT [computed tomography a type a scan using x-rays to create cross section of internal body structures] abdomen and pelvis with IV contrast performed, reported by Radiology, showing 1.9cm linear radio-opaque [object that is seen on x-ray imaging] density [measure of how dark an object appears on scan] Regional [in location to] the anus [The opening of the rectum to the outside of the body] correlation for foreign body. . .I attempted to perform anoscopy [procedure used to examine the anus. It involves the insertion of a short, hollow, lighted tube called an anoscope to visualize the area] . . .but patient was not tolerable to this exam. . .I consulted the on-call general surgeon, [MD B]”. During a review of Patient 1’s “CT Abdomen and Pelvis” dated 4/28/25, exam indicated, “Findings: Bowel: 1.9cm linear radiodensity regional to the anus”. During an interview on 7/7/25, at 2:32 p.m., with MD A, MD A stated, he was the emergency department provider for Patient 1 on 4/27/25. MD A stated, he attempted to perform the anoscopy to see the foreign body in Patient 1, but Patient 1 was unable to tolerate the procedure. MD A stated, he then consulted the general surgeon who had just left the hospital and came back to see Patient 1. MD A stated, MD B told him to transfer the patient to Facility B. MD A stated, he can do an anoscopy exam under procedural sedation [technique used to help patients relax during medical procedures. It involves administering medication that can range from minimal to deep sedation, reducing pain, and anxiety] but deferred to MD B’s decision. During a review of Patient 1’s “General Surgery Consult Note”, dated 4/29/25, by MD B, at 2:40 am, note indicated, “I d/w [discussed with] her in presence of her nurse [Nurse C]. . .[MD A] tried to do an endoscope [anoscopy] and it was unsuccessful too. . .I would suggest to perform vaginal exam and also consult to check her vagina. If there is no FB at her vagina. We can transfer to [Facility B] to have a colorectal surgeon with EUS [Endoscopic Ultrasound- a medical device that combines endoscopy and ultrasound to visualize the digestive tract and surrounding organs, aiding in diagnosis and treatment] to be able to find the FB”. During an interview on 7/7/25, at 12:51 p.m., with MD B, MD B stated, “CT showed foreign body there was a concern in would in the perianal [the area of skin surrounding the anus] to the rectum and [Patient 1] has a lot of pain, we couldn’t do any rectal exam. I told her we need some type of colorectal [refers to the colon (large intestine) and rectum] surgery and we need EUS to look the FB”. MD B stated, he has performed numerous exams under anesthesia for removal of foreign bodies in the rectum/anus. MD B stated, “We have to put the scope in. . .the EUS and take a look in the rectum, if something penetrated in the area I need an US [ultrasound] to see the area, and then figure out how to take it out. I don’t have the ability to do that”. During a review of MD B’s “Clinical Privileges” (Clinical privileges are the permissions granted to healthcare professionals to provide specific medical services within a particular healthcare facility) Dated 2024-2026 indicated, MD B was granted privileges for “General Surgery. . . Core privileges for General Surgery include the ability to admit, evaluate, diagnose, consult, and provide pre[before]-, intra-[during], and postoperative [after surgery] care and perform surgical procedures for patients of all ages to correct or treat various conditions” During a review of facility ‘s on call list dated 4/27/25-4/28/25 indicated, the on-call colorectal surgeon was MD D. During an interview on 7/8/25, at 12:00 p.m., with MD C, MD C stated, he was the on call Gastroenterology surgeon [specializes in surgical procedures of the digestive system] on 4/27/25-4/28/25. MD C stated, he was not consulted regarding any foreign body cases. MD C, his specialty is available to assist the general surgeon on cases of foreign body they may need help with. MD C stated, if a foreign body penetrated into soft tissues it would be hard to perform an endoscopy, sometimes the general surgeon will call us. MD C stated, they can sedate the patient to assist with the procedure. During an interview on 7/8/25, at 9:12 a.m., with MD D, MD D stated, he was a gastroenterology surgeon. MD D stated, the facility here does have an endoscopic ultrasound. During an interview on 7/8/25, at 9:50 a.m., with Chief of General Surgery (CGS), CGS stated, both MD A, and MD B were unable to visualize the foreign body during their anoscopy exam due to patient discomfort. CGS stated, the next steps could have been to offer procedural sedation, or do an exam under anesthesia. CGS stated, he read the CT scan and the assumption would have been that the foreign body is in the anus. CGS stated, it is in the scope of practice as a general surgeon to perform an exam under anesthesia to look for the foreign body. During an interview on 7/1/25, at 11:28 a.m., with MD E, MD E stated, he is an emergency department physician at Facility A. MD E stated, if a patient is not able to tolerate an anoscopy procedure, “you don’t want to delay care”. It could be completed in the OR [operating room]. You can do procedural sedation also. MD F stated, the next step if the patient cannot tolerate the anoscopy would be to do the procedure under sedation or in