Corona Regional Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to comply with the provisions in §CFR 489.24, when the facility failed to ensure reassessment, monitoring, and stabilizing treatment were provided, for one of 20 sampled patients (Patient 20), when Patient 20 came to the emergency department (ED, a department which is open 24 hours a day dedicated to providing treatment to patients with sudden, severe, or life-threatening injuries and illnesses) with chest pain and was given an ESI (Emergency Severity Index, a five-level triage [the process of sorting and prioritizing patients based on the urgency of their symptoms] tool used in the to categorize patient acuity [the severity of the illness or symptoms] and resource needs from Level 1 [meaning most urgent] to Level 5 [meaning least urgent]) level of 3 (three) instead of ESI level 2 (two), and was left in the ED lobby for an hour and 20 minutes while waiting for further treatment. This failure resulted in Patient 20 going into cardiac arrest (a sudden, unexpected loss of heart function, breathing, and consciousness) in the ED lobby and subsequently passing away (Refer to tag A-2407).”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to ensure reassessment, monitoring, and stabilizing treatment were provided, for one of 20 sampled patients (Patient 20), when Patient 20 came to the emergency department (ED, a department which is open 24 hours a day dedicated to providing treatment to patients with sudden, severe, or life-threatening injuries and illnesses) with chest pain and was given an ESI (Emergency Severity Index, a five-level triage [the process of sorting and prioritizing patients based on the urgency of their symptoms] tool used in the to categorize patient acuity [the severity of the illness or symptoms] and resource needs from Level 1 [meaning most urgent] to Level 5 [meaning least urgent]) level of 3 (three) instead of ESI level 2 (two), and was left in the ED lobby for an hour and 20 minutes while waiting for further treatment. This failure resulted in Patient 20 going into cardiac arrest (a sudden, unexpected loss of heart function, breathing, and consciousness) in the ED lobby and subsequently passing away. Findings: On May 12, 2026, at 10:15 a.m., a review of Patient 20’s record was conducted with the Director of Clinical Operations (DCO). A facility document titled, “Patient Summary Report,” was reviewed. The document indicated, “...Acuity...[ESI] 3 - Urgent ...Location Information...list of all locations...02/17/26 [February 17, 2026] 16:29:00 [4:29 p.m.]...Nurse unit room...ED WR [waiting room]...17:50:25 [5:50 p.m.]...[room in the ED]...Bed...B...” A facility document titled, “Triage Note,” dated February 17, 2026, at 4:31 p.m., was reviewed. The document indicated, “...Primary Pain...Assessment tool...numeric (a pain assessment tool from 0 to 10, with 0 meaning no pain, and 10 meaning worst pain)...numeric pain scale: 2...” A facility document titled, “ED Physician Report,” dated February 17, 2026, at 4:56 p.m., was reviewed. The document indicated, “...Chief Complaint...pt [Patient 20] reports substernal [situated or occurring beneath the sternum (breastbone)] cp [chest pain] radiating [to spread outward in all directions from a central point] to back since 1510 [3:10 p.m.] this afternoon after eating. Pt took aspirin [a common over the counter medication used to treat mild to moderate pain, and also commonly prescribed in low doses to prevent heart attacks], 3 [three] tabs [tablets] 81mg [milligrams, unit of measurement], pt reports he had relief but pain returned...radiating to the back and into his left arm...on arrival to the emergency department the pain is returning...reports the pain is worse when he is seated...reports the chest pain is both pressure-like and also burning-like in quality...Physician called to the waiting room for code blue [an emergency announcement indicating a life-threatening medical crisis] activation. Patient [Patient 20] found on the floor of the waiting room, sonorous [continuous, low-pitched, snoring-like lung sounds caused by air flowing through the large airways] respirations, nonresponsive [failing to react to a stimulus, question, or request]...chest compressions [a life-saving first-aid technique used during cardiac arrest to manually pump blood from the heart to the brain and vital organs] initiated during transfer...for loss of pulses on physical examination...Time of death called...Diagnosis...Chest pain...Cardiac Arrest...” There was no documented evidence Patient 20’s chest pain or condition was reassessed or monitored after triage and the medical screening exam (MSE, a process used to determine whether or not an individual has an emergency medical condition) was completed. An interview was conducted on May 12, 2026, at 10:15 a.m., with the ED Director (EDD). The EDD stated, when determining ESI level, patients presenting with chest pain are usually triaged as ESI 2 and then the physician determines how the patient’s treatment should continue. The EDD stated the nurses were previously triaging patients complaining of chest pain at the ED as ESI 3 based on the vital signs (routine measurements which indicate the state of the body’s basic functions, which include temperature, pulse rate, respiration rate, and blood pressure) if the patient appears stable. The EDD stated the facility’s administration recognized patients waiting in` the lobby was an issue and had come up with a new process of triaging patients at the ED. An interview was conducted on May 12, 2026, at 1:10 p.m., with the Medical Director (MD). The MD stated, for a patient with current ongoing chest pain, the patient should have an ESI level of 2. The MD stated the standard of care for a patient with chest pain would be to place the patient on a cardiac monitor (heart monitor, a device which records one’s heart rate and rhythm). The MD stated, regardless of where the patient complaining of chest pain is, whether on an ED bed or at the lobby, the patient should still be monitored and continuously assessed. The Journal of Nuclear Cardiology article titled, “Most patients are triaged using the emergency severity index,” dated September 30, 2016, was reviewed. The article indicated, “...The original ESI handbook (2012) states that each patient with chest pain must be assessed on the basis of the level 1 criteria... Most patients with complaints suspicious for acute coronary syndrome (ACS, a term used for conditions characterized by suddenly reduced blood flow to the heart, which limits oxygen and can cause permanent heart muscle damage)...Thus, the presence of high risk criteria for myocardial ischemia [heart attack] will be categorized into ESI level 2...” A facility policy and procedure (P&P) titled, “Triage ESI Level System,” last revised December 2025, was reviewed. The P&P indicated, “...The Pivot [area of the ED lobby where a nurse triages and assesses the patients] RN [registered nurse] will notify the clinical supervisor [licensed professional who oversees other clinicians within the ED] of any ESI level 1 or ESI level 2 patients presenting to the ED. Patients will be moved to the treatment area...ESI level 2: potentially life or limb threatening and could worsen without intervention...examples may include...chest pain (including pain above the waist) with typical or atypical symptoms...ESI level 3: Any condition that requires evaluation and treatment, is not time critical and will not worsen if untreated for a few hour...””

“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: 42512 Based on interview and record review, the facility failed to ensure patients or their representatives were informed in advance of their rights to appeal discharge, for two of 22 sampled patients (Patients 1, and 2) when the Important Message from Medicare [IMM, a document indicating the patient’s right to appeal his discharge] was not given timely. These failures had the potential for patients to not be able to appeal their discharge. Findings: 1. On March 3, 2026, at 2:46 p.m., a concurrent interview and review of Patient 1’s record were conducted with the Assistant Chief Nursing Officer (ACNO). A facility document titled, “History and Physical [H&P],” dated February 27, 2026, at 3 p.m., indicated Patient 1 was admitted to the facility for a toe infection. A review of the facility document titled, “Important Message from Medicare,” dated March 2, 2026, at 10:10 a.m., was conducted. The document indicated Patient 1 signed the IMM form on March 2, 2026, three days after Patient 1 was admitted. The ACNO stated the IMM is given to all Medicare patients within 24 hours of admission. The ACNO stated the facility should have provided the IMM to the patient by March 1, 2026. On March 4, 2026, at 1:26 p.m., an interview was conducted with the Patient Access Manager (PAM). He stated the expectation was for patient access staff to present the IMM to the patient or representative within 48-hours of admission per Centers for Medicare (CMS). The PAM stated he has one full time patient access staff that is responsible for presenting and obtaining a signature of the IMM. The PAM stated this staff member works Monday through Friday, eight hours per day. The PAM stated the patient was admitted late on a Friday. The PAM stated the patient access staff who was responsible for the IMM was not available to give the IMM to the patient until Monday, which was three days after admission. 2. On March 3, 2026, at 3:15 p.m., a concurrent interview and review of Patient 2’s record were conducted with the Assistant Chief Nursing Officer (ACNO). A facility document titled, “History and Physical [H&P],” dated February 26, 2026, at 4:31 p.m., indicated Patient 2 was admitted to the facility for weakness, low oxygen, cough with black sputum [mixture of mucus and saliva] and shortness of breath. A review of the facility document titled, “Important Message from Medicare,” dated March 2, 2026, at 10:17 a.m., was conducted. The document indicated Patient 2 signed the IMM form on March 2, 2026, four days after Patient 1 was admitted. The ACNO stated the IMM is given to all Medicare patients within 24 hours of admission. The ACNO stated the facility should have provided the IMM to the patient by March 1, 2026. On March 4, 2026, at 1:26 p.m., an interview was conducted with the Patient Access Manager (PAM). He stated the expectation was for patient access staff to present the IMM to the patient or representative within 48-hours of admission per Centers for Medicare (CMS). The PAM stated he has one full time patient access staff that is responsible for presenting and obtaining a signature of the IMM. The PAM stated this staff member works Monday through Friday, eight hours per day. The PAM stated the IMM should have been given within 48 hours of admission. A review of the facility’s policy and procedure (P&P) titled, “Important Message from Medicare,” dated April 2024, was conducted. The P&P indicated, “...All inpatients within 2 [two] calendar days of admission and no more than 7 [seven] days prior to an elective admission. A copy of the IMM must also be provided to each beneficiary within a maximum of 2 [two] calendar days and a minimum of 4 [four] hours prior to discharge. The IM must be signed by all Medicare, Medicare Advantage and Senior HMO (Health Maintenance Organization) patients or the patient’s representative to indicate receipt and understanding of the notice...””

“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: 42512 Based on interview and record review, the facility failed to ensure patients or their representatives were informed in advance of their rights to appeal discharge, for two of 22 sampled patients (Patients 1 and 2) when the Important Message from Medicare [IMM, a document indicating the patient’s right to appeal his discharge] was not given timely. These failures had the potential for patients to not be able to appeal their discharge. Findings: 1. On March 3, 2026, at 2:46 p.m., a concurrent interview and review of Patient 1’s medical record were conducted with the Assistant Chief Nursing Officer (ACNO). A facility document titled, “History and Physical [H&P],” dated February 27, 2026, at 3 p.m., indicated Patient 1 was admitted to the facility for a toe infection. A review of the facility document titled, “Important Message from Medicare,” dated March 2, 2026, at 10:10 a.m., was conducted. The document indicated Patient 1 signed the IMM form on March 2, 2026, three days after Patient 1 was admitted. The ACNO stated the IMM is given to all Medicare patients within 24 hours of admission. The ACNO stated the facility should have provided the IMM to the patient by March 1, 2026. On March 4, 2026, at 1:26 p.m., an interview was conducted with the Patient Access Manager (PAM). The PAM stated the expectation was for patient access staff to present the IMM to the patient or representative within 48-hours of admission per Centers for Medicare (CMS). The PAM stated he has one full time patient access staff that is responsible for presenting and obtaining a signature of the IMM. The PAM stated this staff member works Monday through Friday, eight hours per day. The PAM stated the patient was admitted late on a Friday. The PAM stated the patient access staff who was responsible for the IMM was not available to give the IMM to the patient until Monday, which was three days after admission. 2. On March 3, 2026, at 3:15 p.m., a concurrent interview and review of Patient 2’s medical record were conducted with the Assistant Chief Nursing Officer (ACNO). A facility document titled, “History and Physical [H&P],” dated February 26, 2026, at 4:31 p.m., indicated Patient 2 was admitted to the facility for weakness, low oxygen, cough with black sputum [mixture of mucus and saliva] and shortness of breath. A review of the facility document titled, “Important Message from Medicare,” dated March 2, 2026, at 10:17 a.m., was conducted. The document indicated Patient 2 signed the IMM form on March 2, 2026, four days after Patient 1 was admitted. The ACNO stated the IMM is given to all Medicare patients within 24 hours of admission. The ACNO stated the facility should have provided the IMM to the patient by March 1, 2026. On March 4, 2026, at 1:26 p.m., an interview was conducted with the Patient Access Manager (PAM). He stated the expectation was for patient access staff to present the IMM to the patient or representative within 48-hours of admission per Centers for Medicare (CMS). The PAM stated he has one full time patient access staff that is responsible for presenting and obtaining a signature of the IMM. The PAM stated this staff member works Monday through Friday, eight hours per day. The PAM stated the IMM should have been given within 48 hours of admission. A review of the facility’s policy and procedure (P&P) titled, “Important Message from Medicare,” dated April 2024, was conducted. The P&P indicated, “...All inpatients within 2 [two] calendar days of admission and no more than 7 [seven] days prior to an elective admission. A copy of the IMM must also be provided to each beneficiary within a maximum of 2 [two] calendar days and a minimum of 4 [four] hours prior to discharge. The IM must be signed by all Medicare, Medicare Advantage and Senior HMO (Health Maintenance Organization) patients or the patient’s representative to indicate receipt and understanding of the notice...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure the patients’ rights were promoted, for three of 20 sampled patients (Patients 11,12, and 17), when: 1. For Patient 11, the patient’s contact information for the next of kin was not updated (Refer to A0144); 2. For Patient 12, the facility document titled, “Condition of Admissions,” (COA, a facility form giving the facility permission to provide treatment to the patient while agreeing to the facility’s terms of admission) was not signed by the patient nor the patient’s family member during the patient’s admission to the facility (Refer to A0144); and 3. For Patient 17, allegations of patient abuse were not escalated and reported to the patient’s physician, the Chief Nursing Officer (CNO), the Administrator, and the Human Resources Department (HR, a department responsible for managing all matters related to employees), in accordance with the facility’s policy and procedure (P&P) (Refer to A 0144). The cumulative effects of these systemic failures resulted in an unauthorized disclosure of Patient 11’s protected health information. These failures had the potential for Patient 12 to receive treatment without his informed consent (consent for a treatment or procedure given by the patient after receiving education from a healthcare professional about the risks, benefits, and alternatives of a given procedure or intervention), and for Patient 17 to experience continued abuse.”

