Kern Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46958 Based on interview and record review, the hospital staff failed to ensure a physician’s orders (PO) was obtained for restraints for one of one sampled patient (Patient 1). This failure resulted in a violation of Patient 1’s right to be free from unnecessary restraints. Findings: During a concurrent interview and record review on 7/22/25 at 8:40 a.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 1’s PO was reviewed. Patient 1’s PO for “Restraints for Non-Violent Behavior (RNVB)” dated 7/19/25-7/20/25 was reviewed. The RNVB indicated,order started on 7/19/25 at 8:57 a.m., “Restraint Type: Bilateral Soft Wrist,” and ended on 7/20/25 at 8:57 a.m. Next order dated 7/20/25 was started at 11:05 p.m. “Restraint Monitoring (RM)” dated 7/20/25 was reviewed and the RM indicated “Soft Wrist” applied from 10:28 a.m. to 8:14 p.m. RNLA stated there was no PO and there should’ve been a PO for the time while Patient 1 was on restraints. During a review of the facility’s policy and procedure (P&P) titled, “Restraints: Management of Non-Violent, Non-Self-Destructive Patient Behavior/Situations,” dated 9/2024, the P&P indicated, “V. Procedure: B. Implementation of Restraints for Non-Violent, Non-Self-Destructive Behavior/Situations 2. Obtain a Physicians Order for Restraint a) Obtain an order from a qualified attending, resident and/or authorized designee. . .d) In an emergency situation, when the attending or designee is not immediately available to give the order, a qualified RN [Registered Nurse] may initiate the restraint. The RN will notify the attending or designee as soon as possible to obtain the order.””

“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: 46958 Based on interview and record review, the hospital failed to develop a care plan for one of one sampled patient (Patient 2) when the care plan was not developed according to patient needs. This failure resulted in care plans not being developed and implemented for admitted patients and had the potential for unmet care needs. Findings: During a review of Patient 2’s “Behavioral Health Notes (BHN),” dated 6/12/25, the BHN indicated “Patient [Patient 2] reports that she is still breast-feeding her 3-year-old.” During a concurrent interview and record review on 7/21/25 at 1 p.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 2’s BHN, dated 6/14/25 was reviewed. The BHN indicated “Spoke to pt’s [Patient 2] fiancé ROI [Release of Information] on file. Called Fiancé to ask if pt is breastfeeding. Fiancé reports pt does breastfeed one child.” During a review of Patient 2’s “BHN,” dated 6/15/25, at 6:58 p.m. indicated, “Pt [Patient 2] endorses breast pain/tenderness. Pt received breast pump and is able to pump in private room with female staff for safety without any issues.” During a concurrent interview and record review on 7/21/25 at 1:30 p.m. with RNLA, Patient 2’s BHN, dated 6/15/25 was reviewed. The BHN indicated Patient used the breast pump. RNLA stated Patient 2 received the breast pump on 6/15/25 (three days later). During a concurrent interview and record review on 7/21/25 at 1:40 p.m. with RNLA, a document in Patient 2’s record “Document in Plan,” dated 6/12/25 was reviewed. RNLA stated the Document in Plan is an Interdisciplinary Plan of Care (IPOC). IPOC indicated there was no care plan for breast pump or breast feeding. RNLA stated there was no care plan for breast pump or breast feeding, and there should be a care plan developed. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care (IPOC) Non-Psychiatric Patients),” dated 2/2024, the P&P indicated, “III. Policy Statement: It is the policy of [Hospital] that all inpatients will have an interdisciplinary plan of care (IPOC) to assist in setting priorities of care that promote health, wellbeing and healing, and to provide for continuity of care between all disciplines.””

“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: 46958 Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled “Infant Feeding,” when a breast pump was not provided to one of one sampled patient (Patient 2). This failure resulted in discomfort for Patient 2. Findings: During a review of Patient 2’s “Behavioral Health Notes (BHN),” dated 6/12/25, the BHN indicated, “Patient [Patient 2] reports that she is still breast-feeding her 3-year-old.” During a review of Patient 2’s “Progress Note (PN),” dated 6/13/25, the PN indicated, patient [Patient 2] said that she should be released because she’s breastfeeding 2 kids.” During a review of Patient 2’s “BHN,” dated 6/13/25, at 7:48 p.m. indicated, “I [Patient 2] haven’t breastfed my baby for four days.” During a review of Patient 2’s “BHN,” dated 6/14/25, at 8:52 a.m. indicated, “I’m [Patient 2] breastfeeding both of my kids. I feel bad; I breastfeed them eight times a day. . .I [nurse] explained to the pt [patient] that I would talk with doctor regarding her breastfeeding concerns.” During a review of Patient 2’s “BHN,” dated 6/15/25, at 6:58 p.m. indicated, “Pt [Patient 2] endorses breast pain/tenderness.” During a concurrent interview and record review on 7/21/25 at 1 p.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 2’s BHN, dated 6/14/25 was reviewed. The BHN indicated “Spoke to pt’s [Patient 2] fiancé ROI [Release of Information] on file. Called Fiancé to ask if pt is breastfeeding. Fiancé reports pt does breastfeed one child.” RNLA stated nurses knew about it on 6/14/25 and Patient 2 still didn’t receive breast pump. During a concurrent interview and record review on 7/21/25 at 1:30 p.m. with RNLA, Patient 2’s BHN, dated 6/15/25 was reviewed. The BHN indicated Patient used the breast pump and she feels better. RNLA stated Patient 2 received breast pump on 6/15/25. During a review of Patient 2’s “Grievance,” dated 6/19/25, the Grievance indicated, “I [Patient 2] arrived Wednesday night around 10 or 11 pm (June 11, 2025) and requested a breast pump as I am breast-feeding mom. I continued to ask, and was told to let my milk dry up. Even with the continued requests, I did not receive a pump until Day 5.” During a review of the facility’s P&P titled, “Infant Feeding,” dated 1/2028, the P&P indicated, “V. Procedure: E. Step V - Show parents how to breastfeed and how to maintain lactation, even if they are separated from their infants. . . 6. If the parent is separated from infant, the parent will be shown how to hand express milk within two (2) hours of separation. The parent will be given a hospital-grade double electric pump and kit, and instructed on use. Parent will be educated to hand express or pump at least ten (10) times in 24-hours.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47444 The facility failed to meet the regulatory requirements for the Condition of Participation: §482.13 Patient’s Rights as evidenced by: Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 1) was provided safe care when: 1. Emergency Department (ED) staff did not communicate and implement high fall risk interventions when Patient 1 was placed in a room out of the line of site of the ED staff, and the patient was left unattended while attempting to use the bathroom (Refer to A-0144). 2. The ED staff did not communicate and implement Physical Therapy (PT) recommendations for the use of a front wheel walker (FWW - assistive device) and nursing assistance when out of bed (OOB). (Refer to A-0144) 3. Medical Surgical (MS - general care area of hospital) staff did not communicate and implement PT recommendations for the use of a FWW and nursing assistance when OOB. (Refer to A-0144) 4. MS staff did not communicate and implement high fall risk interventions when Patient 1 was left unattended while using the urinal (handheld container used to urinate at the bedside). (Refer to A-0144) These failures resulted Patient 1 falling twice, suffering a brain injury, and an unexpected death. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure safe patient care, in compliance with Conditions of Participation for Patient’s Rights.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 47444 Based on interview, and record review, the hospital failed to follow its policy and procedure (P&P) titled, “Patient Safety Observation,” for one of four sampled patients (Patient 1) when: 1. There was no order for Patient 1’s safety observation. 2. Patient 1’s safety observation logs were incomplete. These failures had the potential for decreased communication among Patient 1’s health care team and placing the patient’s safety at risk. Findings: 1. During a concurrent interview and record review on 4/2/25 at 10:32 a.m. with Director of Licensing and Certification (DLC), Patient 1’s “Orders,” dated 2/22/25 through 2/24/25 were reviewed. The Orders indicated Patient 1 did not have a order for Remote Safety Observation (RSO - staff monitoring video remotely for patient safety). DLC stated there were no orders for Patient 1 to have RSO and there should have been an order. During a concurrent interview and record review on 4/2/25 at 11:45 a.m. with Director of Acute Care (DAC), Patient 1’s “Med Sitter (MS - list of patients on RSO)” document (undated) was reviewed. The MS indicated Patient 1 was on RSO starting 2/22/25 at 10:11 p.m. through 2/24/25 at 12:58 a.m. DAC stated Patient 1 was admitted to the medical surgical unit on 2/22/25 at approximately 10 p.m. DAC stated Patient 1 was identified as a high risk for falls and was started on RSO until he was transferred to the direct observation unit (DOU) on 2/24/25 at approximately 1 a.m. 2. During a concurrent interview and record review on 4/2/25 at 11:41 a.m. with Medical Surgical Patient Safety Observer (MSPSO) 2, Patient 1’s “Remote Patient Safety Observer (PSO) Observation Log (ROL),” dated 2/22/25 through 2/23/25 was reviewed. There was no ROL for RSO for 2/23/25. MSPSO 2 stated she was responsible for RSO of Patient 1 during the day shift (7 a.m. to 7 p.m.) on 2/23/25. MSPSO 2 stated ROL documentation of the patient’s activity and events should have been documented every hour. MSPSO 2 stated there was no ROL for 2/23/25 day shift. During an interview on 4/2/25 at 1:45 p.m. with Medical Surgical Registered Nurse Supervisor (MSRNS), MSRNS stated when a patient is assessed as a high risk for falls the staff utilize RSO. MSRNS stated the registered nurses are able to place orders for the RSO. MSRNS stated the MSPSO is responsible for monitoring and documenting the behavior and status of the patient every hour on the ROL. During a concurrent interview and record review on 4/3/25 at 8:12 a.m. with MSPSO 1, Patient 1’s “ROL,” dated 2/22/25 through 2/23/25 was reviewed. There was no ROL for RSO on 2/23/25. MSPSO 1 stated she was responsible for RSO of Patient 1 during the night shift (7 p.m. to 7 a.m.) on 2/23/25. MSPSO 1 stated the staff should document every hour on the ROL. MSPSO 1 stated there was no ROL for 2/23/24 on the night shift. During a review of the hospital’s P&P titled, “Patient Safety Observation,” dated July 2023, the P&P indicated, “It is the policy of [hospital name] that the assignment of patient safety observers is determined by nursing staff on a case-by-case basis, considering established inclusion and exclusion criteria and individual patient needs. The level and type of observation (in-person or remote) will be determined based on the patient’s specific needs and level of risk. All decisions regarding patient observation will be made in the best interest of the patient’s safety and with the goal of preventing harm to the patient and others. . . 4. Patient behavior, activity and safety will be documented hourly and upon change in behavior on Associated Form, #3807, Remote Bedside Patient Safety Observer Observation Log. . . E. Requirements for all Remote and In-Person Observations 1. Observation Orders a) Nursing orders for a specific type of observation will be entered into the medical record and reviewed and renewed daily, as indicated.””