the OR. During a review of Patient 1’s “Emergency Transfer Notification” dated 4/28/25, at 0506 a.m., document indicated, “Physician Authorization 2. Reason for Transfer Need for higher level of care than provided at [Facility A]”. During a review of a recorded phone call between MD B and MD F dated 4/28/25, phone call indicated, a physician to physician phone call occurred to explain the reason for the transfer of Patient 1 from Facility A to Facility B. MD F stated, he was a general surgeon at Facility B and needed clarification of why the transfer was necessary. MD F stated, if we accepted the patient (Patient 1) “we would just put the patient under general anesthesia and take a look”. MD F stated, “the problem is I don’t have the experience for the EUS and I don’t want to something I cannot do that [sic] I never did this”. MD F stated, “an exam under anesthesia [is a medical procedure where a patient undergoes an examination while under anesthesia to allow for a more thorough and comfortable assessment] is a standard general surgery operation, I’m just trying to understand, we would not take them [Patient 1] for an ultrasound, we would just take them to the OR [operating room] and just put them under general anesthesia”. MD B stated, “The point is the foreign body is not just the anus”. MD F stated, “So we would just take the patient to the OR and look under anesthesia, this is a very standard general surgery operation, so I’m just wondering why on a recorded line why you as a general surgeon feel like you’re unable to do this operation”. MD B stated, “Yeah I told them because we did an anoscope to take a look at that and it goes through the vagina and I’m not sure from the just anoscope I don’t have anything to do that [sic] I need somebody with access if they cannot find it they can get the EUS to see where it is there. If its in the anus I can go and find that a lot of foreign body I have removed from the anus but this is not inside the of the anus this is something inside the perineal [he area of the body between the anus and the external genitalia] area and we don’t know where is that [sic] “. MD F stated, “So as a general surgeon you feel you’re not able to handle this perianal”. MD B stated, “No I can’t”, if this is inside the anus I can. . .we don’t know which part of the tissue it is”. MD F stated, “Ok, we’ll take this patient”. The recorded phone call indicated, MD B left the line, while MD F spoke with Staff Member (SM) G. MD F stated, we can find out if this is an EMTALA violation or not once the patient gets here. SM G stated, “I’ve heard some other surgeons say, I’m sorry you’re a general surgeon if you’re board certified you should be able to take care of this”. During an interview on 7/8/25 at 1p.m., with MD F, MD F stated, he was a general surgeon at Facility B. MD F stated, his facility got a request for transfer of Patient 1 so for a foreign body in the anal area. MD F stated, he requested to speak with the transferring surgeon to ask why they were not able to treat the patient. MD F stated, in his clinical opinion, as a surgeon for Patient 1’s case you would not need an endoscopic ultrasound. MD F stated, if a patient is not able to tolerate an anoscopy procedure the next step would be to perform an exam under anesthesia and any board certified general surgeon is able to perform this procedure. During a review of Patient 1’s “Operative Report” dated 4/28/25 at 4:48 p.m., Report indicated, “”Procedure: Rectal exam under anesthesia, removal of foreign body. . .findings: 2cm chicken bone approximately 3 cm from the anal verge [end of the anal canal and the point where stool exits the body]”. During an interview with Patient 1 on 7/16/25, at 106 p.m., Patient 1 stated, she went to Facility A’s Emergency Department with severe 10/10 pain in her rectum and abdomen. “To be honest it was the worst experience of my life”. Patient 1 stated, MD A attempted to look inside my behind to see, but it was too painful, so he called the surgeon (MD B). Patient 1 stated, the surgeon (MD B) could not do the procedure either because it was too painful, I’ve been through childbirth and this was worse. Patient 1 stated, MD B left the room and didn’t say anything to me after the attempt. Patient 1 stated, the ED Doctor (MD A) came back in and told her “I’m going to be honest with you he [MD B] said to send you home, but we need to take care of your emergency, if you leave you will just come back in a few hours, so I’m going to call the ambulance and have you sent to [Facility B]”. Patient 1 stated, the facility never offered to give her sedation or to perform surgery to find out what was causing her pain. Patient 1 stated, “[MD A] told me the reason I’m sending you to [Facility B] is because the surgeon doesn’t want to deal with you”. During a review of the facility’s Policy and Procedure (P&P) titled, “Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)”, dated 2025 the P&P indicated, “It is the policy of [Facility A] to comply with state and federal laws regarding EMTALA in accordance with the policy below. . .D. Patient who have an EMC 1. When a Physician or Qualified Medical Professional determines that the patient has an EMC the hospital shall: a within the capability of the staff and facilities, provide further medical examination and treatment as required to stabilize the patients EMC”.”