“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: 34933 Based on interview and record review, the facility failed to ensure the patients’ rights were promoted, for three of 20 sampled patients (Patients 11,12, and 17), when: 1. For Patient 11, the patient’s contact information for the next of kin was not updated; 2. For Patient 12, the facility document titled, “Condition of Admissions,” (COA, a facility form giving the facility permission to provide treatment to the patient while agreeing to the facility’s terms of admission) was not signed by the patient nor the patient’s family member during the patient’s admission to the facility; and 3. For Patient 17, allegations of patient abuse were not escalated and reported to the patient’s physician, the Chief Nursing Officer (CNO), the Administrator, and the Human Resources Department (HR, a department responsible for managing all matters related to employees), in accordance with the facility’s policy and procedure (P&P). These failures resulted in an unauthorized disclosure of Patient 11’s protected health information. These failures had the potential for Patient 12 to receive treatment without his informed consent (consent for a treatment or procedure given by the patient after receiving education from a healthcare professional about the risks, benefits, and alternatives of a given procedure or intervention), and for Patient 17 to experience continued abuse. Findings: 1. On January 5, 2026, at 2 p.m., a review of Patient 11’s record was conducted with the Director of Medical Surgical/Telemetry (a unit where patients require less care than required in intensive care, with some patients on continuous remote monitoring of their heart rates and rhtyhms) (DMST). Patient 11 arrived to the Emergency Department (ED, a unit for patients with emergency conditions) on November 29, 2025, with a chief complaint of rib pain after a bicycle accident. A review of an untitled facility document, dated November 29, 2025, at 9:25 a.m., was conducted. The document indicated, “...Contact Information Nearest Relative Name [name of Family Member (FM) 1]...Emergency Contact Name [name of FM 1]...Admitting information...Date 11/29/25 [November 29, 2025] Time 0925 [9:25 a.m.]...” A review of an untitled facility document, dated November 29, 2025, at 12:38 p.m., was conducted. The document indicated, “...Contact Information Nearest Relative Name [name of FM 2]...Emergency Contact Name [name of FM 2]...Admitting Information...Date 11/29/25 [November 29, 2025] Time 1238 [12:38 p.m.]...” A facility document titled, “Progress Note-Physician,” dated November 30, 2025, at 10:12 a.m., authored by Physician (MD) 2, was reviewed. The document indicated, “...still have pain...but I [MD 2] talked to the patient [Patient 11] patient’s family [FM 2] was not there. Actually I [MD 2] was looking for the family as well when I [MD 2] saw the patient [Patient 11] in the morning. [FM 2] was not presented...I spoke to NP [Nurse Practitioner, an advanced practice nurse] pulmonology [a branch of medicine concerned with the the treatment and diagnosis of illnesses the lungs] team directly, and got the plan, I [MD 2] reviewed the written recommendation, I called her [sic] current family [FM 1] listed in our system. Explained the pulmonology plan...” On January 6, 2026, at 11 a.m., a review of Patient 11’s record and concurrent interview were conducted with the Admitting Manager (AM). The AM stated the process of updating a patient’s information begins when the patient is in the ED. The AM stated the charge nurse will enter the patient’s information into the facility’s computer system and when the physician completes the medical examination, admitting (the entry point where patients are officially checked in and assigned a bed in the hospital)/registration is activated, and a representative will see the patient and collect the demographic information (information which includes age, gender, income, race, education, location, or marital status and get the COA signed. The AM stated she was notified of Patient 11 being upset because MD 2 provided updates on Patient 11’s condition to FM 1 instead of FM 2 even if Patient 11 provided his current information while he was in the ED. The AM stated Patient 11 was seen by admitting on November 29, 2026 at 9:25 a.m., but the contact information for FM 2 was not updated resulting in an unauthorized call made by MD 1 to FM 1 instead of calling FM 2. The AM stated maybe MD 2 took note of FM 1’s information before the change in Patient 11’s information was made and called FM 1. The AM stated the updated contact information for FM 2 should have been documented right away on Patient 11’s record. A review of the facility policy and procedure titled, “ED Registration Process,” dated November 2017, was conducted. The policy indicated, “...After being triaged [the preliminary assessment of patients to determine the urgency of their need for treatment] by an ER [ER, ED] nurse, patients will be given a Preliminary Registration Form. This information will only include all demographics information. The ER Registration representative will input this information into the computer system and generate a face sheet, patient label and armband...Enter and update all additional information into the financial comments system...” 2. A review of Patient 12’s record was conducted on January 6, 2026, at 1:40 p.m., with the DMST. A review of the facility document titled, “History & Physical,” dated October 15, 2025, was conducted. The document indicated Patient 12 was admitted to the facility on a 5150 hold (an involuntary 72-hour placement in the hospital if a patient is deemed a danger to himself or others) for psychosis (a mental illness characterized by distorted perception of reality, involving seeing things that aren’t there and false beliefs). The document indicated Patient 12 had a history of bipolar disorder (sometimes called manic-depressive disorder, a condition with mood swings which range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness which is characterized by disturbances in thought). On January 6, 2026, at 2 p.m., a concurrent review of Patient 12’s record and interview were conducted with the DMST. The DMST stated there was no documentation a COA was completed and signed by Patient 12 nor was Patient 12’s next of kin contacted to sign the COA. A review of the facility’s P&P titled, “Condition of Admission,” dated November 2024, was conducted. The policy indicated, “...Purpose: to define responsibilities in obtaining consent for patients entering [name of Facility] for treatment; establish guidelines if the patient is unable to consent on their behalf; patient refusal, ensuring patient rights are protected as they relate to treatments/procedures performed and patient’s responsibility. A hospital cannot allow treatment without the risk of liability, unless the patient or a person legally authorized to act on his/her behalf has consented to the treatment...The registration staff must make every effort prior to the patient being discharged from the Emergency Room Department [ED] to obtain signature...If the patient is admitted and the patient’s medical condition remains unchanged, no legal guardian or representative is available, the COA consent will be delivered to the patient’s legal guardian or representative by telephone...” 3. On January 6, 2026, at 6:47 p.m., a self-reported incident from the facility was sent to the California Department of Public Health, (CDPH, a state agency) which indicated, “...This is to notify the Department about an allegation from the patient [Patient 17] involving pulling on her arm and hurting her...On the morning of 1/2/2026 [January 2, 2026], it was reported to the charge nurse that the nurse grabbed her arm and hurt it. Upon investigation of the incident and interview of the nurse and RT [Respiratory Therapist, a health professional who helps assess and treat breathing problems] who was caring for another patient in the adjacent bed and stepped into the patient [Patient 17’s] space immediately upon hearing the comment, it was observed that the alleged nurse was not in closed proximity to the patient as she was at the foot of the bed when the patient stated “why did you grab my arm?” The nurse backed against the wall and denied hurting her arm. The patient then began to cry and subsequently the Clinical Supervisor came into the room to check on her after the nurse escalated the concern...” On January 7, 2026, at 10 a.m., a review of Patient 17’s record and a concurrent interview were conducted with the DMST. A facility document titled, “History & Physical,” dated December 30, 2025, authored by MD 5, was reviewed. The document indicated Patient 17 was brought to the ED via ambulance with complaint of difficulty breathing associated with chest tightness for three days. A facility document titled, “Progress Note-Nurse,” dated January 2, 2026, at 9:12 a.m., authored by Registered Nurse (RN) 5, was reviewed. The document indicated, “...0800 [8 a.m.] patient [Patient 17] sitting in bed receiving breathing treatment, crying. States she is in pain. Does not want to take ordered pain medication. Asking for dilaudid [sic, Dilaudid, a strong pain medication]. Explained to her that the doctor refused to order dilaudid [sic] for her. She threw her breathing treatment on the floor and started yelling that she is on the spectrum [autism spectrum disorder (ASD), a developmental condition of differences in the brain affecting social communication, interaction, and behavior] and people did not understand her. Requesting to change doctors. She started screaming that I [RN 5] grabbed her. Then she requested to change nurses...” There was no documented evidence Patient 17’s arm was assessed after the alleged abuse. There was no documented evidence the physician was notified of the alleged abuse. There was no documented evidence RN 5 was removed from patient care after Patient 17 made the allegation of abuse involving RN 5. There was no documented evidence the alleged abuse on Patient 17 was reported to Human Resources Department. During a concurrent interview, the DMST stated, when a patient makes an allegation of abuse, it should be reported to the charge nurse, then the charge nurse should get the details and send the staff home. The DMST stated, the House Supervisor, the Administrator on call, the family, and Risk Management should be notified and Risk Management should conduct the investigation. The DMST stated the Human Resources Department is also notified and the patient is asked if they want to press charges against the staff. On January 7, 2026, at 10:50 a.m., an interview was conducted with Patient 17. Patient 17 stated, on January 2, 2026, at around 8:15 a.m., RN 5 came to the room and stated, “What do you need?” Patient 17 stated she informed RN 5 she was diagnosed with autism and needed an explanation of why the physician did not order Dilaudid and that she wanted to change her physician. Patient 17 stated RN 5 walked around the hospital bed and pulled the curtain closed and stated, “What can I do for you?” in a mean, quiet voice while grabbing her arm against the table. Patient 17 stated she asked RN 5 why she grabbed her arm then the Respiratory Therapist who was in the room came over to assist. On January 7, 2026, at 11:10 a.m., an interview was conducted with House Supervisor (HS) 2. HS 2 stated she was notified of the allegation made by Patient 17 on January 2, 2026, at 08:50 a.m., and she went to speak with Patient 17 along with the Director of Risk Management (DRM). HS 2 stated Patient 17 reported RN 5 slapped her [Patient 17’s] arm down on the bedside table and RN 5 told Patient 17,”You’re not listening to me.” HS 2 stated, for any alleged physical abuse, the house supervisor is to send the nurse home and notify the patient’s physician. HS 2 stated she did not send RN 5 home and did not notify Patient 17’s physician of the alleged physical abuse towards Patient 17. On January 7, 2026, at 11:21 a.m., an interview was conducted with the Unit Secretary (US). The US stated, on January 2, 2026, at around 8:30 a.m., she heard Patient 17 yell, “You hit me, you hit me,” so she went to the room to check on Patient 17. The US stated Patient 17 reported RN 5 slammed her [Patient 17’s] hand on the bedside table. On January 7, 2026, at 11:30 a.m., an interview was conducted with the DRM. The DRM stated Patient 17 was interviewed and reported RN 5 hit her [Patient 17’s] hand on the bedside table three times but Patient 17 told a different staff she was grabbed one time by RN 5. The DRM stated Patient 17 had “psych (psychological, the mental and emotional state of a person’s mind) issues” which also led to Patient 17’s accusation of abuse to be found unsubstantiated by the facility. The DRM stated there were several witnesses who heard Patient 17 say, “Why did you grab my arm?” but no one saw the incident happen. The DRM stated Patient 17’s arm was assessed and there was no redness or swelling. The DRM stated she only documented the asssessment of Patient 17’s arm on MIDAS (an internal reporting system which is not part of the patient’s record). The DRM stated RN 5 was not sent home after the alleged abuse and Patient 17 was reassigned to a different nurse. The DRM stated, according to the facility’s policy, RN 5 should have been sent home, and Patient 17’s physician and family should have been notified. On January 7, 2026, at 1:45 p.m., an interview was conducted with the Director of Human Resources (DHR). The DHR stated, for all abuse allegation, an investigation is initiated and the employee is taken off the unit and sent home. The DHR stated he is usually notified of all allegations of abuse and he will give the recommendation to relieve staff but he was not notified of the incident involving RN 5 and Patient 17. On January 7, 2026, at 3:15 p.m. an interview was conducted with the CNO. The CNO stated she was not notified of the abuse allegation involving Patient 17 and RN 5. The CNO stated it is the facility’s policy to notify the physician, the CNO, the Administrator, and the Human Resources Department of an allegation of abuse, and the staff involved should be sent home. A review of the facility’s P&P titled, “Reporting Abuse Neglect Allegations,” dated April 2017, was conducted. The policy indicated, “...[Name of Facility] will ensure that patients are free from all forms of abuse, neglect, or harassment...Prompt escalation to the department leadership and Chief Nursing Officer or designee will be made regardless of time of day...If and employee observes, receives verbal report of, is told of, or suspects an incident of physical abuse, sexual abuse, mental abuse, or neglect has occurred the employee shall escalate reporting of the allegation to the appropriate Chain of Command [a reporting and communication system used where each person reports to a single authority figure] and to hospital administration immediately...The Department supervisor will notify the Department Director and Hospital Administration. If after hours, weekend, or holiday, the Nursing House Supervisor will be notified and will in turn will notify the CNO and Administrator On Call regarding the allegation of abuse...The Supervisor will immediately place the employee(s) involved on Administrative leave [a temporary removal from work duties]with notification to the Director of Human Resources, pending completion of the investigation...” A review of the facility’s P&P titled, “Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting,” dated, March 2020 was conducted. The policy indicated, “...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. [Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, and/or family members and friends...””