“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 one of four sampled patients (Patient 1) was provided safe care when: 1. The Emergency Department (ED) staff did not communicate and implement high fall risk interventions when Patient 1 was placed in a room out of the line of site of the ED staff, and the patient left unattended while attempting to use the bathroom. 2. The ED staff did not communicate and implement Physical Therapy (PT) recommendations for the use of a front wheel walker (FWW - assistive device) and nursing assistance when out of bed (OOB). 3. Medical Surgical (MS - general care area of hospital) staff did not communicate and implement PT recommendations for the use of a FWW and nursing assistance when OOB. 4. MS staff did not communicate and implement high fall risk interventions when Patient 1 was left unattended while using the urinal (handheld container used to urinate in at the bedside). These failures resulted Patient 1 falling twice, suffering a traumatic brain injury, and an unexpected death. Findings: 1. During a review of Patient 1’s “History and Physical Reports (H&P),” dated 2/22/25 at 1:10 p.m., the H&P indicated Patient 1 was brought to the ED after hitting his head during a ground level fall at home. The H&P indicated Patient 1 was having weakness, used a walker at home, and required assistance with activities of daily living (ADLs - basic self-care activities like bathing, dressing, and eating). During a concurrent interview and record review on 4/2/25 at 8:07 a.m. with ED Registered Nurse (EDRN) 3, Patient 1’s “Patient Experienced a Fall (PEF),” dated 2/22/25 at 7:40 p.m. was reviewed. The PEF indicated Patient 1 had an unwitnessed fall in his ED room on 2/22/25 at 7:35 p.m. EDRN 3 stated she was assigned to care for Patient 1 in the ED for the 2/22/25 night shift (7 p.m. to 7 a.m.). EDRN 3 stated Patient 1 was not in his room when she received report from the day shift (7 a.m. to 7 p.m.) EDRN 2. EDRN 3 stated she was in another patient’s room when ED Patient Care Technician (EDPCT) informed her that Patient 1 was on the ground in his room. EDRN 3 stated Patient 1 was assessed as a high risk for falls and needed to be in the line of site of the nurse’s station for observation. EDRN 3 stated it was common that patients assessed as a high risk for falls were assigned a one-to-one observer (1:1 - one staff is assigned to monitor one patient), but Patient 1 did not have a 1:1 observer. During a concurrent interview and record review on 4/2/25 at 9:24 a.m. with EDRN 1, Patient 1’s “ED Triage (EDT),” dated 2/22/25 at 10:31 a.m. was reviewed. The EDT indicated Patient 1’s Morse Fall Risk Score was 50 (assessment used to determine risk of falls, 0-24 low risk, 25-45 moderate risk, 45 or above high risk). The EDT indicated, “ED Additional Fall Risk Interventions: Do not leave patient unattended while toileting.” EDRN 1 stated Patient 1 was assessed as a high risk for falls, was placed in an ED room, but was not in the line of site of staff for observation. EDRN 1 stated patients assessed as high risk for falls usually have a 1:1 observer, but Patient 1 did not have a 1:1 observer. During an interview on 4/2/25 at 10:45 a.m. with EDRN 2, EDRN 2 stated he was assigned to care for Patient 1 in the ED for the 2/22/25 day shift. EDRN 2 stated if a patient has a history of falls and during the assessment the nurse scores the patient a high risk for falls, then he would work with the charge nurse to move the patient closer to the nurses station for observation. EDRN 2 stated he did not recall if that was done for Patient 1 on 2/22/25. During a concurrent interview and record review on 4/3/25 at 10:43 a.m. with EDRN 4, Patient 1’s “EDT,” dated 2/22/25 at 10:31 a.m. was reviewed. The EDT indicated Patient 1 was assessed as a high risk for falls and staff were not to leave Patient 1 unattended while toileting. EDRN 4 stated the triage nurse should have communicated with EDRN 2 that Patient 1 was a high risk for falls and should not be left unattended while toileting. EDRN 4 stated Patient 1 needed to be placed in a room that could be seen from the nurses station for observation. During an interview on 4/3/25 at 1:33 p.m. with Director of Emergency Department (DED), the DED stated the expectation was if a nurse assessed a patient to be a high risk for falls, the patient should be moved to a room in the line of site of the nurses station for observation. 2. During an interview on 4/2/25 at 10:45 a.m. with EDRN 2, EDRN 2 stated he did not recall receiving report from PT on 2/22/25 for recommendations to use the FWW with nursing when OOB. During a concurrent interview and record review on 4/2/25 at 11:32 a.m. with Director of Rehabilitation Services (DRS), Patient 1’s “PT (physical therapy) Inpatient Evaluation (PTE),” dated 2/22/25 at 3 p.m. (completed in the ED) was reviewed. The PTE indicated, “Mobility Level Score 4 [unsteady, walk assisted (minimal assist)]. . . Pt [Patient 1] is recommended to use a FWW [front wheeled walker] for any OOB [out of bed] activity at this point. Pt is safe to be OOB w/ [with] nursing, but will need assistance due to unsteadiness.” DRS stated according to the evaluation Patient 1 was not safe to be up independently. DRS stated the recommendations for Patient 1’s use of FWW and OOB with nursing would be communicated to the EDRN assigned to Patient 1’s care. DRS stated walkers were available in the ED for patient use. DRS stated it was best practice to document who the recommendations were reported to, but there was no documentation that PT gave report. 3. During a concurrent interview and record review on 4/2/25 at 1:45 p.m. with Medical Surgical Registered Nurse Supervisor (MSRNS), Patient 1’s “PTE,” dated 2/22/25 was reviewed. The PTE indicated Patient 1 had a mobility level score of four. MSRNS stated a mobility level score of four meant the patient needed assistance when out of bed and during ambulation. MSRNS stated the staff should report the use of assistive devices (FWW) and other special interventions needed to incoming staff. During an interview on 4/3/25 at 8:50 a.m. with Medical Surgical Patient Care Technician (MSPCT) 1, MSPCT 1 stated she was assigned to care for Patient 1 when he was transferred from the ED to the MS unit on 2/22/25 at approximately 10 p.m. MSPCT 1 stated MSRN 2 reported that Patient 1 was a high risk for falls, but MSRN 2 did not indicate the patient required a FWW and nurse assistance when OOB. MSPCT 1 stated she did not ask Patient 1 if he used a walker and did not provide him one. 4. During a concurrent interview and record review on 4/2/25 at 1:59 p.m. with MSRNS, Patient 1’s “Morse Fall Risk Score” dated 2/23/25 at 7:25 p.m. was reviewed. The Morse Fall Risk Score for Patient 1 was 85 (patients who score 45 or above are considered a high for falls). MSRNS stated Patient 1 was a very high risk for falls. MSRNS stated she spoke to MSPCT 1 after Patient 1’s fall, and MSPCT 1 stated if she had known Patient 1 required a walker then maybe he would not have fallen. When MSRNS was asked if it was best practice for staff to leave Patient 1’s side while standing and using a urinal, MSRNS provided no response. During an interview on 4/3/25 at 8:12 a.m. with MS Patient Safety Observer (MSPSO) 1, MSPSO 1 stated she was assigned to remote observation (video screen used to monitor patient safety from a separate location) for Patient 1 on 2/23/24. MSPSO 1 stated Patient 1 needed to use the restroom and tried to get out of bed. MSPSO 1 stated she pressed the alarm so staff would respond to Patient 1 immediately. MSPSO 1 stated she observed MSPCT 1 enter Patient 1’s room and assist him to stand at the side of the bed. MSPCT 1 handed Patient 1 a urinal then left his side to go around to the other side of the bed and fix the linens. MSPSO 1 stated it appeared that Patient 1 went to sit on the side of his bed, missed the bed and fell to the floor. MSPSO 1 stated Patient 1 was a high risk for falls and MSPCT 1 should not have left his side while he was up OOB using the urinal. During a concurrent interview and record review on 4/3/25 at 8:34 a.m. with Medical Doctor (MD) 1, Patient 1’s “Progress Notes (PN),” dated 2/23/25 at 10:34 a.m. was reviewed. The PN indicated, “Patient [1] states that he is doing fine this morning. Denies any concerns at this time. Patient reports that he has been eating and sleeping well. Patient states that his weakness has improved. . . Imaging CT [computed tomography - a type of x-ray] Brain/Head w/o [with out] Contrast [medication used to enhance the x-ray] 2/22/25 12:10 [p.m.] . . . Impression . . . 