“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: 46939 The facility failed to have an effectively functioning Governing body when: 1. Governing Body failed to ensure medical staff bylaws comply with federal regulations. (See A047) The cumulative effect of these systemic problems resulted in the hospital’s inability to provide care in a safe and effective manner in accordance with the statutory-mandated 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: 46939 The facility failed to protect and promote patients’ rights when: 1. The facility failed to provide evidence it thoroughly investigated abuse allegations from three of 30 sampled patients (Patient 4, Patient 6 & Patient 16). 2. Facility failed to remove an alleged perpetrator of abuse (Medical Doctor (MD) A) from patient care immediately per facility policy. The cumulative effect of these systemic problems resulted in the hospital’s inability to provide care in a safe and effective manner in accordance with the statutory-mandated Condition of Participation for Patient Rights.”

“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: 46939 Based on interview and record review, the facility failed to ensure nursing staff followed standards of care in Nursing Services as evidenced by: 1. Nursing staff did not implement care plan interventions for turning and repositioning Patient 11 for over 100 instances as evidenced by an absence of charting. Patient 11 developed a new pressure injury. (See A396) 2. Nursing staff did not implement care plan interventions by failing to chart multiple wound dressing changes for Patient 12’s pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin.) as ordered by the wound care nurse. (See A396). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment.”

“MEDICAL STAFF - BYLAWS CFR(s): 482.12(a)(3) [The governing body must] assure that the medical staff has bylaws. This Standard is not met as evidenced by: 46939 Based on interview and record review the facility failed to ensure the Governing Body implemented it’s medical staff bylaws regarding investigating an allegation of abuse or an act detrimental to patient safety when: 1. The Governing Body did not assure the medical staff bylaws were implemented regarding investigating an abuse allegation against a medical staff member (Medical Doctor A) for one of 30 sampled patients (Patient 4). This failure resulted in the facility being unaware if abuse allegation by Patient 4 occurred. This failure also had the potential for other patients assigned to care by Medical Doctor (MD) A at risk for abuse. Findings: 1. During an interview on 6/19/25, at 1 p.m., with Patient 4, Patient 4 stated, she was molested by MD A on 5/25/25. Patient 4 stated, I came to the facility for issues with my kidneys. Patient 4 stated, she was assessed by MD A who pulled her gown to the side and cupped her breast. Patient 4 stated, she made no complaint about chest pain or difficulty breathing so she felt the assessment was inappropriate. Patient 4 stated, she had been assessed by multiple male doctors and nurses and no one had exposed her breasts in such a way. Patient 4 stated, MD A pulled her underwear down to inspect her nephrostomy tube (a thin, flexible tube inserted through the skin into the kidney to drain urine). During a record review of internal incident report dated 5/25/25, regarding Patient 4, report indicated, Registered Nurse (RN) B filled out the report. Report indicated, “Pt [patient] reported inappropriate touching and comments by doctor [MD A] to break RN [RN C] who reported to charge nurse [RN B] . . .House sup [supervisor] and I spoke to pt who told us what happened during MD assessment. Pt reported inappropriate touching ‘cupping’ by MD after he had already assessed her (‘he returned back from the door, to look at my tattoos and ‘cupped my breast’). . .Risk Management notified”. During an interview on 6/24/25, at 1:43 p.m., with Accreditation Regulatory and Licensing Manager (ARLM), ARLM stated, “our abuse process we don’t do an investigation of whether the patient is correct or not, we take the patient experience, we allow the police department to make the final call”. ARLM stated, The patient safety and risk was involved and they check that we follow policy. During an interview on 6/24/25, at 2:10 p.m., with the ARLM, the ARLM stated, the police did not call us back with a recommendation regarding the abuse allegation with Patient 4. The ARLM stated, the facility does not do an investigation of abuse allegations like the police do, we check for compliance with our policies and make the patient feel safe. During an interview on 6/24/25, at 2:30 p.m., with the Chief Quality Officer (CQO), the CQO stated, any allegation of abuse comes to the Chief Medical Officer or my office, and one of us will coordinate and speak to the staff to get their side of the story, and if it is validated then the physician will come off the schedule. The CQO also stated, the policy for sexual abuse and mandated reporting applies to physicians as well. The CQO stated, for abuse allegations we let the police do their investigation. The CQO