“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: 48776 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedures (P&P) were implemented, for two of 20 sampled patients (Patients 10 and 17), when: 1. For Patient 10, a nursing assessment was not completed following the patient’s allegation someone hit him in his abdomen (stomach); and 2. For Patient 17, allegations of patient abuse were not escalated and reported to the patient’s physician, the Chief Nursing Officer (CNO), the Administrator, and the Human Resources Department (HR, a department responsible for managing all matters related to employees). These failures had the potential to compromise the timely identification of injury on the patient and may delay appropriate medical intervention for Patient 10, and for Patient 17 to experience continued abuse. Findings: 1. On January 7, 2026, 10:45 a.m., a review of Patient 10’s record was conducted with the Manager of the Medical, Surgical, and Telemetry unit (a unit where continuous electronic monitoring of a patient’s heart rhythm and other vital signs is conducted) (MMST) 1. A facility document titled, “History & [and] Physical,” dated December 30, 2025, was reviewed. The document indicated Patient 10 was admitted to the facility for chest pain and had a prior medical history of stroke (a condition when the brain’s blood supply is disrupted which prevents oxygen and nutrients from reaching brain cells, and can cause permanent damage, disability, or death if not treated immediately). The document indicate Patient 10 was aphasic (a person with a disorder which makes it hard to communicate, affecting speaking, usually after a stroke, but does not affect intelligence) but was able to write. A facility document titled, “Progress Note- Nurse,” dated January 2, 2026, at 3:39 a.m., was reviewed. The document indicated, “...Pt [Patient 10] becoming very paranoid [suspicious and distrustful of others, often believing, people are trying to harm, or plot against them] of staff. Pt states someone hit him in his sleep...” A facility document titled, “Progress Note- Nurse,” dated January 2, 2026, at 3:47 a.m., was reviewed. The document indicated, “...Via [by] writing on paper, Pt making claims that someone hit him in his stomach and is agitated. Primary RN [Registered Nurse] alerted Charge RN...” There was no documented evidence Patient 10 was assessed after he made the allegation of abuse. There was no documented evidence a nursing assessment was completed to evaluate Patient 10’s abdomen following the allegation of abuse in accordance with the facility’s P&P. MMST 1 stated a nursing assessment of Patient 10’s abdomen should have been conducted after the allegation of abuse on Patient 10 was made but this was not done. On January 7, 2026, at 11:30 a.m., a concurrent interview and record review were conducted with the Director of the Medical, Surgical, and Telemetry units (DMST). The DMST stated the facility’s department standard is to assess the body area involved in an alleged abuse when it occurs. The DMST stated Patient 10’s abdomen should have been assessed as close to the date of the alleged abuse as possible and this was not conducted. On January 8, 2026, at 9:45 a.m., a concurrent interview and record review were conducted with the Director of Risk Management (DRM). The DRM stated Patient 10’s abdomen should have been assessed as close to date of the alleged abuse as possible and this was not done. The DRM stated the facility’s policy was not followed. On January 8, 2026, at 1 p.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated Patient 10’s abdomen should have been assessed immediately on the date the patient alleged the abuse once the facility staff became aware of the allegation. The CNO stated the facility’s policy was not followed and the nursing staff were required to conduct and document an abdominal assessment promptly following the allegation to determine whether the patient sustained any injury and this was not done. A review of the facility’s P&P titled, “Patient’s Rights and Responsibilities,” dated August 2024, was conducted. The P&P indicated, “...Safety and Free from Verbal, Mental and Physical Abuse, Harassment...The patient has the right to expect reasonable safety as far as the hospital practice and environment are concerned...The patient has the right to receive care in a safe setting, free from verbal, mental or physical abuse, harassment...” A review of the facility’s P&P titled, “Assessment and reassessment of patients,” dated August 2024, was conducted. The P&P indicated, “...Ongoing assessment/reassessment will be completed per department standard...” 2. On January 6, 2026, at 6:47 p.m., a self-reported incident from the facility was sent to the California Department of Public Health, (CDPH, a state agency) which indicated, “...This is to notify the Department about an allegation from the patient [Patient 17] involving pulling on her arm and hurting her...On the morning of 1/2/2026 [January 2, 2026], it was reported to the charge nurse that the nurse grabbed her arm and hurt it. Upon investigation of the incident and interview of the nurse and RT [Respiratory Therapist, a health professional who helps assess and treat breathing problems] who was caring for another patient in the adjacent bed and stepped into the patient [Patient 17’s] space immediately upon hearing the comment, it was observed that the alleged nurse was not in closed proximity to the patient as she was at the foot of the bed when the patient stated “why did you grab my arm?” The nurse backed against the wall and denied hurting her arm. The patient then began to cry and subsequently the Clinical Supervisor came into the room to check on her after the nurse escalated the concern...” On January 7, 2026, at 10 a.m., a review of Patient 17’s record and a concurrent interview were conducted with the DMST. A facility document titled, “History & Physical,” dated December 30, 2025, authored by MD 5, was reviewed. The document indicated Patient 17 was brought to the ED via ambulance with complaint of difficulty breathing associated with chest tightness for three days. A facility document titled, “Progress Note-Nurse,” dated January 2, 2026, at 9:12 a.m., authored by Registered Nurse (RN) 5, was reviewed. The document indicated, “...0800 [8 a.m.] patient [Patient 17] sitting in bed receiving breathing treatment, crying. States she is in pain. Does not want to take ordered pain medication. Asking for dilaudid [sic, Dilaudid, a strong pain medication]. Explained to her that the doctor refused to order dilaudid [sic] for her. She threw her breathing treatment on the floor and started yelling that she is on the spectrum [autism spectrum disorder (ASD), a developmental condition of differences in the brain affecting social communication, interaction, and behavior] and people did not understand her. Requesting to change doctors. She started screaming that I [RN 5] grabbed her. Then she requested to change nurses...” There was no documented evidence Patient 17’s arm was assessed after the alleged abuse. There was no documented evidence the physician was notified of the alleged abuse. There was no documented evidence RN 5 was removed from patient care after Patient 17 made the allegation of abuse involving RN 5. There was no documented evidence the alleged abuse on Patient 17 was reported to Human Resources Department. During a concurrent interview, the DMST stated, when a patient makes an allegation of abuse, it should be reported to the charge nurse, then the charge nurse should get the details and send the staff home. The DMST stated, the House Supervisor, the Administrator on call, the family, and Risk Management should be notified and Risk Management should conduct the investigation. The DMST stated the Human Resources Department is also notified and the patient is asked if they want to press charges against the staff. On January 7, 2026, at 10:50 a.m., an interview was conducted with Patient 17. Patient 17 stated, on January 2, 2026, at around 8:15 a.m., RN 5 came to the room and stated, “What do you need?” Patient 17 stated she informed RN 5 she was diagnosed with autism and needed an explanation of why the physician did not order Dilaudid and that she wanted to change her physician. Patient 17 stated RN 5 walked around the hospital bed and pulled the curtain closed and stated, “What can I do for you?” in a mean, quiet voice while grabbing her arm against the table. Patient 17 stated she asked RN 5 why she grabbed her arm then the Respiratory Therapist who was in the room came over to assist. On January 7, 2026, at 11:10 a.m., an interview was conducted with House Supervisor (HS) 2. HS 2 stated she was notified of the allegation made by Patient 17 on January 2, 2026, at 08:50 a.m., and she went to speak with Patient 17 along with the Director of Risk Management (DRM). HS 2 stated Patient 17 reported RN 5 slapped her [Patient 17’s] arm down on the bedside table and RN 5 told Patient 17,”You’re not listening to me.” HS 2 stated, for any alleged physical abuse, the house supervisor is to send the nurse home and notify the patient’s physician. HS 2 stated she did not send RN 5 home and did not notify Patient 17’s physician of the alleged physical abuse towards Patient 17. On January 7, 2026, at 11:21 a.m., an interview was conducted with the Unit Secretary (US). The US stated, on January 2, 2026, at around 8:30 a.m., she heard Patient 17 yell, “You hit me, you hit me,” so she went to the room to check on Patient 17. The US stated Patient 17 reported RN 5 slammed her [Patient 17’s] hand on the bedside table. On January 7, 2026, at 11:30 a.m., an interview was conducted with the DRM. The DRM stated Patient 17 was interviewed and reported RN 5 hit her [Patient 17’s] hand on the bedside table three times but Patient 17 told a different staff she was grabbed one time by RN 5. The DRM stated Patient 17 had “psych (psychological, the mental and emotional state of a person’s mind) issues” which also led to Patient 17’s accusation of abuse to be found unsubstantiated by the facility. The DRM stated there were several witnesses who heard Patient 17 say, “Why did you grab my arm?” but no one saw the incident happen. The DRM stated Patient 17’s arm was assessed and there was no redness or swelling. The DRM stated she only documented the assessment of Patient 17’s arm on MIDAS (an internal reporting system which is not part of the patient’s record). The DRM stated RN 5 was not sent home after the alleged abuse and Patient 17 was reassigned to a different nurse. The DRM stated, according to the facility’s policy, RN 5 should have been sent home, and Patient 17’s physician and family should have been notified. On January 7, 2026, at 1:45 p.m., an interview was conducted with the Director of Human Resources (DHR). The DHR stated, for all abuse allegation, an investigation is initiated and the employee is taken off the unit and sent home. The DHR stated he is usually notified of all allegations of abuse and he will give the recommendation to relieve staff but he was not notified of the incident involving RN 5 and Patient 17. On January 7, 2026, at 3:15 p.m. an interview was conducted with the CNO. The CNO stated she was not notified of the abuse allegation involving Patient 17 and RN 5. The CNO stated it is the facility’s policy to notify the physician, the CNO, the Administrator, and the Human Resources Department of an allegation of abuse, and the staff involved should be sent home. A review of the facility’s P&P titled, “Reporting Abuse Neglect Allegations,” dated April 2017, was conducted. The policy indicated, “...[Name of Facility] will ensure that patients are free from all forms of abuse, neglect, or harassment...Prompt escalation to the department leadership and Chief Nursing Officer or designee will be made regardless of time of day...If and employee observes, receives verbal report of, is told of, or suspects an incident of physical abuse, sexual abuse, mental abuse, or neglect has occurred the employee shall escalate reporting of the allegation to the appropriate Chain of Command [a reporting and communication system used where each person reports to a single authority figure] and to hospital administration immediately...The Department supervisor will notify the Department Director and Hospital Administration. If after hours, weekend, or holiday, the Nursing House Supervisor will be notified and will in turn will notify the CNO and Administrator On Call regarding the allegation of abuse...The Supervisor will immediately place the employee(s) involved on Administrative leave [a temporary removal from work duties]with notification to the Director of Human Resources, pending completion of the investigation...” A review of the facility’s P&P titled, “Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting,” dated, March 2020 was conducted. The policy indicated, “...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. [Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, and/or family members and friends...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 48776 Based on interview and record review, the facility failed to ensure an initial screening to determine discharge planning (process that involves determining the appropriate discharge destination for a patient and identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination, and beginning the process of meeting the patient’s identified post discharge needs) needs and to develop a hospital discharge plan, for two of 20 sampled patients (Patients 7 and 11). This failure had the potential to impede or delay the identification of Patients 7 and 11’s needs for care after discharge from the facility which may result in the needs of Patients 7 and 11 to not be met after their discharge from the facility. Findings: 1. On January 8, 2026, at 11:45 a.m., a review of Patient 7’s record was conducted with the Manager of the Medical, Surgical, and Telemetry unit (a unit where continuous electronic monitoring of a patient’s heart rhythm and other vital signs is conducted) (MMST) 1. A facility document titled, “History & [and] Physical,” dated October 21, 2025, was reviewed. The document indicated Patient 7 was admitted to the facility for low back pain and bilateral lower extremity paresthesia (abnormal sensation of tingling, numbness, prickling, or burning on both legs). A facility document titled, “Discharge Summary,” dated October 26, 2025, was reviewed. The document indicated Patient 7 underwent a posterior lumbar decompression and fusion with iliac crest bone graft (a type of back surgery which involves taking pressure off the nerves in the lower back and permanently joining the affected spinal bones together using a piece of the hip bone). The document further indicated, “...Post [after] Discharge Care...Discharge Request...Continue dressing changes every 3 [three] days, monitoring wound for infection...Mobility & Ambulation Level...PT [physical therapy, a healthcare service which helps people move better, reduce pain, and regain physical function after injury, surgery or illness, using exercise, hands-on care such as massage, and education to improve mobility]...Ambulation [walking] Device...Front-wheel walker [mobility aid with two wheels on the front legs and two rubber tips on the back legs, used to assist with walking]...” There was no documented evidence a case management (a collaborative process where a healthcare professional coordinates, plans, and monitors a patient’s care to ensure they get the right services, achieve health goals, navigate the system, and transition safely from hospital to home) assessment was completed to determine care needs necessary upon discharge for Patient 7, in accordance with the facility’s policy and procedure (P&P). On January 8, 2026, at 12:15 p.m. a concurrent interview and record review were conducted with the Director Case Management (DCM). The DCM stated all patients need to be assessed for their discharge needs within 24 to 48 hours of admission by a case manager (a healthcare professional who coordinates and advocates for a patient’s care from admission to discharge), and this was not done for Patient 7. The DCM further stated it was unknown what Patient 7’s discharge needs were or if the patient had a walker at home or if home health was needed for Patient 7’s safe discharge home because the discharge planning was not conducted by the case manager. A review of the facility’s P&P titled, “Discharge Planning and Social Service Needs,” dated August 2024, was conducted. The P&P indicated, “...All patients admitted to inpatient services will be evaluated by Case Management within two (2) working days after admission to determine continuum of care needs and availability of community resources...Case managers/social workers will review the concurrent medical record to determine the medical diagnosis of the patient, taking into consideration...Severity of illness, projected clinical and physical outcomes...Changes in lifestyle...Ability to perform ADL’s [activities of daily living, basic self-care tasks like bathing, dressing, eating, toileting, and moving around] pre-hospitalization and upon discharge...Safety issues and ability to return to pre-admission living situation...patients will be evaluated for post-hospital needs to provide a safe and appropriate continuum of care...” A review of the facility’s P&P titled, “Discharge Planning,” dated April, 2024, was conducted. The P&P indicated, “...Each patient is screened...the Case Manager/Social Worker [a healthcare professional who advocates for patient needs] will perform...screen to include the discharge needs assessment, which is done no later than 2 [two] days...The discharge planning evaluation will take into consideration the patient’s immediate and emerging needs, long-term care needs physiological, psychological, social and cultural concerns...The evaluation of the patient’s likely needs may include medical equipment DME [durable medical equipment, reusable, heavy-duty equipment used at home for health reasons, such as a wheelchair, walker, hospital bed], home health [skilled medical care and therapy provided at home by licensed professionals], hospice [end of life care], skilled nursing facility [a facility for short-term recovery after a hospital stay, offering medical care, therapies, and help with daily tasks, provided by trained nurses and therapists], rehabilitation hospital [a specialized hospital which provide intensive therapy and medical care after a serious injury, illness, or surgery]...” 