3. No acute intracranial hemorrhage.” MD 1 stated Patient 1 “did not look like he was in bad shape when came to ED.” MD 1 stated Patient 1’s Glasgow Coma Scale (GCS - assess level of consciousness, 3-8 severe head injury, 9-12 moderate head injury, 13-15 mild head injury) was 15 when he arrived to the ED. The medical team was anticipating to discharge Patient 1 home or to a rehabilitation care facility. During an interview on 4/3/25 at 8:50 a.m. with MSPCT 1, MSPCT 1 stated she was with Patient 1 when he fell on 2/23/25 at approximately 8:25 p.m. MSPCT 1 stated she entered Patient 1’s room and observed him trying to sit on the side of the bed. MSPCT 1 stated she put the bed rail down and assisted Patient 1 to sit on the side of the bed, but he wanted to stand up to use the urinal. MSPCT 1 stated once Patient 1 was standing, she handed him the urinal, left his side, and went around to the other side of the bed to straighten the bed linen. MSPCT 1 stated Patient 1 started to step back and she told him “one moment” in Spanish (Patient 1 was Spanish speaking), as she started to go around the bed to assist him, he fell to the floor on his left side and hit his head on the wall. MSPCT 1 stated when Patient 1 hit his head he started making a “snoring” sound. MSPCT 1 stated Patient 1 had a laceration and swelling on the left side of his face just below his eye. MSPCT 1 stated she was assigned to care for Patient 1 the night before (2/22/25) and knew that he was a high fall risk. MSPCT 1 stated Patient 1 was not using a FWW at the time of the fall. The FWW was hanging on the wall behind the door (in his room). During a concurrent interview and record review on 4/3/25 at 10:30 a.m. with MD 2, Patient 1’s “Discharge Documentation (DD),” dated 2/25/25 at 12:20 p.m. was reviewed. The DD indicated Patient 1 had a fall with head injury while admitted to MS unit (on 2/23/25). The DD indicated Patient 1 was moved to the Direct Observation Unit (DOU - unit providing a step-down level of care between intensive care unit and MS unit) and the initial exam indicated a GCS score of 11 (a score of 9-12 indicates a moderate head injury). The DD indicated staff took Patient 1 for a CT where he began vomiting. Upon return to the DOU Patient 1’s GCS was a 6 (a score of 3-8 indicates a severe head injury) and the staff intubated (tube placed in airway to assist with breathing) the patient to protect the airway. The DD indicated Patient 1 was pronounced dead on 2/24/25 at 7:17 p.m. MD 2 stated the fall with the head injury, while admitted to the hospital, likely caused Patient 1’s death. During a concurrent interview and record review on 4/3/25 at 10:32 a.m. with MD 2, Patient 1’s “Computed Tomography (CT),” dated 2/22/25 at 12:10 p.m. was reviewed. MD 2 stated there was no evidence of bleeding in Patient 1’s brain after the fall at home and prior to the falls in the hospital. During a concurrent interview and record review on 4/3/25 at 10:33 a.m. with MD 2, Patient 1’s “CT,” dated 2/23/25 at 9:22 p.m. was reviewed. MD 2 stated the CT was done after Patient 1’s fall with head injury (2/23/25 at 8:25 p.m.) while admitted on MS unit. MD 2 stated the CT showed subdural hemorrhages (bleeding in the brain). During a concurrent interview and record review on 4/3/25 at 10:34 a.m. with MD 2, Patient 1’s “CT,” dated 2/24/25 at 5 a.m. was reviewed. MD 2 stated the CT showed Patient 1 had significantly worsening bleeding in his brain. During a concurrent interview and record review on 4/3/25 at 10:37 a.m. with MD 2, Patient 1’s “Certificate of Death (CD),” dated 2/27/25 was reviewed. The CD indicated, “Cause of Death (A) Traumatic Brain Injury [TBI - caused by external force] (B) Ground Level Fall (C) Ischemic Strokes [blood clots in the brain].” MD 2 stated Patient 1’s fall with the TBI, while admitted to the hospital, caused Patient 1’s death. During a review of the hospital’s P&P titled, “Fall Risk Assessment and Prevention,” dated April 2024, the P&P indicated, “To provide a consistent process for nursing assessment of patient fall risk and implementation of an individualized fall prevention plan. . . A. Assessment and Interventions . . . 2. Admitted patients 14 years of age or older. . . 3) Fall prevention interventions (see Addendum B) will be implemented according to the calculated risk. . . (c) High Risk - Implement high-risk fall prevention interventions. . . 4) The following fall prevention standards will be integrated into nursing practice: . . . (b) Patient fall risk and special prevention strategies will be communicated during hand-off. . . (d) Patients will be mobilized early, per Up Sooner, Safer standardized procedures. . . (g) Environmental safety will be continually monitored and supported throughout care. . . 6. Emergency Department (ED) a) Fall Risk Assessment . . . (c) Staff will complete a safety plan and implement the necessary precautions. . . Addendum B . . . Fall Prevention Interventions - Nurse will include in IPOC or Assess Patient’s Need: High Risk. . . Shift Report Communicate patient’s fall risk status during bedside report. Review history of falls and special prevention strategies. Plan of Care Collaborate with multi-disciplinary team members in planning individualized care, i.e. pharmacy, PT, OT. . . Safety. . . Do not leave patient unattended while toileting. . . Consider placing patient in room near nursing station for closer observation during first 24-48 hours of admission. Consider use of staff observer for patient safety.” During a review of the hospital’s P&P titled, “Progressive Mobility Program: Up Sooner, Safer,” dated August 2024, the P&P indicated, “To set forth [Hospital’s name] standards for assessment and mobilization of patients, which promotes return to maximum functional capacity and supports requirements for safe patient handing [sic] by caregivers. . . B. RN Responsibilities for Admitted Acute Care Patients. . . c) Assess patient mobility level each day shift, upon change in level of care and change in patient condition, per the Mobility Assessment Algorithm (refer to Addendum B). . . 2. Communicate mobility level and planned activities within care team and to patient/support person(s) via: . . . SBAR [Situation/Background/Assessment, Recommendation communicate tool to provide information] /verbal report. . . c) Integrate planned mobility activities into the care schedule utilizing appropriate safe patient handling equipment according to assessed mobility level, per Up Sooner, Safer: Progressive Mobility/Safe Patient Handling Guide (refer to Addendum C). . . C. PT [Physical therapy] and OT [Occupational therapy] Responsibilities. . . 2. Intervention a) Provide recommendations and establish PT/OT treatment plan in addition to Up Sooner, Safer progressive mobility program. . . 3. Other Responsibilities. . . b) Collaborate regarding patient discharge needs with health care team. . . Addendum C Up Sooner, Safer: Progressive Mobility/Safe Patient Handling Guide. . . 4 - Walk Assisted (Minimal Assist). . . Durable Medical Equip [equipment]: - Cane/Crutches/Walker.” During a review of the hospital’s P&P titled, “Patient Safety Observation,” dated July 2023, the P&P indicated, “It is the policy of [hospital name] that the assignment of patient safety observers is determined by nursing staff on a case-by-case basis, considering established inclusion and exclusion criteria and individual patient needs. The level and type of observation (in-person or remote) will be determined based on the patient’s specific needs and level of risk. All decisions regarding patient observation will be made in the best interest of the patient’s safety and with the goal of preventing harm to the patient and others. . . A. Registered Nurse (RN) Responsibilities 1. Patient Assessment a) Nursing assessments/screens will be used to determine the most appropriate interventions and, as necessary, the use of a remote or in-person patient observer to support the safety needs of the patient in accordance with [hospital name] policies and standards. . . (b) Utilization of patient safety equipment/assistive devices. . . 2) Alternative Interventions (a) Relocation or placement of the patient closer to the nurse’s station for observation or change in patient room for reduction of stimulation. . . (b) Engagement of family or support persons for additional patient companionship during hospitalization, as appropriate. (1) Family and support persons are not qualified observers but may agree to provide companionship. Nursing will meet with the volunteer(s) develop a plan for participation and provision of information on safety and staff communication. 3. Communication with Health Care Team a) Communicates with the provider regarding patient safety and the medical plan of care, e.g. necessity of IV lines, urinary catheters, central lines, sequential compression devices and medication management. b) Collaborates with physical therapy and dietary, as appropriate. . . 2. Remote Bedside Observation versus In-Person Observation . . . a) All patients who qualify for observation must first be trialed with remote observation monitoring before in-person observation is approved, unless the patient, in need of observation, meets the following exclusion criteria: . . . 4) Emergency Department (ED) patient (remote bedside observation not used in the ED). . . 2) Fall risk patients with a condition that increases risk of injury, if a fall were to occur. . . (c) Coagulation disorders.” During a review of the hospital’s P&P titled, “Patient Rights and Responsibilities,” dated April 2022, the P&P indicated, “2. Patients have a right to: . . . Receive care in a safe setting.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48901 Based on interview and record review, the facility failed to prevent a delay in care for one of 20 sampled patients (Patient 16) when: 1. A medical screen exam (MSE - medical screening, examination, and evaluation by a physician to determine if an emergency medical condition exists) was not completed in a timely manner. 2. Registered Nurses (RN) did not use the emergency standardized procedures (SP) prior to the MSE. 3. Patient 16 did not have vital signs (VS - heart rate [HR], respiratory rate [RR], oxygen saturation [Sat- a measure of how much hemoglobin is currently bound to oxygen], blood pressure [BP], temperature [temp] and pain level) completed as required. These failures resulted in Patient 16 waiting in the Emergency Department (ED) for 7 hours and leaving without being seen (LWBS - no MSE). Findings: 1. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RN Informatics (RNI), Patient 16’s medical record (MR) was reviewed. The MR indicated the following: RN 1 documented on 1/7/25 at 9:54 p.m. “ED Triage Chief Complaint: PT [Patient 16] C/O [complain of] ABD [abdominal] PAIN AND VOMITING X [times] 3 DAYS. . . Triage Pain Assessment. . . Numeric Rating Pain Scale: 3 (0-3 mild pain). . . Numeric Pain Acceptable Intensity Scale: 0 = No pain. . . Recommended ESI [Emergency Severity Index - a number that indicates how urgent a patient’s condition is and how many resources they need] Level: 3 [an urgent triage level for patients who need immediate attention but can wait up to 30 minutes for treatment].” MD 1 and MD 2 documented on 1/8/25 at 5:29 a.m. “Attempt made to medically evaluate patient however patient left prior to being seen by provider. Unable to render care.” MD 3 documented on 1/11/25 at 1:02 a.m. “Unspecified abdominal pain (Final). . . Vomiting, unspecified (Final)-Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider (Final)-Discharge Disposition: Left Prior to MSE by Provider (LWBS).” RN 2 documented on 1/8/25 at 5:05 a.m. “Supervised Shelter. . . Wait too long. . . Refusal of Treatment Form: Form not read, patient left.” RNI stated she is not sure why Patient 16 waited 7 hours without an MSE. RNI stated there was no other physician documentation. During an interview on 1/28/25 at 11:13 a.m. with Chief of Emergency Medicine (COEM), COEM stated it is not ideal or appropriate for Patient 16 to wait 7 hours to have an MSE completed. During a review of the facility’s policy and procedure (P&P) titled, “COBRA/EMTALA Compliance,” dated September 2022, the P&P indicated, “III. POLICY STATEMENT: It is the policy of [Facility 1] to meet its statutory duty to provide a medical screening examination and emergency care, as required by the patient’s condition after triage. . .V. PROCEDURE: A. 1. If an individual comes to the ED, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s ED, including all ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists.” 2. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RNI, Patient 16’s MR was reviewed. MR indicated, “Pain History Grid. . . Pain Site #1. . . Location: Abdominal lower. . . Quality: Aching.” RNI stated the MR does not indicate diagnostic studies, medications, or other treatments were ordered. During an interview on 1/28/25 at 11:13 a.m. with COEM, COEM stated he is surprised that the RNs did not initiate the SP during the 7 hours Patient 16 waited for a MSE to help alleviate some of Patient 16’s concerns/symptoms. During a review of the facility’s P&P titled, “Standardized Procedures, Unit-Specific, Emergency Department,” dated August 2023, the P&P indicated, “I. PURPOSE: Emergency standardized procedures (SP) provide a means for nursing staff to implement orders approved by the medical staff of the Emergency Department (ED). The Registered Nurse (RN) can initiate/implement standardized procedures to provide care for patients with presenting symptoms and complaints. By providing diagnostic studies and offering defined medications prior to the medical screening examination (MSE), the wait time now becomes productive. . . V. PROCEDURE: A. Triage - SP are chief complaint driven. . .3. Emergency SP are enacted upon and are carried out by the ED RN. . . Associated Form A. . . APPROVED ED STANDARDIZED PROCEDURES. . . NOTE: If no provider in triage, the ED RN may initiate the following Standardized Procedures based on the patient’s Chief Complaint. . . ED NUR [Nursing] Lower Abdominal Pain. . .CBC w/diff [blood test that measures complete blood count], BMP [basic metabolic panel - blood test that measures various substances in the blood] and UA [urinalysis - urine test to assess various substances and conditions].” 3. During a concurrent interview and record review on 1/27/25 at 2:32 p.m. with RNI, Patient 16’s MR was reviewed, the MR indicated: 1/7/25 at 9:54 p.m. BP: 144/87; HR 93; RR: 18; Sat: 97%; Temp: 36.7 C; Pain level: 3 1/8/25 at 2:21 a.m. BP 129/76; HR 101; RR: 18; Sat: 97%; Temp: 37.2 C; pain level: (missing). RNI stated Patient 16 had an ESI level of 3 and VS and reassessments should be done every 2 hours and it was not completed as per documentation. During a review of the facility’s P&P titled, “Triage Process in the Emergency Department,” dated September 2024, the P&P indicated, “III. POLICY STATEMENT: It is the policy of [Facility 1] that all patients presenting at the ED will be triaged to determine the type and urgency of their condition. . . V. PROCEDURE: A. Triage Acuity Process. . .c) Level Three - Urgent . . . 1) Patient requiring two (2) or more resources with stable vital signs. . .5. After triage, reassessments occur based on the following guidelines. . .c) ESI Level III - Reassessments approximately every two (2) hours. . . VIII. DOCUMENTATION. . . D. Vital signs and documentation of patient’s condition/status during reassessment.””

“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 facility failed to ensure four of 12 sampled transferred patients (Patient 2, Patient 6, Patient 12 and Patient 20) transfer consent was complete prior to transfer to another Facility. This failure had the potential to result in Patient 2, Patient 6, Patient 12 and Patient 20 not understanding the transfer process to make an informed decision before consenting to the transfer. Findings: During a review of Patient 2’s medical record (MR), dated 11/5/24, the MR indicated Patient 2 was a 16-year-old female who arrived via ambulance on 11/5/24 at 12:29 a.m. with chief complaint of intentional overdose and suicide attempt. Patient 1 ingested 100 325 mg (milligram) aspirin tablets. Patient 1’s family member (FM) found the empty bottle at home and called Emergency Medical Services (EMS). Patient 1 was assigned an Emergency Severity Index (ESI) score of 2 (emergent - needing prompt care). Patient 2 was alert and oriented and the FM was at the bedside. Facility 1 transferred Patient 2 to Facility 3 on 11/5/24 at 4:17 a.m. via ALS (Advance Life Support) Ambulance with a Registered Nurse (RN) for “HLOC (higher level of care).” During a concurrent interview and record review on 1/27/25 at 1:05 p.m., with RN 3, Patient 2’s “IMPORTANT LEGAL NOTICE” (ILN), dated 11/5/24, was reviewed. The ILN indicated there was no signature by Patient 2 or Patient 2’s FM consenting to the transfer. RN 3 stated the ILN should have been signed by Patient 1’s FM. During a review of Patient 6’s MR, dated 10/2/24, the MR indicated Patient 6 was an 86-year-old female arrived at the emergency department (ED) on 10/2/24 at 8:53 a.m. Patient 6 was referred to the ED because Patient 6’s outpatient ultrasound (US- an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside the body) showed the kidneys were swollen due to a buildup of urine. Patient 6 had a history of chronic kidney issues. Patient 6 was assigned an ESI level 3 (urgent but non-life-threatening emergency). Patient 6 was alert and oriented. After a MSE, it was determined Patient 6 needed to be admitted for further care. Facility 1 transferred Patient 6 to Facility 4 on 10/2/24 at 8:24 p.m. via basic life support (BLS) ambulance for insurance reasons. During a concurrent interview and record review on 1/28/25 at 9 a.m. with RN 4, Patient 6’s ILN, dated 10/2/24, was reviewed. The ILN indicated the statement “Based on my examination of the patient and the information available to me at the time of transfer, I certify that the risks of transfer are outweighed by the benefits reasonably anticipated from proper care at the receiving facility,” was not checked. The ILN indicated Patient 6 did not indicate the understanding of the risks and benefits of the transfer, and did not indicate if Patient 6 consented to or refused the transfer. The ILS indicated the time Patient 6 signed the consent was not documented, and the employee who witnessed Patient 6’s signature did not date or time their signature. RN 4 stated the form was not complete and should be completed. 48901 During a review of Patient 12’s MR, dated 9/21/24, the MR indicated Patient 12 was a 35-year-old male who presented to the ED on 9/21/24 at 4 a.m. via ambulance, with chief complaint of “shot in the left eye with a pepper gun.” Patient 12 was alert and oriented. The ED assigned Patient 12 an ESI score of 2. Facility 1 transferred Patient 12 to Facility 2 via ALS ambulance on 9/21/24 at 7:54 a.m. for, “Requires specialty care.” During a concurrent interview and record review on 1/27/25 at 1:56 p.m. with RN Informatics (RNI), Patient 12’s ILN, dated 9/21/24, was reviewed. RNI stated Patient 12’s signature including date/time was missing. RNI stated Medical Doctor’s (MD unidentified) signature was missing the date/time. During a review of Patient 20’s MR, dated 8/12/24, the MR indicated Patient 20 was a 55-year-old male who presented to the ED on 8/12/24 at 10:35 a.m. via ambulance, with chief complaint of left lower extremity pain, swelling, and wound. Patient 20 was alert and oriented. The ED assigned Patient 20 an ESI score of 3. Facility 1 transferred Patient 20 to Facility 3 via BLS ambulance on 8/12/24 at 9:55 p.m. for insurance reason. During a concurrent interview and record review on 1/27/25 at 3:20 p.m. with RNI, Patient 20’s ILN, dated 8/12/24, was reviewed. RNI stated Patient 20’s signature including date/time was missing. RNI stated the RN’s (unidentified) signature was missing the date/time. During an interview on 1/28/25 at 1:40 p.m. with MD 4, MD 4 stated transfer forms need to be complete before transferring the patient to another facility. During a review of the facility’s policy and procedure (P&P) titled, “COBRA/EMTALA Compliance,” dated September 2022, the P&P indicated, “C. Transfer of Patient Without Emergency Medical Condition. . . e) Transfer Summary. . . (n) Declaration of the person signing the he/she is assured, within reasonable medical probability, that the transfer creates no medical hazard to the patient. . . D. Transfer of Patient with Emergency Medical Condition. . . 2. Transfer Request or Physician Certification. . . d) Criteria for Appropriate Transfer. . . (c) In which the transferring Facility sends to the receiving facility copies of all available medical records related to the patient’s emergency condition that are available at the time of transfer, including . . . the written informed consent.” During a review of the facility’s P&P titled, “Transfers to Another Facility,” effective date 9/2024, the P&P indicated, “Physician Responsibilities. . . d) Discuss with the patient/consent giver the risks, benefits, alternatives and consent for the treatment and for the transfer. . . Nursing Responsibilities a) Validate the patient’s consent for transfer to and treatment at another facility by reviewing the physician’s documentation and verifying the patient’s understanding of the risks, benefits and alternatives to the transfer. . .d) Complete and/or review the following documents (as applicable) for completion prior to transfer of patient: 1) Transfer Form, mandatory.