stated, the investigation for Patient 4’s abuse entailed a phone call to MD A, and looking at MD A’s charting. The CQO further stated, “I am not sure if the Police called us back” regarding Patients 4’s abuse allegation. During an interview on 6/24/25, at 2:48 p.m., with the Senior Director of Risk Management and Patient Safety (DRM),the DRM stated, “We don’t do an investigation, we report and we call the police and they would do an investigation, there is no investigation that occurs”. The DRM stated, the police don’t always get back to us, its not a routine part of their practice. During an interview on 6/25/25, at 11:10 a.m., with RN C, RN C stated, she was rounding as the break nurse on 5/25/25, and Patient 4 made an allegation against MD A. RN C stated, Patient 4 told her that MD A made a weird assessment on her, that he cupped her breasts and pulled her underwear down farther than other staff had in prior assessments to check her nephrostomy tube. RN C stated, I reported the allegation to the charge nurse and called MD A. RN C stated, when she called MD A, she notified him of the allegation from the patient. MD A told her that he did pull her underwear down to assess her nephrostomy tube and for bladder distention (swelling). During a review of Patients 4’s “Progress Note” dated 5/25/25, by MD A, note indicated, “Physical exam not performed”. During an interview on 6/25/25, at 3:45 pm, with MD A, MD A stated, He saw Patient 4 on 5 /25/25 ad she was being transferred to another facility for a urological (anything related to urology, the branch of medicine focused on the urinary system) procedure. MD A stated, “No physical exams were performed on the patient [4] that day”. During an interview on 7/1/25, at 3:30 p.m., with the Accreditation Regulatory and Licensing Director (ARLD), a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 4. During a review of requested investigation evidence for Patient 4 indicated, on 5/25/25 staff informed the DRM about Patient 4’s abuse allegation against MD A. Facility notified the police department. The Facility emailed the CQO, Chief Medical Officer, Chief Nursing Officer and the DRM. An internal incident report was completed. No other evidence was provided. Investigative evidence indicated, there was not sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 4’s abuse allegation. During a review of the facility’s “Medical Staff Bylaw” dated 2022, Bylaws indicated, “Article 7 Corrective Action. . .any person may provide information the Medical Staff about the conduct, performance, or competencies of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (1) detrimental to patient safety or to delivery of quality patient care within the hospital; (2) unethical; (3) contrary to the medical staff bylaws and rules or regulations; or (4)below applicable professional standards, a request for an investigation or action against such member may be initiated. . .Investigation upon receipt, the Medical Staff Executive Committee may act on the proposal or request or direct that an investigation be undertaken”.”

“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: 46939 Based on interview and record review, the facility failed to promote patient’s rights when: 1. Facility failed to provide evidence it investigated abuse allegations in a timely and thorough manner for three of 30 sampled patients (Patient 4, Patient 6 & Patient 16). 2. Facility failed to remove an alleged perpetrator of abuse (Medical Doctor (MD) A) from patient care immediately per facility policy after an allegation of abuse for one of 30 sampled patients (Patient 4). These failures resulted in the facility being unaware if Patient 4, Patient 6 & Patient 16 were subjected to abuse, and had the potential for other patients to be subject to abuse by alleged perpetrator MD A. Findings: 1. A. During an interview on 6/19/25, at 1 p.m., with Patient 4, Patient 4 stated, she was molested by MD A on 5/25/25. Patient 4 stated, I came to the facility for issues with my kidneys. Patient 4 stated, she was assessed by MD A who pulled her gown to the side and cupped her breast. Patient 4 stated, she made no complaint about chest pain or difficulty breathing so she felt the assessment was inappropriate. Patient 4 stated, she had been assessed by multiple male doctors and nurses and no one had exposed her breasts in such a way. Patient 4 stated, MD A pulled her underwear down to inspect her nephrostomy tube (a thin, flexible tube inserted through the skin into the kidney to drain urine). During an record review of internal incident report dated 5/25/25, regarding patient 4, report indicated, Registered Nurse (RN) B filed out the report. Report indicated, “Pt [patient] reported inappropriate touching and comments by doctor [MD A] to break RN [RN C] who reported to charge nurse [RN B] . . .House sup [supervisor] and I spoke to pt who told us what happened during MD assessment. Pt reported inappropriate touching ‘cupping’ by MD after he had already assessed her (‘he returned back from the door, to look at my tattoos and ‘cupped my breast’). . .Risk Management notified”. During