2.On January 5, 2026, at 2 p.m., a review of Patient 11’s record was conducted with the Director of Medical Surgical/Telemetry (DMST). A facility document titled, “History & Physical,” dated November 29, 2025, was reviewed. The document indicated, Patient 11 was admitted to the facility for rib pain after a bike accident. A review of the facility document titled, “Acute Care Patient Summary,” dated December 2, 2025, was conducted. The document indicated, “...Discharge Request 12/02/25 [December 2, 2025] 12:39 [12:39 p.m.]...Home Routine...” A review of the facility document titled, “Progress Note-Nurse,” dated December 2, 2025, at 4:21 p.m., was conducted. The document indicated, “...Pt [Patient 11] and family member given discharged education and paperwork. All questions answered...Pt escorted via wheelchair to front of hospital to private vehicle safely...” A review of the facility document titled, “Discharge Planning Assessment,” dated December 2, 2025, at 5:21 p.m., was conducted. The document indicated, “...Discharge Planning Case Management Discharge Plan: Pt [Patient 11] is alert and oriented. He was admitted for a biking accident and obtained some cracked ribs...He will go home upon discharge...” There was no documented evidence Patient 11’s psychosocial history (an assessment of mental and social well-being) and discharge planning needs were assessed within 24 to 48 hours of Patient 11’s admission to the facility in accordance with the facility’s P&P. On January 6, 2026, at 10:35 a.m., a concurrent interview and review of Patient 11’s record were conducted with Registered Nurse Case Manager (RNCM) 7. RNCM 7 stated the initial case management assessment should be completed within 24 to 48 hours of the patient’s admission to the facility. RNCM 7 stated she did not remember conducting an initial case management visit on Patient 11 and, upon review of the completed assessment, the psychosocial needs assessment of mental and social well-being] of Patient 11 were not addressed. In addition, RNCM 7 was unable to explain why the discharge assessment was completed on December 2, 2025, at 5:21 p.m., one hour after Patient 11’s discharge from the facility on December 2, 2025, at 4:21 p.m. On January 6, 2026, at 1047 a.m., a concurrent interview and record review were conducted with the DCM. The DCM stated a face-to-face case management assessment must be completed within 24 to 48 hours of the patient’s admission and all areas of the assessment must be completed. The DCM stated the psychosocial assessment portion of the assessment should have been completed for Patient 11. A review of the facility’s P&P titled, “Discharge Planning and Social Service Needs,” dated August 2024, was conducted. The policy indicated, “...All patients admitted to inpatient services will be evaluated by Case Management within two (2) working days after admission to determine continuum of care needs and availability of community resources...Emotional Assessment 1. Case managers/social workers will interview the patient, family, nursing and others involved in the patient’s care to determine the emotional status of the patient. Assessment should include...a. Patient’s affect [a person’s facial expressions, body language, vocal tone and gestures serving as a visible indicator of mood] b. Compliance with treatment, both in the hospital and at home c. Anger and denial issues d. Death and dying issues e. Support system: family, friends, peers, significant others f. Psychiatric [relating to mental illness or its treatment] history or concurrent psych diagnosis...Social and Cultural Assessment...Case managers/social workers will assess the patient for social and cultural variables that may impact continuum of care or end-of-life issues. Assessment should include...a. Support system: available family, friends and significant others b. Language barriers c. Cultural sick care practices and health care beliefs (including psychiatric) d. Financial status and access to needed health care e. Possible abuse issues: child, elder, spousal, alcohol, drugs f. Patient’s educational level...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure, for one of 21 sample patients (Patient 15), who was on a 5150 hold (a legal hold which allows for a 72-hour involuntary detention for a patient who was deemed to be a danger to himself or others or was gravely disabled [unable to provide for their basic personal needs due to a mental health disorder]), the patient was prevented from eloping (leaving a healthcare facility without authorization or notification) from the facility. (A0144) The cumulative effect of this facility’s failure had the potential to place Patient 15 at risk for harm and injury.”

“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: 50304 Based on interview and record review, the facility failed to ensure, for one of 21 sample patients (Patient 15), who was on a 5150 hold (a legal hold which allows for a 72-hour involuntary detention for a patient who was deemed to be a danger to himself or others or was gravely disabled [unable to provide for their basic personal needs due to a mental health disorder]), the patient was prevented from eloping (leaving a healthcare facility without authorization or notification) from the facility. This failure had the potential to place Patient 15 at risk for harm and injury. Findings: On September 23, 2025, at 2:22 p.m., a review of Patient 15’s record was conducted with the Clinical Effectiveness Coordinator (CEC). A facility document titled, “History & [and] Physical,” dated August 1, 2025, was reviewed. The document indicated, “...pt [Patient 15] requesting psych eval [psychiatric evaluation, an assessment of a person’s mental state], pt states he had been “missing” for the last 5 [five] days...hx [history of] schizophrenia [a serious mental health condition that affects how people think, feel, and behave], bipolar [a mood disorder characterized by extreme mood swings between periods of mania (highs) and depression (lows)]...” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated July 31, 2025, was reviewed. The document indicated, “...Pursuant to...5150...[Name of Clinical Therapist]...To [Name of Facility B]...Application is here made for the assessment and evaluation of [name of Patient 15]...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder...A danger to self...” The document indicated an X mark was placed next to “A danger to self.” A facility document titled, “Order Information for: Observation Level (Sitter, a facility staff who provides continuous, non-medical supervision, and support for patients at risk of falls, self-harm, agitation, or other safety issues),” dated July 31, 2025, was reviewed. The document indicated, “...Original order entered and electronically signed...Purpose of observation...Suicide [the act of causing one’s own death] Risk...Level of observation...1:1 [one staff directly observing one patient] observation at all times...” A facility document titled, “Psychiatrist [a physician who specialized in diagnosing and treating mental disorders] Initial Evaluation Note,” dated August 2, 2025, authored by Physician [MD] 1 was reviewed. The document indicated, “...came to the ED [Emergency Department] saying he drove from [name of state] to [name of another state] and had AH [auditory hallucination, when someone hear sounds or voices which are not actually there] asking him to drive...so he followed them...He is a danger to self if he leaves and recklessly drives around...Recommend inpt [inpatient, a patient who stays in a hospital while under treatment] psych [psychiatric, relating to mental illness and/or its treatment] hospital...” A facility document titled, “Progress/SOAP (Subjective, Objective, Assessment, Plan, a standardized medical documentation format) Note,” dated August 2, 2025, authored by MD 2 was reviewed. The document indicated, “...Chief complaint: “I go through all these highs, and then I bottom out...Recommendations for treatment...transfer to inpatient psychiatry...” An untitled facility document, dated August 4, 2025, was reviewed. The document indicated, “...Date: 8/4/25 [August 4, 2025]...Time performed: 7 a.m....1:1 observation: Sitter in close proximity to the patient...Belongings bag placed in locked dirty utility room storage...Yes...COMMENTS...Belongings in closet...Name of Sitter...Sitter completing Checklist...” The document indicated an X was marked under “belongings bag placed in locked dirty utility room storage.” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated August 4, 2025, was reviewed. The document indicated, “...Pursuant to...5150...Application is here made for the assessment and evaluation of [name of Patient 15]...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder:...A danger to self...A danger to others...” The document indicated check marks were placed on the boxes next to “A danger to self” and next to “A danger to others.” A facility document titled, “Progress Note-Nurse,” dated August 4, 2025, at 2:24 p.m., authored by Registered Nurse (RN) 3, was reviewed. The document indicated, “...MD went to bedside to notify patient [Patient 15] that he will be transferring to psych facility. Patient got upset and changed into his clothes...Escalated situation to charge nurse...Despite multiple efforts, patient still left...Code green [a hospital code to alert staff regarding a missing or eloping high-risk adult patient] was called and multiple security personnel and House Supervisor [a nursing leader who manages a hospital’s overall operations and patient care, especially outside of regular business hours] came to support the situation as patient was searching for car to leave premises...” There was no documented evidence a Code Gray (a hospital code for staff and security personnel is required to diffuse potentially volatile and/or violent situation) was called in accordance with the facility’s policy and procedure when Patient 15 was eloping from the facility on August 4, 2025. There was no documented evidence Patient 15’s belongings were placed in a secured storage in accordance with the facility’s policy and procedure when Patient 15 was eloping from the facility on August 4, 2025. On September 23, 2025, at 2:45 p.m., an interview was conducted with RN 3. RN 3 stated, when a patient is put on a 5150 hold, the patient is not free to leave the facility because they are a “harm” to themselves or others. RN 3 stated Patient 15 cannot leave because he was on a 5150, and “it is not safe for the patient to leave.” RN 3 stated Patient 15 got agitated. RN 3 stated she did not call Code Gray when Patient 15 was eloping from the facility on August 4, 2025. On September 24, 2025, at 10:41 a.m., an interview was conducted with the Security Manager (SM). The SM stated that when a code green is announced, security personnel will close all hospital doors, and other staff will position themselves to man the entrances and exits at the facility. The SM stated security will stop anyone and will not allow them to leave the facility until the code green is “cleared” [a hospital announcement signifying the emergency has been resolved and normal operations can resume] is announced. The SM stated the security personnel should have prevented Patient 15 from leaving the facility when Patient 15 was eloping from the facility on August 4, 2025. . On September 24, 2025, at 11:12 a.m., an interview was conducted with the Director of Quality (DQ). The DQ stated it is important to prevent a patient on a 5150 hold to leave the facility because they are a danger to themselves or others. The DQ stated Code Gray was not called when Patient 15 was eloping from the facility. The DQ stated the nurse, charge nurse, or the sitter should have called Code Gray during the incident when Patient 15 became agitated and eloped. The DQ stated the facility staff should have stopped Patient 15 from leaving the hospital when Patient 15 was eloping from the facility on August 4, 2025. On September 24, 2025, at 11:26 a.m., an interview was conducted with the sitter (Sit). The Sit stated Patient 15’s belongings were in the closet in his room. The Sit stated she did not know Patient 15’s belongings should not be left in the patient’s room. The Sit stated she should have given Patient 15’s belongings to the House Supervisor. The Sit stated she did not call Code Gray when Patient 15 started getting agitated on August 4, 2025, and she should have. On September 24, 2025, at 2:21 p.m., a review of the video footage of the facility’s main lobby on August 4, 2025, at 2:05 p.m., was conducted with the Chief Nursing Officer (CNO) and the DQ. The CNO identified Patient 15, the facility staff, and the security personnel who were being shown in the video footage. In the video footage, Patient 15 was observed passing in front of a security personnel. The security personnel was observed to not stop Patient 15 from leaving the facility. Seven facility staff were observed following after Patient 15 and four security personnel were observed chasing after the patient. There were no facility staff nor security personnel observed stopping Patient 15 from leaving the facility. On September 24, 2025, at 2:21 p.m., an interview was conducted with the CNO. The CNO stated it is important to stop patients on a 5150 hold from eloping for the patients’ “safety.” A facility policy and procedure titled, “Suicide Risk Assessment,” dated August 2024, was reviewed. The policy indicated, “...The purpose of this policy is to outline the requirements for ensuring the safety of patients...with the actual or potential thoughts of self-harm or suicide. The hospital is committed to ensuring the rights of all patients receiving care in a safe setting...and providing education and training to staff...Patients at risk for suicide who are being admitted to the inpatient unit...In the absence of family, belongings are inventoried and secured...” A facility policy titled, “Code Gray,” dated August 2024, was reviewed. The policy indicated, “...Purpose...promotes a controlled therapeutic environment for patient care...has created a security response code termed “Code Gray” for use when a show of force may be required to diffuse potentially volatile and/or violent situation...Any hospital employee, who perceives a threat, observes an escalation in threatening behavior [raised voice, a tense posture, clinched fist] or encounters escalating abusive behavior will notify the hospital...Operator by dialing 303, requesting a “Code Gray”, identifying their name, the exact location and nature of the disturbance...Physical restraint shall be used only when alternative methods are not sufficient to protect patients or others from injury...” A facility policy titled, “Code Green,” dated August 2024, was reviewed. The policy indicted, “...Purpose...to establish guidelines for the unauthorized absence of a patient from the facility...to establish guidelines to manage patients who are identified as an elopement risk...Patients identified as a high risk for elopement will have the following initiated...remove all belongings from bedside and secure...House wide, simultaneous to the “code green” being called all staff will: a. Monitor and restrict access both in and out of the facility...””