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42744 Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, “Patient Rights and Responsibilities” for 8 of 32 sampled patients (Patient 21, Patient 22, Patient 2, Patient 9, Patient 11, Patient 12, Patient 13, and Patient 14) when staff could not provide documentation of Patient Rights and Responsibilities (PRR) or Notice of Privacy Practices (NOPP) being provided. This failure had the potential for patients and their representatives not to be informed of their rights and responsibilities or privacy practices. Findings: During a review of the form titled, “Document Signature Checklist (DSC),” dated 6/23, the DSC indicated checkboxes for “Notice of Privacy Practices (NOPP)” and “Patient Rights & Responsibilities.” The DSC indicated by signing the form, the patient or legal representative had received or refused a copy of the documents checked. During an interview on 12/2/24 at 3:07 p.m. with Revenue Cycle Manager (RCM), RCM stated when patients register, the patients’ rights and responsibilities should be reviewed verbally with the patient by the Patient Access Representative. RCM stated the DSC must be checked off to indicate patient rights information was discussed with the patient. RCM stated there was a handout for Patient Rights and an area on the DSC indicating if the patient received or declined copies of the handout. RCM stated without the checkmark on the DSC beside “Patient Rights & Responsibilities” and “Notice of Privacy Practices” we don’t know if the patient got the information. During a concurrent interview and record review on 12/2/24 at 3:31 p.m. with RCM, Patient 21’s DSC, dated 10/17/24 at 7:03 p.m., was reviewed. The DSC indicated nothing was checked off on the document signature list. DSC box indicated, “have been offered but declined copies of documents checked from the above list” was checked off. RCM stated the form was signed by Patient 21’s mother but there was no evidence that patient rights were discussed or patient received a copy of the NOPP. RCM stated it should have documented and the top three on the document signature list (Conditions of Admissions, Notice of Privacy Practices, and Patient Rights & Responsibilities) should have been checked off. During a concurrent interview and record review on 12/2/24 at 3:37 p.m. with RCM, Patient 22’s DSL, dated 10/17/24 at 10:19 p.m., was reviewed. Patient 22’s DSC indicated nothing was checked off on the document signature list. DSC box indicated, “have been offered but declined copies of documents checked from the above list” was checked off. RCM stated the DSC was signed by the mother. RCM stated a copy of the signed NOPP dated 10/17/24 was found in Patient 22’s medical record. RCM stated there was no verification or validation patient rights and responsibilities was discussed. 29618 During a concurrent interview and record review on 12/2/24 at 2:27 p.m. with Director of Informatics (Registered Nurse [RN] 2), the facility’s form titled, “Document Signature Checklist (DSC)” for Patient 2 was reviewed. The DSC had checkboxes for “Notice of Privacy Practices (NOPP)” and “Patient Rights & Responsibilities (PRR).” RN 2 stated the check boxes were to indicate what was provided to the patient. The DSC also had a section with check boxes and a signature line to indicate if the Patient or Patient Representative had received or declined a copy of the documents checked. Patient 2’s DSC had one box checked, and it was not for NOPP or PRR. RN 2 stated “This is all they did. It’s (Patient Rights) not checked.” During a concurrent interview and record review on 12/3/24 at 2:17 p.m. with RN 2, the DSC for Patient 9 was reviewed. There was no check mark for PRR being provided to Patient 9. RN 2 confirmed the finding. During a concurrent interview and record review on 12/3/24 at 2:25 p.m. with RN 2, the DSC for Patient 11 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 11. RN 2 confirmed the finding. During a concurrent interview and record review on 12/3/24 at 2:30 p.m. with RN 2, the DSC for Patient 12 was reviewed. There was no check mark for PRR being provided to Patient 12. RN 2 stated “Patient rights isn’t checked.” During a concurrent interview and record review on 12/3/24 at 2:35 p.m. with RN 2, the DSC for Patient 13 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 13. RN 2 stated there was no Patient Rights provided. During a concurrent interview and record review on 12/3/24 at 2:51 p.m. with RN 2, the DSC for Patient 14 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 14. RN 2 stated there was no documentation for Patient Rights being provided. During a review of the facility’s P&P titled, “Patient Rights and Responsibilities,” dated 4/22, the P&P indicated, “V. PROCEDURE: A. Notification of Patient: 1. Patients will receive a copy of the Rights and Responsibilities upon admission/registration to inpatient and outpatient settings at [hospital]. (See Addendum A.) B. Overview of Patient Rights and Responsibilities: . . . 2. Patients have the right to: . . . q) Confidential treatment of all communications and records pertaining to the patient’s care and stay in the hospital. The patient will receive a separate Notice of Privacy Practices that explains the patient’s privacy rights in detail and how [hospital] may use and disclose PHI [protected health information].””

“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: 42744 Based on interview and record review, the facility failed to: 1. follow their policy and procedure (P&P) titled, “Patient Safety Observation” for monitoring one of seven sampled patients (Patient 21) presenting to the Emergency Department (ED) with suicidal ideation and at high risk for self-harm. This failure had the potential for suicidal patients to harm themselves while in the ED. 2. follow their policy and procedure for reporting an allegation of abuse for one of one sampled patients (Patient 2). This failure had the potential to place Patient 2 at risk for further abuse. Findings: During a review of Patient 21’s “Patient Information (PI),” dated 10/17/24 at 6:58 p.m., the PI indicated Patient 21 was registered in the ED at 6:58 p.m. During a review of Patient 21’s “Visit History Viewer (VHV),” dated 11/17/24 from 7:01 p.m. to 10/18/24 at 11:48 a.m., the VHV indicated Patient 21 was in the ED waiting room from 7:01 p.m. until 10:11 p.m. then moved to the ED bed designated as “OF11.” During a concurrent interview and record review on 12/2/24 at 2:53 p.m. with Registered Nurse (RN) 1, Patient 21’s Columbia Suicide Severity Rating Scale (C-SSRS- validated tool used to determine a patient’s risk for suicide) was reviewed. RN 1 stated Patient 21 was brought to the ED via private vehicle with suicidal ideation. RN 1 stated Patient 21 scored a “10- high risk” on the C-SSRS done by the triage nurse. During a concurrent interview and record review on 12/2/24 at 3:40 p.m. with RN 1, Patient 21’s “Emergency Documentation (EDD),” dated 10/17/24 at 7:51 p.m. was reviewed. The EDD indicated, “Patients presents with mother for SI [suicidal ideation] with plan of overdosing on ibuprofen [pain medication] or cutting herself. Patient texted her friend and her sister discussing the plan. Denies HI [homicidal ideation] at this time.” During a review of Patient 21’s “Observation Log (OL),” dated 10/17/24, the OL indicated Patient 21’s line of sight observation started at 10:45 p.m. and documentation continued every 15 minutes until Patient 21 was discharged on 10/18/24 at 11:39 a.m. During a review of Patient 21’s “Violent and Self-Destructive Restraint Flow Sheet (RFS),” dated 10/18/24, the RFS indicated Patient 21 was placed in 4 limb restraints for being a danger to self and others. During a review of Patient 21’s “Restraint/Seclusion Nursing Notes (RNN),” dated 10/18/24 at 1:10 a.m., the RNN indicated Patient 21 had removed plastic fasteners from the stretcher bedrails and attempted to use them to cut her arms. RNN indicated Patient 21 was banging her head and arms on the wall and floor and knocked a hole in the wall with her right elbow. RNN indicated Patient 21 kicked a security guard and attempted to bite and assault staff. RNN indicated after Patient 21 was placed in restraints she attempted to tip the gurney over. During an interview on 12/2/24 at 4:54 p.m. with Director of Emergency Services (DES), DES stated Patient 21 came into the ED at 6:58 p.m. and remained in the waiting room after triage. DES stated Patient 21’s suicidal monitoring observations did not start until 10:45 p.m. DES stated, based on the policy for a patient who is high risk for suicide, Patient X required a one-to-one (1:1) observation with documentation every 15 minutes, which was not documented in Patient 21’s medical record until 10:45 p.m. DES stated if no bed was available in the ED, Patient 21’s should have been placed in a “law enforcement chair (chairs within direct site of the nurse’s station used by patients brought in by law enforcement).” DES stated that had always been the policy but there have been deviations in practice on the night shift. During a concurrent interview and record review on 12/2/24 at 5:23 p.m. with RN 1, Patient 21’s Medical Record (MR) was reviewed. RN 1 stated there was no documentation in Patient 21’s MR of observation in the ED waiting room every 15 minutes. During an interview on 12/3/24 at 11:06 a.m. with DES, DES stated Patient 21’s suicide risk assessment was a “10” which was high risk and any patient with a risk assessment over “6” should have been brought back to the main ED. DES stated Patient 21 should have been brought back right away and had line of site and 1:1 observation, but wasn’t brought back until 10:11 p.m. DES stated RN 3 told her Patient 21 was with her mom, so she had someone to watch her and keep her safe. DES stated the policy was Patient 21 should have been taken to the law enforcement area if no beds were available and observation should have been started. During a review of the facility’s P&P titled, “Patient Safety Observation,” dated 7/23, the P&P indicated, “I. PURPOSE: To establish guidelines for the use of patient safety observers, both in-person and virtual, to ensure the safety of patients at risk of harm to themselves or others. . . C. In-Person Observation 1. Line of Sight Observation a) This observation level is utilized for patients, who exhibit potential for self-harm or harm to others, but do not require immediate intervention. B) Patient behavior, activity and safety will be observed and documented at least every 15 minutes and upon behavior change on Associated Form, #3115, In-Person Observation Log . . . 