an interview on 6/24/25, at 1:43 p.m., with the Accreditation Regulatory and Licensing Manager (ARLM), the ARLM stated, “our abuse process we don’t do an investigation of whether the patient is correct or not, we take the patient experience, we allow the police department to make the final call”. The ARLM stated, The patient safety and risk was involved and they check that we follow policy. During an interview on 6/24/25, at 2:10 p.m., with the ARLM, the ARLM stated, the police did not call us back with a recommendation regarding the abuse allegation with Patient 4. The ARLM stated, the facility does not do an investigation of abuse allegations like the police do, we check for compliance with our policies and make the patient feel safe. During an interview on 6/24/25, at 2:30 p.m., with the Chief Quality Officer (CQO), the CQO stated, any allegation of abuse comes to the Chief Medical Officer or my office, and one of us will coordinate and speak to the staff to get their side of the story, and if it is validated then the physician will come off the schedule. The CQO also stated, the policy for sexual abuse and mandated reporting applies to physicians as well. CQO stated, for abuse allegations we let the police do their investigation. The CQO stated, the investigation for Patient 4’s abuse entailed a phone call to MD A, and looking at MD A’s charting. The CQO further stated, “I am not sure if the Police called us back” regarding Patients 4’s abuse allegation. During an interview on 6/24/25, at 2:48 p.m., with the Senior Director of Risk Management and the Patient Safety (DRM), the DRM stated, “We don’t do an investigation, we report and we call the police and they would do an investigation, there is no investigation that occurs”. The DRM also stated, the police don’t always get back to us, its not a routine part of their practice. During an interview on 6/25/25, at 11:10 a.m., with RN C, RN C stated, she was rounding as the break nurse on 5/25/25, and Patient 4 made an allegation against MD A. RN C stated, Patient 4 told her that MD A made a weird assessment on her, that he cupped her breasts and pulled her underwear down farther than other staff had in prior assessments to check her nephrostomy tube. RN C stated, I reported the allegation to the charge nurse and called MD A. RN C stated, when she called MD A, she notified him of the allegation from the patient. MD A told her that he did pull her underwear down to assess her nephrostomy tube and for bladder distention (swelling). During a review of Patients 4’s “Progress Note” dated 5/25/25, by MD A, this note indicated, “Physical exam not performed”. During an interview on 6/25/25, at 3:45 pm, with MD A, MD A stated, He saw Patient 4 on 5 /25/25 ad she was being transferred to another facility for a urological (anything related to urology, the branch of medicine focused on the urinary system) procedure. MD A stated, “No physical exams were performed on the patient [4] that day”. During an interview on 7/1/25, at 3:30 p.m., with the Accreditation Regulatory and Licensing Director (ARLD), a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 4. During a review of requested investigation evidence for Patient 4 indicated, on 5/25/25 staff informed the DRM about patient 4’s abuse allegation against MD A. Facility notified police department. Facility emailed the CQO, Chief Medical Officer, Chief Nursing Officer and the DRM. An internal incident report was completed. No other evidence was provided. Investigative evidence indicated, there was not sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 4’s abuse allegation. 1. B. During a review of “Event Reporting Tool” for the California Department of Public Health (CDPH) dated, 5/8/25, Report completed by Facility regarding Patient 6. Report indicated, On 5/7/25 Patient 6 reported inappropriate sexual behavior occurred from several staff members to his private parts while receiving care on facility campus several months prior. During an interview on 7/1/25, at 3:05 p.m., with the Manager of Patient Experience (MPE), the MPE stated, she was informed of the abuse allegation from Patient 6 by the risk management department, that Patient 6 wanted to file a grievance. The MPE also stated, we do the intake we document it and share with patient safety. MPE stated, we do the reports to law enforcement, but do not investigate the allegation. During an interview on 7/1/25, at 3:08, with the ARLD, the ARLD stated, “the investigation belongs to the state and regulatory agencies” regarding investigating abuse allegations. During an interview on 7/1/25, at 3:30 p.m., with theARLD, a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 6. During a review of requested investigation evidence for Patient 6 indicated, on 5/7/25, facility was informed of Patient 6’s abuse allegation against facility staff. On 5/8/25, a family member called patient experience to express abuse allegation from Patient 6 against facility staff. Patient experience took the patient and family members concerns as a grievance. No further evidence of investigation was provided. Investigative evidence indicated, there was no sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 6’s abuse allegation. 