“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: 50433 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 21 sampled patients (Patients 1, 3, 12, 15, and 21), when: 1. For Patient 1, an intravenous (IV, a small tube placed into a vein to deliver fluids, medicine, blood or nutrients directly into a person’s bloodstream) tubing set (a sterile, plastic medical device used to deliver fluids, medicine, blood or nutrients directly into a person’s bloodstream) was observed disconnected with the end attached to a secondary access port on the same tubing; 2. For Patient 21, Registered Nurse (RN) 1 was observed entering Patient 21’s room, putting on gloves, and touching surfaces in the room without performing hand hygiene (the process of cleaning and disinfecting one’s hands to remove dirt and germs); 3. For Patient 15, who was on a 5150 hold (a legal hold which allows for a 72-hour involuntary detention for a patient who was deemed to be a danger to himself or others or was gravely disabled [unable to provide for their basic personal needs due to a mental health disorder]), the patient was allowed to elope (a patient leaving a healthcare facility without authorization or notification) from the facility; and 4. For Patients 3 and 12, the physician was not notified about a critical laboratory result (a laboratory test outcome for a life-threating condition requiring immediate medical attention to prevent significant patient harm) in accordance with the facility’s P&P. These failures had the potential to result in increased risk of infection, delayed response to critical laboratory results, prolonged hospitalizations, patient harm, and possible death. Findings: 1. On September 22, 2025, at 9:17 a.m., during a tour of Unit A conducted with the Infection Prevention Coordinator (IPC) and the Clinical Effectiveness Coordinator (CEC), Patient 1 was observed in her room sitting in bed. During a concurrent interview with Patient 1, Patient 1 stated she was not sure if she was supposed to be connected to her IV. An IV pump (a programable medical device used to accurately deliver fluids, medicine, blood or nutrients through an IV tubing) was observed with an IV tubing hanging from it with its end connected to an access port (a small, specialized component that allows healthcare providers to inject or add medication and fluids to a patient’s intravenous (IV) line without having to start a new IV) on the same tubing. The IV tubing was observed to not be connected to Patient 1 and its end was observed to not be covered by a sterile cap (a medical device used in hospitals to seal the end of an IV tubing or catheter to protect the access point from contamination by bacteria [a single-cell organism which is invisible to the naked eye] and other organisms that may cause infections). On September 22, 2025, at 2:26 p.m., a review of Patient 1’s record was conducted with the Effectiveness Coordinator (EC). A facility document titled, “History and Physical,” dated September 19, 2025, was reviewed. The document indicated Patient 1 was admitted to the facility on September 19, 2025, with a diagnosis of acute gastroenteritis (inflammation [a normal part of the body’s response to injury or infection causing redness, swelling, pain, and warmth to the affected area) of the stomach and intestines, causing pain, vomiting, and diarrhea). A facility document titled, “MAR [Medication Administration Record],” dated September 21, 2025, through September 23, 2025, was reviewed. The document indicated Patient 1 received metronidazole (an antibiotic, a medication used to treat infections) IV every eight hours and ceftriaxone (an antibiotic) IV daily. On September 22, 2025, at 9:20 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated IV looping (a healthcare practice where a nurse bends the end of a disconnected IV line back onto itself) should not be doneN 1 stated there are sterile caps to place on the end of the IV tubing when it is disconnected from the patient. On September 24, 2025, at 2 p.m., an interview was conducted with CN 2. CN 2 stated when an IV tubing is disconnected from a patient with the intend to use it again, a sterile cap is placed at the end of the tubing. CN 2 stated looping the IV tubing on itself creates a risk of infection. An article published by the National Institutes of Health (NIH, an agency within the United States Public Health Service, under the Department of Health and Human Services) article titled, “Capping Intravenous Tubing and Disinfecting Intravenous Ports Reduce Risks of Infection,” dated February 2011, was reviewed. The article indicated, “...failure to place a sterile cap on the end of a reusable intravenous (IV) administration set...the tip of the set is exposed to potential contaminants; this can lead to infection...” The facility’s P&P titled, “Intravenous Therapy,” dated September 2018, was reviewed. The P&P indicated, “...Utilize aseptic technique [a set of practices and procedures designed to prevent bacteria, viruses, or other microorganisms (tiny, microscopic organisms which are too small to be seen with the naked eye and require a microscope to be viewed) from contaminating a sterile environment, or entering a patient’s body] when handling IV’s and IV tubing...” 2. On September 22, 2025, at 9:32 a.m., during a tour of Unit B conducted with the IPC and the CEC, RN 1 was observed entering Patient 21’s room. RN 1 was observed to not perform hand hygiene prior to entering Patient 21’s room, putting on gloves, or touching surfaces in Patient 21’s room. On September 22, 2025, at 9:34 a.m., an interview was conducted with RN 1. RN 1 stated it “seems unclear” if he should have performed hand hygiene before entering Patient 21’s room. On September 22, 2025, at 10:38 a.m., an interview was conducted with the Director of Quality (DQ). The DQ stated RN 1 had been previously spoken to about infection control policies and was aware of the facility’s hand hygiene expectations. The facility’s P&P titled, “Hand Hygiene Program,” dated June 2024, was reviewed. The P&P indicated, “...Bacteria and other microorganisms can be transmitted to the hands by direct or indirect contact...To protect the patient and the employee, hands are to be washed or decontaminated before and after each contact with the patient and/or patient’s equipment...” 3. On September 23, 2025, at 2:22 p.m., a review of Patient 15’s record was conducted with the Clinical Effectiveness Coordinator (CEC). A facility document titled, “History & [and] Physical,” dated August 1, 2025, was reviewed. The document indicated, “...pt [Patient 15] requesting psych eval [psychiatric evaluation, an assessment of a person’s mental state], pt states he had been “missing” for the last 5 [five] days...hx [history of] schizophrenia [a serious mental health condition that affects how people think, feel, and behave], bipolar [a mood disorder characterized by extreme mood swings between periods of mania (highs) and depression (lows)]...” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated July 31, 2025, was reviewed. The document indicated, “...Pursuant to...5150...[Name of Clinical Therapist]...To [Name of Facility B]...Application is here made for the assessment and evaluation of [name of Patient 15]...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder...A danger to self...” The document indicated an X mark was placed next to “A danger to self.” A facility document titled, “Order Information for: Observation Level (Sitter, a facility staff who provides continuous, non-medical supervision, and support for patients at risk of falls, self-harm, agitation, or other safety issues),” dated July 31, 2025, was reviewed. The document indicated, “...Original order entered and electronically signed...Purpose of observation...Suicide [the act of causing one’s own death] Risk...Level of observation...1:1 [one staff directly observing one patient] observation at all times...” A facility document titled, “Psychiatrist [a physician who specialized in diagnosing and treating mental disorders] Initial Evaluation Note,” dated August 2, 2025, authored by Physician [MD] 1 was reviewed. The document indicated, “...came to the ED [Emergency Department] saying he drove from [name of state] to [name of another state] and had AH [auditory hallucination, when someone hear sounds or voices which are not actually there] asking him to drive...so he followed them...He is a danger to self if he leaves and recklessly drives around...Recommend inpt [inpatient, a patient who stays in a hospital while under treatment] psych [psychiatric, relating to mental illness and/or its treatment] hospital...” A facility document titled, “Progress/SOAP (Subjective, Objective, Assessment, Plan, a standardized medical documentation format) Note,” dated August 2, 2025, authored by MD 2 was reviewed. The document indicated, “...Chief complaint: “I go through all these highs, and then I bottom out...Recommendations for treatment...transfer to inpatient psychiatry...” An untitled facility document, dated August 4, 2025, was reviewed. The document indicated, “...Date: 8/4/25 [August 4, 2025]...Time performed: 7 a.m....1:1 observation: Sitter in close proximity to the patient...Belongings bag placed in locked dirty utility room storage...Yes...COMMENTS...Belongings in closet...Name of Sitter...Sitter completing Checklist...” The document indicated an X was marked under “belongings bag placed in locked dirty utility room storage.” A facility document titled, “APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT,” dated August 4, 2025, was reviewed. The document indicated, “...Pursuant to...5150...Application is here made for the assessment and evaluation of [name of Patient 15]...Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder:...A danger to self...A danger to others...” The document indicated check marks were placed on the boxes next to “A danger to self” and next to “A danger to others.” A facility document titled, “Progress Note-Nurse,” dated August 4, 2025, at 2:24 p.m., authored by Registered Nurse (RN) 3, was reviewed. The document indicated, “...MD went to bedside to notify patient [Patient 15] that he will be transferring to psych facility. Patient got upset and changed into his clothes...Escalated situation to charge nurse...Despite multiple efforts, patient still left...Code green [a hospital code to alert staff regarding a missing or eloping high-risk adult patient] was called and multiple security personnel and House Supervisor [a nursing leader who manages a hospital’s overall operations and patient care, especially outside of regular business hours] came to support the situation as patient was searching for car to leave premises...” There was no documented evidence a Code Gray (a hospital code for staff and security personnel is required to diffuse potentially volatile and/or violent situation) was called in accordance with the facility’s policy and procedure when Patient 15 was eloping from the facility on August 4, 2025. There was no documented evidence Patient 15’s belongings were placed in a secured storage in accordance with the facility’s policy and procedure when Patient 15 was eloping from the facility on August 4, 2025. On September 23, 2025, at 2:45 p.m., an interview was conducted with RN 3. RN 3 stated, when a patient is put on a 5150 hold, the patient is not free to leave the facility because they are a “harm” to themselves or others. RN 3 stated Patient 15 cannot leave because he was on a 5150, and “it is not safe for the patient to leave.” RN 3 stated Patient 15 got agitated. RN 3 stated she did not call Code Gray when Patient 15 was eloping from the facility on August 4, 2025. On September 24, 2025, at 10:41 a.m., an interview was conducted with the Security Manager (SM). The SM stated that when a code green is announced, security personnel will close all hospital doors, and other staff will position themselves to man the entrances and exits at the facility. The SM stated security will stop anyone and will not allow them to leave the facility until the code green is “cleared” [a hospital announcement signifying the emergency has been resolved and normal operations can resume] is announced. The SM stated the security personnel should have prevented Patient 15 from leaving the facility when Patient 15 was eloping from the facility on August 4, 2025. . On September 24, 2025, at 11:12 a.m., an interview was conducted with the Director of Quality (DQ). The DQ stated it is important to prevent a patient on a 5150 hold to leave the facility because they are a danger to themselves or others. The DQ stated Code Gray was not called when Patient 15 was eloping from the facility. The DQ stated the nurse, charge nurse, or the sitter should have called Code Gray during the incident when Patient 15 became agitated and eloped. The DQ stated the facility staff should have stopped Patient 15 from leaving the hospital when Patient 15 was eloping from the facility on August 4, 2025. On September 24, 2025, at 11:26 a.m., an interview was conducted with the sitter (Sit). The Sit stated Patient 15’s belongings were in the closet in his room. The Sit stated she did not know Patient 15’s belongings should not be left in the patient’s room. The Sit stated she should have given Patient 15’s belongings to the House Supervisor. The Sit stated she did not call Code Gray when Patient 15 started getting agitated on August 4, 2025, and she should have. On September 24, 2025, at 2:21 p.m., a review of the video footage of the facility’s main lobby on August 4, 2025, at 2:05 p.m., was conducted with the Chief Nursing Officer (CNO) and the DQ. The CNO identified Patient 15, the facility staff, and the security personnel who were being shown in the video footage. In the video footage, Patient 15 was observed passing in front of a security personnel. The security personnel was observed to not stop Patient 15 from leaving the facility. Seven facility staff were observed following after Patient 15 and four security personnel were observed chasing after the patient. There were no facility staff nor security personnel observed stopping Patient 15 from leaving the facility. On September 24, 2025, at 2:21 p.m., an interview was conducted with the CNO. The CNO stated it is important to stop patients on a 5150 hold from eloping for the patients’ “safety.” A facility policy and procedure titled, “Suicide Risk Assessment,” dated August 2024, was reviewed. The policy indicated, “...The purpose of this policy is to outline the requirements for ensuring the safety of patients...with the actual or potential thoughts of self-harm or suicide. The hospital is committed to ensuring the rights of all patients receiving care in a safe setting...and providing education and training to staff...Patients at risk for suicide who are being admitted to the inpatient unit...In the absence of family, belongings are inventoried and secured...” A facility policy titled, “Code Gray,” dated August 2024, was reviewed. The policy indicated, “...Purpose...promotes a controlled therapeutic environment for patient care...has created a security response code termed “Code Gray” for use when a show of force may be required to diffuse potentially volatile and/or violent situation...Any hospital employee, who perceives a threat, observes an escalation in threatening behavior [raised voice, a tense posture, clinched fist] or encounters escalating abusive behavior will notify the hospital...Operator by dialing 303, requesting a “Code Gray”, identifying their name, the exact location and nature of the disturbance...Physical restraint shall be used only when alternative methods are not sufficient to protect patients or others from injury...” A facility policy titled, “Code Green,” dated August 2024, was reviewed. The policy indicted, “...Purpose...to establish guidelines for the unauthorized absence of a patient from the facility...to establish guidelines to manage patients who are identified as an elopement risk...Patients identified as a high risk for elopement will have the following initiated...remove all belongings from bedside and secure...House wide, simultaneous to the “code green” being called all staff will: a. Monitor and restrict access both in and out of the facility...” 