3. One to One (1:1) Observation . . . c) Have been screened as high risk for suicide utilizing the Columbia Suicide Severity Rating Scale (CSSRS) d) A 1:1 patient safety observer will be deployed to the bedside and suicide precautions will be implemented.” 29618 2. During a concurrent interview and record review on 12/2/24 at 2:30 p.m. with RN 7, Patient 2’s “Progress Note (PG)” dated 11/18/24 at 10:42 a.m. was reviewed. The PG indicated, “On 11/17/24 around 16:30 (4:30 p.m.) received complaints from pt’s (patients) that it smelled like cigarette smoke in the room. Security was called and items removed from pt. Per pt security held both her wrists. Assessed a bruise to left wrist. . .” RN 7 stated the progress note was documented by RN 4. During a concurrent interview and record review on 12/2/24 at 2:48 p.m. with RN 4, Patient 2’s “Electronic Medical Record (EMR)” was reviewed. RN 4 stated Patient 2 said security held her wrist. RN 4 stated she notified the charge nurse and assessed the patient. RN 4 stated “It was a new bruise inside her (Patient 2) wrist.” During an interview on 12/2/24 at 3:01 p.m. with RN 4, RN 4 stated she didn’t recall having Abuse training. When asked if she knew what to report, or who to report to, RN 4 stated “No.” During a concurrent interview and record review on 12/2/24 at 3:02 p.m. with RN 5, RN 5 stated she was the Supervisor of the Unit (2 Center). RN 5 reviewed the PG documented by RN 4. RN 5 stated she wasn’t aware of the allegation. RN 5 stated “She (RN 4) should’ve notified the Charge Nurse, myself, and the House Supervisor.” During a phone interview on 12/3/24 at 8:58 a.m. with Security Officer (SO), SO stated there were calls from staff and patients on 2 center regarding smoke smell in room. SO stated staff knew who it was, and wanted me to let her know she couldn’t smoke, and we needed to confiscate the cigarettes. SO stated “She (Patient 2) had a coffee mug with ashes and cigarettes.” SO stated initially Patient 2 denied she was smoking, and finally admitted. SO stated Patient 2 was told “No Smoking” and she (Patient 2) threatened to punch staff and frailing (moving wildly) her arms. SO stated “I intervened grabbed both wrist, and told her she couldn’t threaten staff.” Patient 2 handed over the cigarette and matches, and I gave them to the nurse. SO stated “Patient 2 said she was going to complain, but I never heard anything.” SO stated he made a report of the incident. During a concurrent interview and record review on 12/3/24 at 9:18 a.m. with RN 6, RN 6 reviewed the PG documented by RN 4. RN 6 stated she told staff to call security to control the situation, because we told Patient 2 there was no smoking. Patient 2 continued to smoke and say it’s her right. RN 6 stated she wasn’t in the room with security and didn’t know what happened. RN 6 stated “I wasn’t aware of the alleged assault. Had I known an occurrence report would have been made, and notified his (security officer) superior.” During an interview on 12/3/24 at 10:20 a.m. with Director of Staff Development (DSD), DSD stated “We send new hires a video training to complete prior to their start date.” During a concurrent interview and record review on 12/3/24 at 10:29 a.m. with Human Resources Business Partner (HRBP), RN 4’s Learning Transcript (LT) was reviewed. The LT indicated RN 4 Date of Hire was 1/2/24. RN 4 completed “New Hire Orientation 12/28/23, Abuse/Mandatory Reporting Requirements 1/4/24, and [Hospital] -All Staff Review 3/12/24.” During a review of the facility document titled “New Hire Orientation (NHO)” undated, the NHO indicated “Standard - Abuse, Neglect & Exploitation, The hospital must: Educate staff on reporting possible abuse . . .” During a review of the facility document titled “[Hospital name] All Staff Review (ASR)” undated, the ASR indicated “Abuse, Neglect and Exploitation- Mandated Reporters are licensed employees. . . Policy ADM -PI-120 Sentinel/Adverse Events- . . . All staff have an obligation to immediately report any incident and/or allegation of abuse of a patient while in the facility. Upon identifying an allegation and/or incident, the individual will: Notify their immediate Supervisor.” During a review of the facility policy and procedure (P&P) titled, “Mandated Reporting Requirements” dated July 2024, the P&P indicated “Procedure: 2.a) Any mandated reporter . . .has observed or has knowledge of an incident that reasonably appears to be abuse . . . shall complete a verbal and written report for each report of known or suspected instance of abuse . . .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 29618 Based on interview and record review, the facility failed to have a careplan for restraint use for one of six sampled patients (Patient 5). This failure resulted in interventions, goals, and expected outcomes not being developed. Findings: During a concurrent interview and record review on 12/3/24 at 1:29 p.m. with Registered Nurse (RN) 2, Patient 5’s Electronic Medical Record (EMR) was reviewed. Patient 5’s “Restraint for Non-Violent Behavior (RNVB)” order dated 11/15/24 indicated “Side Rails x (times) 4 Bilateral Soft Wrist.” RN 2 reviewed the order and stated the restraint use was from 11/15/24 at 2030 (8:30 p.m.) to 11/16/24 at 0600 (6 a.m.). RN 2 reviewed the careplans for Patient 5, and there was no restraint careplan. RN 2 stated “They should have one (careplan for restraints).” During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care (IPOC) (Non-Psychiatric Patients),” review date February 2024, the P&P indicated “III. POLICY STATEMENT: It is the policy of [Hospital name] that all inpatients will have an interdisciplinary plan of care (IPOC) to assist in setting priorities of care that promote health, wellbeing and healing . . . V. PROCEDURE: A. The POC will consist of the following: 1. Actual or potential problems 2. Outcome/goals . . .4. Interventions. . .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 29618 Based on observation, interview, and record review, the facility failed to ensure restraint orders for one of six sampled patients (Patient 4) were followed. This failure resulted in Patient 4 being restrained inappropriately. Findings: During a concurrent observation and interview on 12/2/24 at 11:46 a.m. in Patient 4’s room, Patient 4 was in bed with Sitter at the bedside. Sitter stated Patient 4 was previously in a 4 point restraint, and doctor ordered 2 point restraint. During a concurrent interview and record review on 12/2/24 at 4:15 p.m. with Registered Nurse (RN) 7, Patient 4’s “Electronic Medical Record (EMR”) was reviewed. Patient 4 ‘s order for Restraint For Non-Violent Behavior (RNVB) dated 11/28/24 at 0245 (2:445 a.m.) was reviewed. The RNVB indicated, “Side Rails x (times) 4.” RN 7 stated Patient 4 was seen in the Emergency Department (ED), and the ED Doctor ordered the restraints. During a review of Patient 4’s “Emergency Documentation- ED Note Physician (EDNP)” dated 11/28/24 at 6:06 a.m., the EDNP indicated, “Assessment/Plan, Restraint For Non-Violent Behavior, 11/28/24 2:45:00 PST (Pacific Standard Time), Altered Mental Status, Side Rails x 4 . . .” During a concurrent interview and record review on 12/3/24 at 11:20 a.m. with RN 2, RN 2 reviewed Patient 4’s restraint order dated 11/28/24, and stated it was for Side Rails x 4. RN 2 reviewed Patient 4’s “Restraint Monitoring (RM)” dated 11/28/24, and the RM indicated “Restraint Type/Location, Soft Wrist, Bilateral w (with)/ side rails x4, Soft Ankle, Bilateral w/side rails x4. Restraint applied properly . . .” During an interview on 12/3/24 at 11:46 a.m. with RN 2, RN 2 stated “What was ordered is not what was applied.” RN 2 stated the EMR indicated RN 8 as the nurse who applied and documented the restraints. During an interview on 12/3/24 at 11:58 a.m. with Director Emergency Services (DES), DES stated “We only have two siderails (on the beds).” DES stated the nurse needs to clarify the order (for restraints). During a concurrent interview and record review on 12/3/24 at 3:22 p.m. with RN 8, RN 8 reviewed the RNVB order for Patient 4 to have Side Rails x 4. RN 8 stated “The doctor put it in wrong . . .maybe.” RN 8 stated “I’m assuming the doctor gave a verbal order.” RN 8 was unable to find documentation of verbal order given. RN 8 stated the doctor is new, “I should have clarified the order.” During a review of the facility’s policy and procedure (P&P) titled, “Physician Orders (PO)” dated October 2022, the PO indicated “V. PROCEDURE: 7. Orders that are unclear or that do not comply with hospital policy will be clarified and corrected prior to implementation. In the event there are concerns or questions regarding a physician order . . .will immediately contact the physician for clarification.””