1. C. During a review of an Internal Incident Report dated 4/22/25, regarding Patient 16, filled out by Nurse Manager (NM) report indicated, “Patient [16] states that a staff member bent her finger back causing pain. . .I personally spoke with the patient. . .Patient verbalized receiving IV [intravenous catheter- thin, flexible tube inserted into a vein for medications or fluids] in her right hand. . .Patient states she is unable to describe the staff member as they stood behind her as they bent her thumb backwards. No bruising noted, swelling is noted, along with an IV from dependent right hand”. During an interview on 7/1/25, at 2:19 p.m., with the NM, the NM stated, a nurse told me about Patient 16’s abuse allegation, stating someone bent her finger. The NM stated, she reported the allegation internally and notified risk management who stated they would reach out to the police department. During an interview on 7/1/25, at 2:29 p.m., with the DRM, the DRM stated, the abuse allegation from a patient against a staff member would be that “HR [human resources] would investigate”. The DRM stated, Risk Management does not investigate abuse allegations. During an interview on 7/1/25, at 3:30 p.m., with ARLD, a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 16. During a review of requested investigation evidence for Patient 16 indicated, on 4/21/25 facility was aware of Patient 16’s abuse allegation against staff, the NM was informed to create an internal incident report. Investigation steps by the NM included a chart review and interview with Patient 16. No further investigation noted. Provided evidence indicated, there was no sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 16’s abuse allegation. During a review of the ARLD job description dated 7/1/25, description indicated, “The director of Quality. . .provides leadership to ensure high quality, safe care by ensuring organizational systems and processes comply with Joint Commission (Accreditation Organization) accreditation standards, state and federal regulations and other identified standards. . .provides oversight and guidance to staff addressing regulatory and public reporting requirements”. During a review of the ARLM job description dated 7/1/25, description indicated, “The manager of Accreditation. . .is responsible to assist the enterprise and the Director of Quality [ARLD] in achieving and maintaining compliance with the Joint Commission standards, CMS [The Center for Medicare and Medicaid Services] Conditions of Participation (CoPs), California Title 22 regulations and CDPH regulations”. During a review of the DRM job description dated 7/1/25, indicated, “The Senior Director is responsible for planning, evaluating and managing the operations of Risk Management and Patient Safety programs and its effects on the culture of safety for the enterprise with the objective of maintain patient safety. . .Oversees an expanded cause analysis approach [a problem-solving method focused on identifying the underlying causes of problems, rather than just addressing their symptoms] to include root cause analysis. . .Identifies and promotes the use of FMEA (failure mode and effects analysis) to address potential safety risks”. 2. During an interview on 6/24/25, at 1:43 p.m., with the ARLM, the ARLM stated, MD A continued to work his shift after the abuse allegation, and was still on the schedule to work from 5/25/25-5/28/25 from 7 a.m.-5 p.m. During an interview on 6/24/25, at 2:30 p.m., with the CQO, the CQO stated, the facility policy titled, “Sexual Assault Response” and “Reporting of Abuse, Elder or Dependent Adult” would apply to physicians in general and to MD A in this abuse allegation with Patient 4. During a review of the Physician Work Schedule dated 5/25/25-5/28/25, indicated MD A worked on 5/25/25 from 7a.m.-5p.m. On 5/26/25 from 7a.m.-5p.m. On 5/27/25 from 7a.m.-5p.m. On 5/28/25 from 7a.m.-5p.m. During an interview on 6/25/25, at 3:45 p.m., with MD A, MD A stated, he continued to work his full shift on 5/25/25 after the allegation from Patient 4. During a review of the Facility’s P&P titled “Sexual Assault Response” dated 2025, the P&P Indicated, “Purpose: To provide staff with direction on how to respond to incidents of suspected sexual assault. . .f. If allegation against [facility] staff member, follow guidelines outlined in Reporting of Abuse, Elder, or Dependent Adult procedure”. During a review of the Facility’s P&P titled, “Reporting of Abuse, Elder or Dependent Adult” dared 2024, the P&P indicated, “Coverage: [Facility] staff, Physicians, and volunteers. . .3. For incidents of suspected abuse, or allegations of assault or inappropriate touching while the patient is hospitalized, the following actions will be taken: a. . .If a staff member who is currently assigned to patient care is suspected or accused of assault, abuse or inappropriate touching, the Manager or Assistant Hospital Manager/Hospital Supervisor will immediately remove the staff member form the patient care area”.”