4a. On September 22, 2025, at 9:32 a.m., during a tour of Unit C conducted with the Quality Improvement Analyst (QIA), CN 3 was observed receiving a phone call from the laboratory with a critical laboratory result for Patient 12. CN 2 was observed sending a text message to the physician to notify the physician of the critical laboratory test result. On September 22, 2025, at 3:38 p.m., a review of Patient 12’s record was conducted with the CEC. A facility document titled, “History and Physical,” dated September 21, 2025, was reviewed. The document indicated Patient 12 was admitted to the facility on September 21, 2025, with a diagnosis of respiratory failure (a medical condition when not enough oxygen passes from the lungs to the blood). On September 22, 2025, at 9:34 a.m., an interview was conducted with CN 2. CN 2 stated the facility’s policy indicated [brand name of text messaging service] was an acceptable form of communication. b. On September 23, 2025, at 10:40 a.m., a review of Patient 3’s record was conducted with the EC. A facility document titled, “History and Physical,” dated August 12, 2022, was reviewed. The document indicated Patient 3 was admitted to the facility on August 12, 2022, with a diagnosis of abdominal pain. A facility document titled, “Communication Log,” dated August 17, 2022, was reviewed. The document indicated, “...Reason for Notification...Critical Result...Comment...[brand name of text messaging service]...” On September 23, 2025, at 2 p.m., an interview and concurrent review of the facility’s P&P titled, “Physician Notifications,” were conducted with CN 2. CN 2 stated critical laboratory values, as well as changes in a patient’s condition, imaging results, changes in vital signs, and when patients have arrived at their assigned hospital rooms, are communicated to physicians through [brand name of text messaging service]. After CN 2 reviewed the facility’s P&P titled, “Physician Notifications,” CN 2 stated, “it doesn’t look like critical laboratory values are supposed to be communicated through text messages.” The facility P&P titled, “Physician Notifications,” dated April 2024, was reviewed. The P&P indicated, “...Notifications to physicians will be in person, verbal, or by telephone...For immediate notification, FAX, [brand name of text messaging service] or leaving a voicemail is not an acceptable method for notifying the physician...The Nurse will utilize an approved method to communicate to the physician...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50433 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) for infection prevention were implemented, for two of 21 sampled patients (Patients 1 and 21), when: 1. For Patient 1, an intravenous (IV, a small tube placed into a vein to deliver fluids, medicine, blood or nutrients directly into a person’s bloodstream) tubing set (a sterile, plastic medical device used to deliver fluids, medicine, blood or nutrients directly into a person’s bloodstream) was observed disconnected with the end attached to a secondary access port on the same tubing; and 2. For Patient 21, Registered Nurse (RN) 1 was observed entering Patient 21’s room, putting on gloves, and touching surfaces in the room without performing hand hygiene (the process of cleaning and disinfecting one’s hands to remove dirt and germs). These failures had the potential to expose patients to pathogens (bacteria, virus, or other microorganisms [living organisms invisible to the naked eye] which can cause infections) which could result in infections, prolonged hospitalizations, and increased risk of death. Findings: 1. On September 22, 2025, at 9:17 a.m., during a tour of Unit A conducted with the Infection Prevention Coordinator (IPC) and the Clinical Effectiveness Coordinator (CEC), Patient 1 was observed in her room sitting in bed. During a concurrent interview with Patient 1, Patient 1 stated she was not sure if she was supposed to be connected to her IV. An IV pump (a programable medical device used to accurately deliver fluids, medicine, blood or nutrients through an IV tubing) was observed with an IV tubing hanging from it with its end connected to an access port (a small, specialized component that allows healthcare providers to inject or add medication and fluids to a patient’s intravenous (IV) line without having to start a new IV) on the same tubing. The IV tubing was observed to not be connected to Patient 1 and its end was observed to not be covered by a sterile cap (a medical device used in hospitals to seal the end of an IV tubing or catheter to protect the access point from contamination by bacteria [a single-cell organism which is invisible to the naked eye] and other organisms that may cause infections). On September 22, 2025, at 2:26 p.m., a review of Patient 1’s record was conducted with the Effectiveness Coordinator (EC). A facility document titled, “History and Physical,” dated September 19, 2025, was reviewed. The document indicated Patient 1 was admitted to the facility on September 19, 2025, with a diagnosis of acute gastroenteritis (inflammation [a normal part of the body’s response to injury or infection causing redness, swelling, pain, and warmth to the affected area) of the stomach and intestines, causing pain, vomiting, and diarrhea). A facility document titled, “MAR [Medication Administration Record],” dated September 21, 2025, through September 23, 2025, was reviewed. The document indicated Patient 1 received metronidazole (an antibiotic, a medication used to treat infections) IV every eight hours and ceftriaxone (an antibiotic) IV daily. On September 22, 2025, at 9:20 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated IV looping (a healthcare practice where a nurse bends the end of a disconnected IV line back onto itself) should not be doneN 1 stated there are sterile caps to place on the end of the IV tubing when it is disconnected from the patient. On September 24, 2025, at 2 p.m., an interview was conducted with CN 2. CN 2 stated when an IV tubing is disconnected from a patient with the intend to use it again, a sterile cap is placed at the end of the tubing. CN 2 stated looping the IV tubing on itself creates a risk of infection. An article published by the National Institutes of Health (NIH, an agency within the United States Public Health Service, under the Department of Health and Human Services) article titled, “Capping Intravenous Tubing and Disinfecting Intravenous Ports Reduce Risks of Infection,” dated February 2011, was reviewed. The article indicated, “...failure to place a sterile cap on the end of a reusable intravenous (IV) administration set...the tip of the set is exposed to potential contaminants; this can lead to infection...” The facility’s P&P titled, “Intravenous Therapy,” dated September 2018, was reviewed. The P&P indicated, “...Utilize aseptic technique [a set of practices and procedures designed to prevent bacteria, viruses, or other microorganisms (tiny, microscopic organisms which are too small to be seen with the naked eye and require a microscope to be viewed) from contaminating a sterile environment, or entering a patient’s body] when handling IV’s and IV tubing...” 2. On September 22, 2025, at 9:32 a.m., during a tour of Unit B conducted with the IPC and the CEC, RN 1 was observed entering Patient 21’s room. RN 1 was observed to not perform hand hygiene prior to entering Patient 21’s room, putting on gloves, or touching surfaces in Patient 21’s room. On September 22, 2025, at 9:34 a.m., an interview was conducted with RN 1. RN 1 stated it “seems unclear” if he should have performed hand hygiene before entering Patient 21’s room. On September 22, 2025, at 10:38 a.m., an interview was conducted with the Director of Quality (DQ). The DQ stated RN 1 had been previously spoken to about infection control policies and was aware of the facility’s hand hygiene expectations. The facility’s P&P titled, “Hand Hygiene Program,” dated June 2024, was reviewed. The P&P indicated, “...Bacteria and other microorganisms can be transmitted to the hands by direct or indirect contact...To protect the patient and the employee, hands are to be washed or decontaminated before and after each contact with the patient and/or patient’s equipment...””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure nursing services were provided in accordance with acceptable standards of practice and the facility’s policy and procedure when treatment and interventions were not provided timely, for one of 30 sample patients (Patient 15), who was suspected to have an acute coronary syndrome (ACS, a range of conditions caused by a sudden reduction in blood flow to the heart muscle), when treatment and interventions were not provided timely and EKG was not done timely. In addition, activity restriction, such as bed rest, was not implemented for the patient (Refer to A 0398). The cumulative effect of these failures resulted in Patient 15’s condition to worsen and may have contributed to the patient’s demise.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 48562 Based on interview and record review the facility failed to ensure the medical record was accurate, for one of 30 sample patients (Patient 18), when: 1. The anesthesia (medication for pain management and sedation) administered to Patient 18 was inaccurately documented on the patient’s record; and 2. The x-ray result of Patient 18 was inaccurately documented. These failures had the potential to affect Patient 18’s care and treatment. Findings: 1. On May 20, 2025, at 9:20 a.m., an interview and review of Patient 18’s record were conducted with the Director of Maternal Child (DMC). A facility document titled, “History & Physical,” dated November 8, 2024, was reviewed and indicated Patient 18 was admitted to the facility on November 8, 2024, for a “scheduled induction [a medical procedure where labor is artificially started to cause childbirth] of term pregnancy [a pregnancy that lasts between 39 weeks, 0 days and 40 weeks, six days].” A facility document titled, “Anesthesia Record,” dated November 10, 2024, was reviewed. The document indicated, “...5:48 [a.m.] Endotracheal Intubation [a medical procedure where a tube is inserted into the airway to help someone breathe]...6:12 [a.m.] ...Anesthesia Method: General [a deep sleep-like state induced by medications to allow surgical procedures to be performed without pain or awareness]...” A facility document titled, “Operative Reports,” dated November 9, 2024, at 8:11 a.m., was reviewed. The document indicated, “ ...Procedure: Emergent Cesarean Section [a surgical procedure where a baby is delivered through incisions made in the mother’s abdomen and uterus]...Anesthesia: General...She [Patient 18] was taken to the operating room, where spinal anesthesia [a type of anesthesia where medication is injected into the surrounding the spinal cord, causing temporary loss of feeling and movement in the lower body]...” The DMC stated the anesthesia record indicated Patient 18 received general anesthesia and was intubated, but the Obstetrician (a physician who specialized in the care of the pregnant woman and delivery of the infant) (MD 1) documented that the patient was given spinal anesthesia. The DMC stated Patient 18 did not receive spinal anesthesia. The DMC stated the MD 1 documented spinal anesthesia in error and the anesthesiologist [medical doctors who specialize in the management of pain and the provision of anesthesia during surgical procedures and other medical interventions] documented the general anesthesia correctly. The DMC stated the anesthesiologist’s documentation is correct and Patient A received general anesthesia and was intubated. 2. On May 20, 2025, at 9:20 a.m., a concurrent interview and review of Patient 18’s record were conducted with the Director of Maternal Child (DMC). A facility document titled, “XR [x-ray, an imaging procedure] Abdomen...,” dated November 9, 2024, at 2:49 p.m., authored by Radiologist (a medical doctor specializing in interpreting images to diagnose and treat diseases and injuries) Medical Doctor (RMD) 1, was reviewed. The document indicated, “...Findings...A rectal tube [a long, slender tube inserted into the rectum for various medical purposes] is present...Impression...Rectal probe in place...” A facility document titled, “XR [X-Ray] Abdomen...,” dated November 9, 2024, at 4:59 p.m., was reviewed. The document indicated, “...Addendum # [number] 1...A catheter [a flexible tube inserted into the bladder to remove urine] is projected over the midline lower pelvis, which looked like a rectal temperature probe. However, this is a foley catheter...” The DMC stated Patient 18 never had a rectal tube nor probe inserted during the patient’s hospitalization. The DMC stated it is not in labor and delivery’s process to ever use a rectal probe or tube on a laboring patient. The DMC stated they looked into the results and determined there is no documentation and no indication for Patient 18 to have any kind of rectal tube or probe. The DMC stated Patient 18 did have a foley catheter (a thin, flexible tube inserted into the bladder to drain urine when normal urination is not possible or practical) in place that was seen and was not mentioned on the original x-ray result authored by RMD 1. The DMC stated RMD 1 documented a rectal tube or probe was present instead of the foley catheter. The DMC stated it comes down to how the radiologist interpreted the images. On May 20, 2025, at 3 p.m., an interview was conducted with RMD 1. RMD 1 stated when she interpreted the images, it did not look like a regular foley she is used to seeing, so she documented it as a rectal temperature tube. RMD 1 stated after reviewing the radiology images with the medial director, it was determined that it was a foley catheter. RMD 1 stated on Patient 18’s x-ray, the bladder and rectum were seen over each other, and at first it looked to be a rectal tube. RMD 1 stated a rectal tube, or probe is how she initially interpreted the images, but she made an addendum to the record to correct the error. On May 21, 2025, at 9:30 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated in the case of Patient 18’s abdominal x-ray, RMD 1 interpreted and documented the findings as a rectal probe instead of a foley catheter and balloon (a portion of the foley catheter that is inflated to keep the catheter in place). The CNO stated Patient 18 had no record of having had a rectal probe or tube placed. The CNO further stated RMD 1 planned to make an addendum to correct the x-ray results. A facility document titled, “Medical Staff Bylaws,” dated October 2021, was reviewed. The document indicated, “...Applicants and members of the medical staff shall be governed by such rules and regulations and medical staff policies as are properly initiated and adopted...” A facility document titled, “ [Name of facility] Medical Staff General Rules and Regulations,” dated October 2021, was reviewed. The document indicated, “...1.3 A member of the medical staff will be responsible for the care and treatment of each patient in the hospital, for the prompt completion and accuracy of the electronic health record, and for necessary special instructions...””