“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: 29618 Based on interview and record review, the facility failed to ensure two of six sampled patients (Patient 16 and Patient 18) in restraints were monitored according to the physician order. This failure had the potential to result in circulatory, motor, and sensory deficits. Findings: During a concurrent interview and record review on 12/3/24 at 4:10 p.m. with Registered Nurse (RN) 2, the Electronic Medical Record (EMR) for Patient 16 was reviewed. Patient 16 was admitted on 11/25/24. The order for Restraint for Non-Violent Behavior (RNVB) dated 11/27/24 at 2052 (8:52 p.m.) was reviewed. RN 2 stated the order was for behavior. The RNVB indicated “Reason for Restraint: Behavior interfering with medical care. Side Rails x (times)4, Bilateral Soft Wrist.” The RNVB indicated “Restraint Monitoring Non-Violent Behavior Q(every) 2 hr (hour), Duration 24 hr.” The monitoring sheet indicated to monitor for Behavior, Active ROM (Range of Motion -the range of movement at a joint that occurs when muscles contract and relax without assistance), and Passive (assist in moving muscles) ROM. During a concurrent interview and record review on 12/3/24 at 4:20 p.m. with RN 2, the Restraint Monitoring was reviewed for 12/1/24. There was no documentation of monitoring at 0600 (6 a.m.). RN 2 stated “There’s no monitoring for 6 a.m.” During a concurrent interviw and record review on 12/3/24 at 4:32 p.m. with RN 2, Patient 18’s EMR was reviewed. Patient 18 was admitted on 11/23/24. Patient 18’s order for RNVB dated 11/23/24 at 2046 (8:46 p.m.) was reviewed. The RNVB indicated “Reason for Restraint: Altered Mental Status. Bilateral Soft Wrist.” The RNVB indicated “Restraint Monitoring Non-Violent Behavior Q2hr Duration 24 hr.” The restraint was applied at 2100 (9 p.m.), and there was no documentation of monitoring at 0000 (Midnight). RN 2 stated “It wasn’t done.” During an interview on 12/4/24 at 11:30 a.m. with RN 1, a policy and procedure for restraint monitoring was requested. RN 1 stated “Order is for 2 hours to monitor. It’s not in policy. It’s an order.” During a review of the facility’s policy and procedure (P&P) titled “Physician Orders (PO)” dated October 2022, the P&P indicated, “Purpose: To provide standards for prescribing and writing orders by physicians and advanced practice providers and for the initiation and administration of those orders by healthcare professionals.””

“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: 29618 Based on observation, interview, and record review, the facility failed to ensure a contracted Registered Nurse (CRN) providing dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services to one of one sampled patient (Patient 11), performed hand hygiene after contact with equipment. This failure had the potential to spread infectious diseases to patients, staff, and visitors. Findings: During an observation on 12/2/24 at 11:32 a.m. of room 3227, Patient 11 was in bed with family at bedside. CRN was connecting tubing to the dialysis machine without wearing gloves. CRN finished the connections, and with no hand hygiene started documenting on a form. During an interview on 12/2/24 at 11:35 a.m. with CRN, CRN stated the tubing isn’t sterile. CRN stated “I should have done hand hygiene, but I don’t see the problem.” During a concurrent interview and record review on 12/2/24 at 4:03 p.m. with Director of Licensing and Accreditation (DLA), DLA provided documentation of Education for CRN. The “Hospital Services HD (Hemodialysis) Annual Procedural Skills Verification Checklist (HSASVC) dated 5/22/24 for CRN was reviewed. The HSASVC indicated CRN was signed off as “Satisfactory performance of skill” on 5/22/24. During a review of the “Hospital Services Agreement (HSA) signed April 17, 2024, the HSA indicated, “3.2 Policies and Procedures. (a) All Company Staff shall comply with the policies and procedures of Hospital in effect on the date hereof that relate to the provision of the Services. . .” During a review of the facility policy and procedure (P&P) titled “Hand Hygiene” dated June 2022, the P&P indicated, “B. Indications for Hand Hygiene 3. Hand hygiene is practiced: b) After 4) Contact with inanimate objects (including medical equipment) in the immediate patient vicinity.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47095 Based on observation, interview, and record review, the facility failed to ensure conditions of admission [COA- a legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits, and acceptance of financial responsibility for medical services] was provided to patients and/or their legal representative for five of 30 sampled patients (Patient 30, Patient 26, Patient 23, Patient 8, and Patient 10). This failure resulted in Patient 30’s legal representative being uninformed of Patient 30’s medical status and course of treatment, and Patient 26, Patient 23, Patient 8, and Patient 10 being uninformed of their patient rights in agreement for care services during their hospitalization. Findings: During a concurrent observation and interview on 8/5/24 at 9:15 a.m., with Emergency Department Supervisor Registered Nurse (EDS), in the doorway of Patient 30’s room, Patient 30 was in bed with continuous electroencephalogram (EEG- test that measures electrical activity in the brain) monitoring and swallow evaluation testing. EDS stated Patient 30 had a conservatorship (A designated court appointed person that makes decisions for medical care on behalf of a person not capable of making their own decisions) and was brought in for a medical evaluation of seizures (uncontrolled abnormal communication between brain cells and the body). During a concurrent interview and record review on 8/5/24 at 1:16 p.m., with EDS, Patient 30’s medical record admission section (MRAS), dated 8/2/24 was reviewed. There was no documentation in the MRAS that Patient 30’s conservator was contacted regarding Patient 30’s medical status, treatment, and admission to the hospital. EDS stated Patient 30’s conservator should have been contacted regarding Patient 30’s medical status and course of treatment. During a concurrent interview and record review on 8/6/24 at 10:23 a.m., with Director Informatics Registered Nurse (DIRN), Patient 26’s MRAS, dated 8/5/24 was reviewed. The MRAS indicated Patient 26 was brought to the Emergency Department (ED) on 8/5/24. DIRN stated there was no COA documentation to provide for Patient 26. DIRN stated the expectation was that Patient 26 was informed of her rights of admission. DIRN stated Patient 26’s COA should have been done. During a concurrent interview and record review on 8/6/24 at 10:48 a.m., with DIRN, Patient 23’s MRAS, dated 6/1/24 was reviewed. The MRAS indicated Patient 23 was brought into the ED on 6/1/24. MIRN stated she was unable to find documentation of a COA for Patient 23. MIRN stated “there is not one [COA]” for Patient 23 and there should be. 42610 During a concurrent interview and record review on 8/6/24 at 10:24 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 8’s MRAS, dated 6/3/24 was reviewed. The MRAS indicated, Patient 8 did not receive the COA. RNIM confirmed Patient 8 did not receive a COA. 49419 During a concurrent interview and record review on 8/6/24 at 1:45 p.m. with Manager of Emergency Department Admitting (MEDA), Patient 10’s COA, dated 6/3/24 was reviewed. The COA indicated, Patient 10 signed his COA at 4:42 p.m. and left discharged at 4:50 p.m. (8 minutes). MEDA stated the expectation was for Patient 10’s COA to be completed when he was admitted on 8/6/24 at 3:08 p.m. for treatment and not when he was discharged. During an interview on 8/6/24 at 1:46 p.m. with Director of Licensing and Accreditation Registered Nurse (DLARN). DLARN stated Patient 10 “Did not receive [COA] timely.” During a review of the facility’s P&P titled, “[Facility] Rules and Regulations,” dated 2/28/12, the P&P indicated, “SECTION C. GENERAL CONDUCT OF CARE- 1. A Condition of Admission form, signed by or on behalf of every patient admitted to the medical center, must be obtained at the time of admission.””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 47095 Based on interview and record review, the hospital failed to ensure the “Advance Health Care Directive” policy and procedure (P&P) was followed for two of 30 sampled patients (Patient 26 and Patient 8). This failure resulted in violation of patient rights to make medical care decisions and formulate an Advance Directive (a written statement of a person’s wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Findings: During a concurrent interview and record review on 8/6/24 at 10:01 a.m. with Director Informatics Registered Nurse (DIRN), Patient 26’s “Care Preference Advance Directive (CPAD),” dated 8/6/24 was reviewed. The CPAD indicated Patient 26 was not offered the opportunity to formulate an Advance Directive. DIRN stated offering Patient 26 to formulate an Advance Directive included documenting not able to obtain. DIRN stated Patient 26’s CPAD section was incomplete and there is no documentation to provide that Patient 26 was offered to formulate and Advance Directive. 42610 During a concurrent interview and record review on 8/6/24 at 10:24 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 8’s “Medical Record (MR),” dated 6/3/24 was reviewed. The MR indicated, Patient 8 was not asked if he had an Advance Directive. RNIM stated there was no documentation Patient 7 was asked about an Advanced Directive or offered assistance to formulate an Advanced Directed. During a review of the facility’s P&P titled, “Advance Health Care Directive,” dated 2/2024, the P&P indicated, “It is the policy of [Facility] to inform the patients of their right to accept or refuse treatment, their right to collaborate in developing goals of treatment, and the right to communicate those decisions, either verbally or in writing (Advance Health Care Directive) to their health care team.””