“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: 46939 Based on interview and record review the facility failed to provide nursing care to meet patients’ needs for two of 30 sampled patients (Patient 11 &12) when: 1. Nursing staff did not implement care plan interventions for turning and repositioning Patient 11 for over 100 instances as evidenced by an absence of charting. Patient 11 developed a new pressure injury. 2. Nursing staff did not implement care plan interventions by failing to chart multiple wound dressing changes for Patient 12’s pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin.) as ordered by the wound care nurse These failures had the potential to be a contributing factor to the deterioration of Patient 11 and Patient 12’s pressure injuries. Findings: 1. During a review of Patient 11’s “H&P [history and physical]” dated 1/11/24, indicated Patient was admitted to the facility on 1/11/24. During a review of Patient 11’s “Flowsheet” dated 1/11/24 indicated, Patient 11’s first skin assessment was charted as “WDL [within defined limits-no skin issues]”, signed by two Registered Nurses. During a review of Patient 11’s “Care Plan” dated 1/11/24, care plan indicated, “Potential for compromised skin integrity. . .Turn patient every 2 hours”. During a concurrent interview and record review on 6/25/25, at 10:40 a.m., with Associate Chief Nursing Officer (ACNO), Patient 11’s “Flowsheets” dated 2/1/24-3/5/24 was reviewed. The flowsheets indicated, there were 102 instances of no charting to indicate Patient 11 was turned and repositioned every 2 hours. ACNO stated, she agrees there is inconsistent charting for numerous instances of missing charting for turning and repositioning for Patient 11 for the date range 2/1/24-3/5/24. During a review of Patient 11’s “Wound Care Noted” dated 3/5/24, note indicated, “Assessment- wounds located at 6 & 12 o’clock and involve peri anal skin [skin around anus] with contact with the fecal management device [a device used to collect and manage fecal matter in patients experiencing fecal incontinence or those with limited mobility or sensation]. . .Impression-full thickness wounds to peri anal skin in contact with the fecal management device. . .pressure injury stage unstageable [a full-thickness skin and tissue loss where the depth of the wound cannot be determined because the wound bed is obscured by dead tissue] During an interview on 7/2/25, at 10:44 a.m., with the Wound Care Nurse (WCN), the WCN stated, if a patient is not turned an repositioned every 2 hours it can cause pressure injuries to occur or worsen. 2. During an interview on 6/25/25, at 1p.m., with the ACNO, the ACNO stated, Patient 12 was admitted to the facility on 10/5/23. During a review of Patient 12’s “Flowsheet” dated 10/5/23 the Flowsheet indicated first skin assessment completed by nursing staff at 2030 (8:30 p.m.) indicated, “WDL”. During a review of Patient 12’s “Care Plan”, dated 10/5/23, Care Plan indicated, “Potential for Compromised Skin Integrity. . .Interventions. . .Collaborate with interdisciplinary team and initiate plans and interventions as needed”. During a review of Patient 12’s “Wound Care Note” dated 10/11/23, Note indicated, “Wound Care- initial visit re [regarding] partial thickness [a wound that involves only a portion of the thickness of a tissue layer] wound to the coccyx [tailbone] not POA [present on admission]. . .Assessment-orally intubated, sedated. . .Impression-stage 2 PI [stage 2 pressure injury-also known as a bedsore or pressure ulcer, is characterized by a partial thickness loss of skin involving the skin] to coccyx. Plan - continue PI preventions measures; dressing will be Duoderm extra thin hydrocolloid spot dressing [type of dressing designed to reduce the risk of further skin breakdown due to friction] . . .change every 3 days”. During a review of Patient 12’s “Wound Care Note” dated 11/2/23, Note indicated, “Wound care- f/up [follow up] re coccyx PI HAPI [hospital acquired pressure injury]. . .During last evaluation, this was a healing stage 2 HAPI. Now with full thickness [a wound that extends through all layers of the skin, potentially reaching subcutaneous tissue, muscle, tendon, or even bone] tissue damage and new deep tissue injury centrally. During a review of Patient 12’s “Wound Care Order” dated 11/2/23, Order indicated, “Wound Care: Coccyx Every 3 days. . .Crusting Technique [The crusting technique is a wound care approach used to manage skin irritation] . . .cover with xeroform gauze [fine mesh gauze occlusive dressing for use on low fluid wound] and ABD pad [abdominal pad-absorbent dressing]. . .Dressing change due 11/3/23”. During a review of Patient 12’s “Flowsheet” dated 11/2/23-11/5/23 indicated, no dressing changes were done during this time period. During an interview on 6/25/25, at 1:48 p.m., with the ACNO, the ACNO stated, there is no documentation of a dressing change for Patient 12 from 11/2/23-11/5/23. During a review of Patient 12’s “Flowsheet” dated 12/5/23-12/10/23 indicated, a dressing change on 12/7/23, the next dressing change after was on 12/11/23. No dressing change was done on 12/8/23-12/10/23. During an interview on 6/25/25, at 2:13 p.m., with the ACNO, the ACNO stated, staff did not chart on 12/10/23 the required dressing change. The ACNO stated, the nursing staff should follow all wound care orders and care plans. During an interview on 7/2/25, at 10:44 a.m., with the WCN, the WCN stated, if a patients wound dressings are not being changed as ordered, the wound can deteriorate and the tissue injury can go deeper. The WCN also