“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: 38479 Based on interview and record review, the facility failed to ensure treatment and interventions were provided timely, for one of 30 sample patients (Patient 15), who was suspected to have an acute coronary syndrome (ACS, a range of conditions caused by a sudden reduction in blood flow to the heart muscle), in accordance with acceptable standards of practice and the facility’s policy and procedure, when EKG was not done timely. In addition, activity restriction, such as bed rest, was not implemented for the patient. These facility failures resulted in Patient 15’s condition to worsen and may have contributed to the patient’s demise. Findings: On May 19, 2025, at 1:40 p.m., a concurrent interview and review of Patient 15’s record was conducted with the Interim Director ICU (Intensive Care Unit, a unit for critically ill patients)/Education Director (IDICU/ED). A facility document titled, “ED Physician Record,” dated September 16, 2024, was reviewed. The document indicated, “...BIBA [brought in by ambulance] from home for evaluation of chest pain, sudden onset, localized to the substernal [below the bone on the mid chest area] region, radiating to the left shoulder and the left side of her neck, onset 10 minutes after she ate dinner...Patient having nausea and vomiting on arrival...POC BG [Point of Care Blood Glucose, blood sugar, normal is 70-100 mg/dL (milligrams per deciliter, a unit of measurement) before meals and below 140 mg/dL two hours after eating] 506...Impression and Plan: STEMI [ST (a wave found on the tracing of heart activity) elevation myocardial infarction, a serious type of heart attack wherein prompt treatment is crucial to minimize the damage to the heart and improve survival chances], cardiac arrest [when the heart stops beating]...Respiratory arrest [when breathing stops]...Condition: Expired...Disposition: Expired...” An emergency medical service (EMS, ambulance) document titled, “1) PATIENT CARE REPORT,” was reviewed. The document indicated, “ ...Arrived at patient [Patient 15]: 09/16/2024 [September 16, 2024] 21:33:26 [9:33 p.m.]...Transporting: 09/16/2024 21:45:18 [9:45 p.m.]... Arrived at Dest. [destination, facility]: 09/16/2024 22:00:40 [10 p.m.]...Primary Impression: Chest Pain- Suspected Cardiac [pain related to heart causes] ...Pain ...09/16/2024 21:42:35 [9:42 p.m.] 10 [pain scale of 1-10, 10 being the worst pain] ...21:50:03 [9:50 p.m.] 10 ...21:52 p.m. [9:52 p.m.] 10 ...2159 [9:59 p.m.] 10 ...” On May 21, 2025, at 1:43 p.m., further review of Patient 15’s record was conducted with the Chief Nursing Officer/Chief Operating Officer (CNO/COO), Emergency Department Manager (EDM), and the Chest Pain Program Coordinator (CPPC). A facility voice recording, labeled “091620242119,” was reviewed twice for content. The voice recording contained the exchanges made during the arrival of Patient 15 to the facility on September 16, 2024. The voice recording indicated, “...35 years old...ETA [estimated time of arrival] 10 minutes...CP [chest pain]...not reading STEMI...” An email document titled, “Timeline,” authored by the ED Director and sent to the CNO and EDM, dated September 30, 2024, was reviewed. The document indicated, “...[name of Patient 15]...c/o [complaining of] Chest Pain: 22:04 [10:04 p.m.] Arrived ED via [name of EMS]; 22:17 [10:17 p.m.] Triage [name of Triage Registered Nurse, TRN]; 22:19 [10:19 p.m.] ED [room number] given, [name of EMS] took patient to BR [bathroom, as verified with EDM] not to room; 22:22 [10:22 p.m.] EKG [a non-invasive medical test that records the electrical activity of the heart, 18 minutes after arrival] done; 22:30 [10:30 p.m., 26 minutes after arrival] Cardiac Workup started by RN 1, New Grad with RN 2 Preceptor; 22:35 [10:35 p.m., 31 minutes after arrival] [Name of ED physician] to room, patient starts having seizure like activity [sudden, abnormal electrical discharges in the brain that can cause temporary changes in behavior, movement, or awareness], Ativan [medication used to treat seizures], Code Blue [a medical emergency, typically a cardiac or respiratory arrest, requiring immediate attention and intervention by the resuscitation team and a universal signal for staff to respond quickly to a patient’s critical condition] called, CPR [cardio-pulmonary resuscitation, chest compressions to try to revive a patient] started; 22:37 [10:37 p.m.] 22:37 [name of respiratory therapist] at bedside; 23:01 [11:01 p.m.] Moved to room [room number]; 23:06 [11:06 p.m.] Code stopped by [name of physician]; 00:47 [12:47 a.m.] Coroner at bedside...” The CPPC, the EDM, and the CNO were unable to provide documentation an EKG was completed 10 minutes from Patient 15’s arrival to the facility on September 16, 2024, nor at 10:22 p.m., as recorded on their “Timeline,” aside from the EKG completed at 10:30 p.m. (26 minutes after arrival), after Patient 15 was walked to the bathroom. During a concurrent interview with the CPPC and the EDM, on May 21, 2025, at 1:43 p.m., the EDM stated, “Patient [Patient 15] is expected to arrive [to the facility].” The EDM stated the “Timeline” data started from registration when Patient 15 arrived by ambulance at the facility at 10:04 p.m., and was triaged by the Triage Registered Nurse (TRN) at 10:17 p.m. The CPPC stated an EKG should have been completed 10 minutes after Patient 15’s arrival to the hospital. On May 21, 2025, at 1:55 p.m., the CPPC and the EDM were interviewed regarding patients coming in for ACS and the activity restriction recommendation for these patients. The CPPC stated an ACS patient should have been placed in a bed right away and the activity should be restricted in accordance with the ACS Algorithm (a systematic approach designed to assist clinicians in rapidly identifying and treating patients experiencing ACS). The CPPC stated, “When patient arrive via EMS, they hand the patient record to the unit clerk to be registered.” The CPPC stated, “depending on availability,” the ED staff would have already pre-assigned a room and a nurse for the patient when the charge nurse receives the EMS call. The CPPC stated the unit clerk, when warranted, will overhead call for “Cardiac Alert [an alert signal for a heart patient],” the EKG will be done in 10 minutes, and laboratory tests will be drawn in 25 minutes. The CPPC stated, within 10 minutes, a physician had to see the patient and review the EKG, and the unit clerk will contact the cardiologist (a physician who specializes in the diagnosis and treatment of heart diseases) and overhead call for “STEMI” if warranted. The EDM stated the facility was responsible for any patient coming in as soon as they come to “our door.” A review of a web article titled, “CLINICAL PRACTICE GUIDELINES 2025 ACC [American College of Cardiology, a nationally recognized organization]/AHA [American Heart Association, a nationally recognized organization]/ACEP [American College of Emergency Physicians, a nationally recognized organization]/NAEMSP [National Association of EMS Physicians, a nationally recognized organization]/SCAI Society for Cardiovascular Angiography and Intervention, a nationally recognized organization] Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” was conducted. The article indicated, “ ...In patients with suspected ACS, acquisition and interpretation of an ECG [EKG] within 10 minutes is recommended to help guide patient management ...In patients with suspected ACS in whom the initial ECG is nondiagnostic [when the ECG does not provide enough information for the provider to arrive at a diagnosis]. Serial 12-lead ECG [a type of ECG] should be performed to detect potential ischemic [a condition where there’s not enough blood flow to a specific part of the body, leading to a lack of oxygen and nutrients] changes, especially when clinical suspicion [a healthcare provider’s awareness and concern about a patient’s potential serious illness or injury, based on their symptoms and medical history] is high, symptoms persistent, or clinical condition [symptoms observed] deteriorates ...” An undated ACS algorithm was reviewed and indicated, “ ...Assess patient for symptoms of acute coronary syndrome (ACS) ...Crushing chest pain ...Pain radiates to jaw, arm, back ...Nausea/vomiting...Sweating ...Shortness of breath ...Rapid sequence of interventions and additional assessments ...If no aspirin allergies, administer aspirin [a blood thinner] (patient should chew)...If no contraindications, administer nitroglycerin ...Administer morphine [a pain medication], if needed...Obtain 12-lead ECG...Apply oxygen [O2] via nasal cannula [a plastic tube used to deliver oxygen through the nostrils] if O2 <94% [normal oxygen level in the blood is 95 to 100 percent and drops to 90% and below during a heart attack], normal is ...Trained professional should assess ECG; ST-segment elevation myocardial infarction (STEMI) ...” A review of facility policy and procedure (P&P) titled, “Cardiac Care Program,” dated November 2024, was conducted. The P&P indicated, “ ...Purpose ...Establishment and maintenance of a Cardiac Care Program through the use of evidence based practices and multidisciplinary involvement to provide a full range of activities and services associated with cardiac prevention, care, treatment and rehabilitation to improve outcomes for patients with cardiac care needs...The Cardiac Care Program is organized by a multidisciplinary team to provide evidence based care through formally defined protocols, order sets, flow processes, continual medical and staff education, interface with EMS and Administrative Support...The Cardiac Care Program provides assessment and treatment in the event of cardiac disease and treatment of acute STEMI diagnosis by the ED provider results in Code STEMI call for rapid treatment using policies and protocols in place...The Cardiac Program provides a plan for the triage and treatment of patients...Procedure...Patient’s arriving to the ED via EMS...cardiac related symptoms...The patient is pre-registered according to current practice by the Unit Coordinator (or designee)...Stat [immediate] EKG is performed for the patient within 10 minutes of arrival and taken to the provider for immediate interpretation. If the first EKG shows no STEMI, subsequent EKGs are done every Q15 [every 15 minutes] for 1 [one] hour. All EKGs are taken directly to the ED Provider for interpretation...””