“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: 47095 Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, “Patient Safety Observation” for three of 30 sampled patients (Patient 29, Patient 27, and Patient 7). This failure had the potential for Patient 29, Patient 27, and Patient 7 to cause self harm. Findings: During a concurrent interview and record review on 8/5/24 at 3:38 p.m. with Emergency Department Supervisor Registered Nurse (EDS), Patient 29’s “Observation Log (OL),” dated 8/5/24 was reviewed. The OL indicated Patient 29 was on a legal hold (5150- A 72 hour legal hold for assessment and evaluation for a person that is a danger to self or others) and had safety observation ordered. EDS stated there was no summary and/or comments entry for Patient 29 at times: 1:30 a.m., 1:45 a.m., and 2 a.m. EDS stated the OL’s purpose was “for safety” of the patient. EDS stated there was no breakfast meal tray safety check done at 8 a.m. and no safe meal tray ordered for Patient 29. EDS stated the expectation for safety was for a safe meal tray ordered and the OL to be completed and no documentation meant “not done.” During a concurrent interview and record review on 8/5/24 at 4:05 p.m. with EDS, Patient 27’s “OL,” dated 8/4/24 was reviewed. The OL indicated Patient 27 was on a legal hold (5150) and had safety observation ordered. EDS stated there was no breakfast meal tray safety check done at 8 a.m.. EDS stated Patient 27’s breakfast meal tray “should have been checked.” During an interview on 8/5/24 at 4:09 p.m. with EDS, EDS stated Patient 27 and Patient 29 were a danger to self harm. EDS stated Patient 27 and Patient 29 were both on legal holds for safety. During an interview on 8/5/24 at 4:11 p.m. with EDS, EDS stated Patient 29 had a Columbia Suicide Severity Rating Scale (CSSRS- Risk stratification assessment for Suicide) score of 25 (a score of 6 or greater is high risk for suicide/self-harm). 42610 During a concurrent interview and record review on 8/6/24 at 10:04 a.m. with Registered Nurse In-patient Manager (RNIM), Patient 7’s OL, dated 6/3/24 was reviewed. The OL indicated, at 6:15 p.m. a meal tray was served to Patient 7. RNIM stated there was no documentation that a meal tray safety check was done. During a review of Patients 7’s “ED Triage (EDT-process of organizing emergency patient priority),” dated 6/3/24 the EDT indicated, “Psychiatric Hold: Yes. . . CSSRS Risk Level: High Risk.” During a review of Patient 7’s “Physician Order (PO),” dated 6/3/24, the PO indicated, “Regular Diet. . . Tray, Safe Meal.” During a review of the facility’s P&P titled, “Scope of Service-Emergency Department”, dated January 2023, the P&P indicated, “The ED will provide and maintain a physical environment that is safe for all patients. . . Safety. . . b) The ED staff will follow established guidelines to ensure safe and efficient delivery of care. . . 4) Close Observation (a) Close observation is defined as constant visual access with ability to reach patient quickly enough to prevent any further injuries. (b) Patients requiring close observation include, but are not limited to, attempted suicide, §5150 hold.” During a review of the facility’s P&P titled, “Patient Safety Observation (PSO)”, dated July 2023, the P&P indicated, “PURPOSE: To establish guidelines for the use of patient safety observers, both in-person and virtual, to ensure the safety of patients at risk of harm to themselves. . . PROCEDURE. . . the use of a remote or in-person patient observer to support the safety needs of the patient in accordance with [Facility] policies and standards. . . Patient behavior, activity and safety will be observed and documented at least every 15 minutes and upon behavior change on Associated Form, #3115, In-Person Observation Log. . . Have been screened as a high risk for suicide utilizing the Columbia Suicide Severity Rating Scale (CSSRS).” During a review of the facility’s training Power Point titled, “PATIENT SAFETY OBSERVATION (PSO)”, (undated), the PSO indicated, “PURPOSE. . To establish guidelines for the use of patient safety observers, both in-person and virtual to ensure the safety of patients at risk of harm to themselves or others. . . EVERY 15-MINUTE DOCUMENTATION IN-PERSON OBSERVATION LOG. . . Meal tray check for contraband. . . EVERY 15- MINUTE DOCUMENTATION (FORMFAST #3115) IN-PERSON OBSERVATION LOG. . . Meal tray check for contraband.” During a review of the facility’s P&P titled, “Safety Tray (ST),” dated 1/2023, the P&P indicated, “POLICIES: Safety trays are ordered for patients who are a threat to themselves or others. PROCEDURES. . . Containers, dishes, and cups used are non-plastic and disposable, typically either Styrofoam or paper. A disposable tray is used. . . No utensils or pre-approved disposable “safety” utensil(s) are provided. . . Food packaging not permitted includes plastic bottles, aluminum containers/cans or foil. . . Tray, Safe Meal. . . Paper tray, disposable plates, a specific paper spoon, straw, no plastic utensils. . . Order Required per Unit. . . YES.””

“MEDICAL STAFF RESPONSIBILITIES - ASSESSMENT CFR(s): An assessment of the patient (in lieu of the requirements of paragraphs (c)(5)(i) and (ii) of this section) be completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the patient is receiving specific outpatient surgical or procedural services and when the medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at paragraph (c)(5)(v) of this section, specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services. The assessment must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 47095 Based on observation, interview and record review the facility failed to ensure a physician medical screening examination (MSE) was completed and documented prior to patient discharge for one of 30 sampled patients (Patient 29). This failure had the potential to result in a disruption in continuity of care. Findings: During a concurrent observation and interview on 8/5/24 at 9:27 a.m. with Emergency Department Supervisor Registered Nurse (EDS), Patient 29 was in the overflow area next to the nurses station. EDS stated “that’s the line-of-sight observation” area. During a concurrent interview and record review on 8/5/24 at 1:58 p.m. with EDS, Patient 29’s Medical Record Documentation Section (MRDS), dated 8/5/24 was reviewed. EDS stated Patient 29 had “only RN [Registered Nurse]” MSE documented. EDS stated there was no physician MSE. EDS stated Patient 29 was discharged on 8/5/24 at 10:47 a.m., and a physician “MSE should be done meaning completed since patient already discharged.” EDS stated all patients are supposed to have a completed physician MSE in order to determine severity of condition and suitable for discharge or transfer. During a concurrent interview and record review on 8/7/24 at 11:25 a.m., with Emergency Department Attending Doctor (EDAD), Patient 29’s MRDS, dated 8/5/24 was reviewed. EDAD stated the MSE was expected to be “completed prior to end of shift.” EDAD stated the expectation with emergency circumstances including trauma and life-sustaining medical interventions would be “24 hours” for MSE completion. EDAD stated he was overseeing ED Residents care provided to Patient 29. During a concurrent interview and record review on 8/7/24 at 11:35 a.m., with EDAD, Patient 29’s electronic MRDS, dated 8/5/24 was reviewed. The MRDS indicated ED Resident (EDR) authentication of completion for Patient 29’s MSE was on 8/7/24 at 11:34 a.m. EDAD stated, EDR’s MSE for Patient 29 was “routed to me today[8/7/24]” awaiting his review, and co-signature. EDAD stated expectation was to “complete MSE by discharge.” During a concurrent interview and policy and procedure (P&P) review on 8/7/24 at 2:26 p.m. with ED Medical Director (EDMD), the P&P titled, “[Facility] Medical Staff Rules and Regulations,” dated 2/28/12 was reviewed. The P&P indicated at the time a patient is discharged all notes must be completed. EDMD stated Patient 29’s physician MSE “should have been completed” per the facility’s Medical Staff Rules and Regulations. During a review of the facility’s P&P titled, “[Facility] Medical Staff Rules and Regulations,” dated 2/28/12, indicated, “SECTION A. ADMISSION, TRANSFER AND DISCHARGE OF PATIENTS- 1. ADMISSION a. The medical staff will comply with all federal and state rules and regulations. . . and the policies and procedures of the hospital. Medical staff members will provide services, including but not limited to medical screening. . . 9. EMERGENCY DEPARTMENT-An appropriate medical record shall be kept for every patient receiving emergency services and be incorporated in the patient’s medical record. . . 10. COMPLETION- a. Each patient’s medical record shall be signed by the member of the medical staff who is responsible for its clinical accuracy. . . c. The patient’s medical record shall be complete at the time of discharge, including progress notes, final diagnosis, and clinical summary. Records are considered complete when the responsible practitioners and health care professionals have dictated or written and authenticated all necessary reports and have authenticated all record entries.” During a review of the facility’s P&P titled, “Legal Medical Record (LMR),” dated 4/2021, the P&P indicated, “c. content. . . all hospital records. . . must comply with the applicable hospitals’ medical staff rules and regulations requirement for content and timely completion. . . 6. All LMR entries will be made as soon as possible after care is provided or observation is made. . . Responsibility for the medical record. . . b) The medical staff and other healthcare professionals are responsible for the documentation in the medical record within required and appropriate timeframe’s to support patient care. . . d) Draft Document/Work in Progress 1) Electronic processes and workflow management require methods to manage work in progress. These work in progress documents are often available in the system as “draft documents” and are viewable.””