stated, it is important to change the dressings as ordered also because it is a chance for the nurse to reassess the wound. During a review of Patient 12’s “Wound Care Note” dated 11/14/23, Note indicated, Pressure injury to the coccyx has progressed to a “Pressure injury Stage 3” [full-thickness skin loss, meaning the damage extends through the epidermis and dermis and into the subcutaneous tissue]”. During a review of Patient 12’s “Wound Care Note” dated 12/12/23, Note indicated, “Impression-wound has deteriorated” During a review of the facility’s Policy and procedure (P&P) titled “Plan for Provision of Nursing Care”, dated 2024, the P&P indicated, “Responsibilities and Accountabilities Registered Nurses. . .Utilize standards of practice in providing and supervising patient care”. During a review of the facilities P&P titled “Plan of Care” dated 2025, the P&P indicated, “Purpose To optimize the patients potential for personal care maintenance, comfort, safety, and to facilitate the maintenance of health status or the achievement of higher levels of wellness. . .Procedure B. Each patient’s care plan is based upon goals for adaptation, and focuses on outcomes to be achieved by discharge. Each plan includes approaches or interventions which support the patients goals”.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 37686 Based on interview and record review, the hospital failed to ensure surgical services were provided in accordance with professional standards of practice for one of 10 sampled patients (Patient 11). During Patient 11’s surgery in 2014, the surgeon did not remove the paper backing from Seprafilm (a product used during surgery to prevent adhesions [bands of scar-like tissue that form between surfaces inside the body and cause them to stick together]). This failure resulted in Patient 11 having multiple small bowel obstructions (a blockage that prevents food and liquid from passing through the small intestine) and requiring surgery to correct her condition. Findings: Review of Patient 11’s History and Physical (H&P), dated 4/2/14, indicated Patient 11 had symptomatic uterine fibroids (noncancerous growths in the uterus that cause symptoms including, but not limited to, heavy menstrual bleeding, pelvic pain, abdominal discomfort, and lower back pain). The H&P indicated Patient 11 wished to proceed with an abdominal myomectomy (a surgical procedure to remove uterine fibroids through an incision in the abdomen). Review of Patient 11’s Operative Report, dated 4/2/14, indicated an abdominal myomectomy was performed. The report indicated three fibroids were surgically removed from Patient 11’s uterus. The report further indicated Seprafilm was placed over the surgical incisions. Review of Patient 11’s H&P, dated 9/30/24, indicated Patient 11 presented to the emergency room with abdominal pain and nausea. Patient 11 had a computerized tomography scan (CT scan, a procedure that produces images of the inside of the body), which revealed a small bowel obstruction. The H&P indicated Patient 11 had approximately six previous small bowel obstructions. Review of Patient 11’s Operative Report, dated 10/1/24, indicated that over the last 10 years, Patient 11 had multiple episodes of recurrent small bowel obstructions and elected to proceed with surgical exploration (surgery to inspect internal organs). The Operative Report indicated, “The patient had extremely dense adhesions of multiple segments of the small bowel to a retained sheet of material, which appeared similar to the packaging paper around Seprafilm. The sheet was densely wadded up between the posterior uterus [back part of the uterus] and multiple segments of small bowel with such adherence that small bowel was inseparable from this area along with significant surrounding inflammatory process [an immune response that causes redness and swelling].” According to the Operative Report, a segment of Patient 11’s small bowel required suture repair and another segment of small bowel had to be resected (cut out). The Operative Report indicated a postoperative (after surgery) diagnosis of, “Multiple recurrent small bowel obstructions secondary to retained foreign body with dense adherence to multiple segments of small bowel.” An interview was conducted with the hospital’s Chief Quality Officer (CQO) and Director of Risk Management (DRM) on 11/22/24 at 10:56 a.m. The CQO stated he thoroughly reviewed Patient 11’s case. He explained that Seprafilm was meant to be left in the patient’s body, but it had a paper backing that was supposed to be removed. The CQO and DRM confirmed that the surgeon who performed Patient 11’s abdominal myomectomy in 2014 failed to remove the paper backing from the Seprafilm that was used during the surgery. Review of the manufacturer’s instructions printed on the back of the Seprafilm package indicated, “Apply Seprafilm and slide out bottom protective sheet, then remove entire sheet.” During an interview with the hospital’s Director of Accreditation, Licensure, and Regulatory (DALR) on 11/25/24 at 3:22 p.m., the DALR confirmed the hospital’s surgical department followed the guidelines of the Association of periOperative Registered Nurses (AORN). Review of the AORN’s undated guidelines titled “Retained Surgical Items” indicated, “Accurately accounting for items used during a surgical procedure is a primary responsibility of the surgeon and surgical first assistant.” The guidelines further indicated, “The surgeon and surgical first assistant should maintain awareness of the location of items in the surgical wound during the course of the procedure.””