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 50433 Based on observation, interview, and record review, the facility failed to ensure surgical services were provided in a well-organized manner, in accordance with acceptable standards of practice, to prevent the risk of cross contamination (the transfer of harmful bacteria from one person or object to another), when: 1. The steam sterilizer (a machine that utilize high-temperature steam and pressure to kill germs) was not maintained in accordance with the manufacturer’s instruction for use (IFU) and brown staining, black matter, and whitish/grey residue were observed throughout the chamber (the internal portion of the sterilizer) for one of three sampled reprocessing (a process used to remove soil and germs and/or inactivate germs) machines (Sterilizer 3) (Refer to A0951); 2a. Singled-use (an item designed to be used once and then discarded) cleaning sponges were not being properly used for multiple surgical cases in accordance with the manufacturer’s IFU, for two of two sampled surgical cases (Refer to A0951); 2b. Hand-held cleaning brushes (a special brush used to clean reusable surgical instruments) were not being cleaned after each use in accordance with the manufacturer’s IFU, for two of two sampled surgical cases (Refer to A0951); 3. Endoscopes were not stored in clean and properly maintained storage units in accordance with the manufacturer’s IFU for one of three sampled storage cabinets (Storage Cabinet 2) (Refer to A0951); 4. Previously reprocessed instruments were observed with orange/red matter, brown staining, discoloration, scratches, pitting (the formation of small, localized depressions or holes), etching (an engraving on the surface of the instrument), and white residue for two of two sampled surgical instrument tray sets (Tray Set 1 and Tray Set 2) (Refer to A0951); 5. Terminal cleaning procedures (a thorough environmental cleaning procedure that is performed at the end of each day when the area is being used) were not implemented per hospital protocol and peeling red tape, medical device stickers, black sticky substances, medical tape, and scattered black/brown spots were observed throughout the floor for one of two sampled reprocessing workrooms (Sterile Processing Department -SPD, an area within a health care facility that processes and controls medical supplies, devices, and equipment) (Refer to A0951); 6. The surgical consent form (a legal document that a patient/patient’s representative signs to give permission for a surgery to be performed) did not indicate the date and time that the physician discussed the surgical procedure with the patient’s representative in accordance with the hospital’s P&P for one of 30 sampled patients (Patient 13) (Refer to A0951); 7. Hand hygiene (the practice of cleaning one’s hand to remove dirt and germs to prevent the spread of infections) was not performed after handling soiled surgical instruments in accordance with the hospital’s policy and procedure (P&P) for one of four sampled Sterile Processing Technicians (SPD Tech 1) (Refer to A0951); 8. The hospital did not ensure eyewash stations were not installed in locations that required employees to perform emergency flushing of the eyes in decontamination (the process of removing or neutralizing germs) sinks for one of two sampled reprocessing workrooms (SPD decontamination workroom) (Refer to A0951); and 9. Sterile supply packs were stored on shelving over an unmaintained drain with exposure to moisture and insects (Refer to A0951). The cumulative effects of these systemic problems had the potential for cross contamination which may result in longer hospitalization, delay in healing, and infection in patients on whom the surgical instruments are used.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 39723 Based on observation, interview, and record review, the hospital failed to ensure the needs of all patients requiring surgical services and gastroenterology services (GI, the study, diagnosis, and treatment of disorders that deal with the digestive system) including the storage of flexible endoscopes (a reusable instrument used to inspect and treat the interior portions of the body) were met when: 1. The steam sterilizer (a machine that utilize high-temperature steam and pressure to kill germs) was not maintained in accordance with the manufacturer’s instruction for use (IFU) and brown staining, black matter, and whitish/grey residue were observed throughout the chamber (the internal portion of the sterilizer) for one of three sampled reprocessing (a process used to remove soil and germs and/or inactivate germs) machines (Sterilizer 3); 2a. Singled-use (an item designed to be used once and then discarded) cleaning sponges were not being properly used for multiple surgical cases in accordance with the manufacturer’s IFU, for two of two surgical cases; 2b. Hand-held cleaning brushes (a special brush used to clean reusable surgical instruments) were not being cleaned after each use in accordance with the manufacturer’s IFU, for two of two surgical cases; 3. Endoscopes were not stored in clean and properly maintained storage units in accordance with the manufacturer’s IFU, for one of three sampled storage cabinets (Storage Cabinet 2); 4. Previously reprocessed instruments were observed with orange/red matter, brown staining, discoloration, scratches, pitting (the formation of small, localized depressions or holes), etching (an engraving on the surface of the instrument), and white residue for two of two sampled surgical instrument tray sets (Tray Set 1 and Tray Set 2); 5. Terminal cleaning procedures (a thorough environmental cleaning procedure that is performed at the end of each day when the area is being used) were not implemented per hospital protocol and peeling red tape, medical device stickers, black sticky substances, medical tape, and scattered black/brown spots were observed throughout the floor for one of two sampled reprocessing workrooms (Sterile Processing Department -SPD, an area within a health care facility that processes and controls medical supplies, devices, and equipment); 6. The surgical consent form (a legal document that a patient/patient’s representative signs to give permission for a surgery to be performed) did not indicate the date and time that the physician discussed the surgical procedure with the patient’s representative in accordance with the hospital’s policy and procedure (P&P), for one of 30 sampled patients (Patient 13); 7. Hand hygiene (the practice of cleaning one’s hand to remove dirt and germs to prevent the spread of infections) was not performed after handling soiled surgical instruments in accordance with the hospital’s P&P, for one of four sampled Sterile Processing Technicians (SPD Tech 1); 8. The hospital did not ensure eyewash stations were not installed in locations that required employees to perform emergency flushing of the eyes in decontamination (the process of removing or neutralizing germs) sinks for one of two sampled reprocessing workrooms (SPD decontamination workroom); 9. Sterile supply packs were stored on shelving over an unmaintained drain with exposure to moisture and insects; and 10. The hospital did not follow the manufacturer’s IFU on daily and weekly routine maintenance services for one of one sampled washer/disinfector (a machine that use a combination of mechanical, chemical, and thermal processes to reprocess surgical instruments). These failures had the potential for injury and prolonged hospitalization, for 30 of 30 sampled patients, and jeopardize the health and welfare of other patients experiencing surgical procedures. Findings: On April 2, 2025, at 1:49 p.m., an immediate jeopardy (IJ- a situation that had threatened or was likely to threaten the health and safety of a patient) situation was called in the presence of the Chief Nursing Officer (CNO) and the Director of Quality and Infection Prevention (DQIP). The CNO and the DQIP were verbally notified of failure of the hospital not implementing safe surgical practices when the steam sterilizer (autoclave, a machine used to kill germs on surgical instruments) was not clean and maintained in accordance with the manufacturer’s IFU; multiple reusable surgical instruments were not clean and/or damaged; single-use cleaning sponges were being used for multiple surgical cases; hand-held brushes used to clean the reusable surgical instruments were not being cleaned after each use; and endoscopes were not stored in a clean and properly maintained storage cabinet in accordance with the manufacturer’s IFU. On April 3, 2025, at 5:52 p.m., the hospital provided an IJ removal plan (RP). The RP included the following components: -Sterilizer cleanliness 1. Daily sterilizer log was implemented for sterilizers. SPD technicians trained to complete checklist/log including chamber inspections, door/gasket, clean drain, printer, and external wipe down. Flush of the chamber drain will be conducted weekly. Purpose, expectations, and completion of the log provided. 2. The policy “OR (operating room)-Autoclave Maintenance” was reviewed and revised to align with clinical standards, manufacturer specifications, and IFU. Policy review included sterilizer chamber inspection, door and gasket inspection, chamber drain strainer cleaning, printer and paper supply check, and exterior surface wipe down. 3. Education provided to SPD technicians/staff regarding daily logs, inspection of sterilizers, and chamber drain cleaning. Expectation that all SPD technicians and staff complete training upon the start of their shift until 100% of staff have completed training. Education to be completed in initial hire and annual competencies (an evaluation of knowledge, skills, and experience to perform job duties correctly) going forward. -Surgical Instrument Integrity: 1. In SPD, staff instructed regarding visual inspection of instrumentation after washing for any breech in the integrity of the instruments. a. If an instrument is damaged, then it will be removed and replaced with another instrument to complete the tray, and the instrument held for evaluation by the third-party vendor who specializes in instrumentation to determine if the instrument should be refurbished or discarded. b. If any instruments in the container are contaminated (potentially infectious and/or soiled with bone, blood, residue), then the whole container will be reprocessed. 2. Water quality will be reevaluated on a periodic basis (quarterly), or more frequently when a trend is noted with the instruments. Completed 3/17/25, next due May 2025, or sooner if indicated. 3. Reinforce “Stop the Line” (an immediate stop in a procedure/process if a potential safety risk or error have been identified) escalation for SPD and OR staff whenever a sterile instrument is identified of questionable integrity. If an instrument is identified, the tray will be pulled (will not be available for patient use), and all instruments set aside for evaluation by the SPD Director/CNO/RM prior to reprocessing. Once evaluated, instruments will be reprocessed (if applicable). 4. Vendor contacted for instrument cleaning/refurbishing (3rd party vendor) to come evaluate instrumentation and determine if instrumentation can be refurbished for use versus discarded. Scheduled for 4/9/25 and 4/12/25 for initial evaluation, followed by regularly scheduled interval based upon identified need. 5. Infection Prevention will conduct a random audit of sterilized (germ free) trays to assure instrument integrity. Number= # of instruments with breech integrity, Denominator = # of instruments reviewed. Goal is 0% with identified issue with integrity. Data will be collected monthly and reported quarterly to the Governing Board (a committee that manages or control the hospital’s activities) until compliance is achieved and sustained for a period of 3 (three) months, then transition to a periodic review. -Sponge utilization in Decontamination Department 1. IFU for sponge products was reviewed and practice was changed from current practice to utilization of one sponge to be used for single OR case as long as the sponge remains intact. (Note: Single case means one patient with multiple cases). 2. Signage was posted in the decontamination area. Education provided to SPD technicians/staff regarding new changes. 3. Education provided to SPD technicians/staff regarding single-use sponge use. Expectation that all SPD technicians/SPD staff complete training upon the start of their shift until 100% of staff have completed the training. Education to be included in initial hire and annual competencies going forward. 4. Infection prevention will audit the number of sponges used with the number of cases daily. Numerator =of sponges per month, Denominator =of cases per month. Goal-number of cases and sponges match within 5 (five) %. Data will be Data will be collected monthly and reported quarterly to the Governing Board until compliance is achieved and sustained for a period of 3 months, then transition to a periodic review. -Brush utilization in Decontamination Department 1. IFU for brush products was reviewed and practice was changed from current practice to utilization of one brush to be used for single OR case as long as the brush remains intact. (Note: Single case means one patient with multiple cases). 2. Signage was posted in the decontamination area. Education provided to SPD technicians/staff regarding new changes. 3. Education provided to SPD technicians/staff regarding single-use brush use. Expectation that all SPD technicians/SPD staff complete training upon the start of their shift until 100% of staff have completed the training. Education to be included in initial hire and annual competencies going forward. 4. Infection prevention will audit the number of brushes used compared to the number of cases. with the number of cases daily. Numerator =of brushes used per month, Denominator =of cases per month. Goal-number of cases and brushes match within 5 %. Data will be Data will be collected monthly and reported quarterly to the Governing Board until compliance is achieved and sustained for a period of 3 months, then transition to a periodic review. -GI Scope Cabinet base tray integrity 1. The scopes were removed from the scope cabinet and cabinet was terminally cleaned (a cleaning process which includes specialized chemicals to eliminate germs). 2. The scopes were all reprocessed. 3. The bottom tray of the cabinet was removed and replaced with an intact tray. 4. The cabinet and base were terminally cleaned prior to replacing the scopes. 5. Scopes were replaced into the scope cabinet. 6. Additional tray will be ordered for back-up 7. Infection prevention will conduct a random audit of cabinet/tray to assure the integrity. Numerator =of observation with no breech in cabinet/tray integrity. Denominator =of observations completed. Goal is 0% with identified issue with integrity. Data will be Data will be collected monthly and reported quarterly to the Governing Board until compliance is achieved and sustained for a period of 3 months, then transition to a periodic review. On April 3, 2025, at 5:52 p.m., the RP for the IJ was reviewed and was found acceptable. On April 4, 2025, at 4:24 p.m., the immediate jeopardy situation was removed onsite in the presence of the CNO, Chief Executive Officer (CEO), and the DQIP, after the RP was verified onsite as implemented through observation, interviews, and record reviews, as evidenced by the cleanliness of the sterilizer, cleanliness and integrity of the surgical instruments, cleanliness of the endoscope storage cabinet, implementation of single case use for cleaning products, staff knowledge of the manufacturer’s IFU, and a tracking system to prevent future reprocessing breeches. 1. An interview was conducted with the DQIP on April 1, 2025, at 8:45 a.m., in the conference room (CR). The DQIP stated the hospital followed the following nationally recognized guidelines: A. Centers for Disease Control and Prevention (CDC, the national public health agency of the United States); B. Association of periOperative Registered Nurses (AORN, a nationally recognized infection control guidelines for perioperative areas); C. Occupational Safety and Health Administration (OSHA, a large regulatory agency of the United States Department of Labor); and D. ANSI/AAMI ST79 (2017) (American National Standards/Association for the Advancement of Medical Instrument, standards development organizations) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities. A concurrent observation and interview were conducted with the DQIP on April 1, 2025, at 8:55 a.m., in the SPD clean workroom. Three sterilizer machines were observed. There was brown staining, black matter, and whitish/grey residue observed throughout Sterilizer 3’s chamber walls. The DQIP stated the sterilizer had “some discoloration.” A request was made to interview the SPD Supervisor. The DQIP stated the SPD Supervisor was away from the medical center and was not available for interview. The DQIP stated, “The SPD Supervisor reports to me.” An interview was conducted with the Lead Sterile Processing Technician (Lead SPDT 1) on April 1, 2025, at 9:05 a.m., in the SPD clean workroom. Lead SPDT 1 stated the SPD staff did not provide routine maintenance or cleaning services for the sterilizer’s machine chamber and the hospital did not have documentation to show that the chamber strainer had been inspected or routinely cleaned. An interview and record review were conducted with the CNO and Lead SPDT 2 on April 2, 2025, at 8:30 a.m., in the conference room. The facility’s document titled, “AMSCO 400 Series Medium Steam Sterilizers: Operator Manual,” dated 2019, indicated, “ ...8.3.1 Clean Chamber Drain Strainer: Recommended Frequency: The chamber drain strainer must be cleaned at least once a day...8.3.2 Flush Chamber Drain...The chamber drain should be cleaned once a week...Drain Cleaning Method...6. Rinse the bottom of the chamber with a small amount of water to prevent detergent residue from baking onto the surface...” Lead SPDT 2 stated she had reviewed the manufacturer’s IFU, and she was not aware that the hospital expected the SPD staff to perform daily or weekly cleaning of the sterilizers. Lead SPDT 2 confirmed the SPD staff were not performing daily or weekly maintenance/cleaning services for the hospital’s sterilizers. A concurrent interview and review of the facility’s document titled, “Field Service Report” (a record that shows the activities and outcomes of a service visit, such as repairs, installations, or maintenance) were conducted with the Biomedical Director (Biomed Director) on April 3, 2025, at 3:45 p.m., in the conference room. The Biomed Director stated his department was responsible for the hospital’s field service reports. The report showed the following: “Work date: 2/21/2025 [February 21, 2025], Type: Chamber cleaning. Notes: Serviced machine. Could not run dart [Daily Air Removal Test, a process used to ensure effective sterilization because air pockets interfere with steam penetration and contact with the items being sterilized, potentially leading to failure of the sterilization process] due to their being a problem with the steam. Unit has been down for over 2 (two) weeks ...” The Biomed Director confirmed the manufacturer had cleaned Sterilizer 3’s chamber on February 21, 2025. The Biomed Director stated the end users (SPD staff) were responsible for daily and weekly routine care of the sterilizers. The Biomed Director stated he was not aware the hospital had been experiencing problems with the steam system. The Biomed Director confirmed that the lack of steam could interfere with the sterilization process. The review of the hospital’s P&P titled, “OR (Operating Room)-Autoclave Maintenance,” reviewed March 2025, was conducted. The P&P indicated, “ ...V. Procedure: SPD personnel will clean sterilizer daily as follows: Clean chamber drain strainer...Once a week, or as needed, the interior of the sterilizer is cleaned as follows: Flush chamber drain...As needed, the SPD personnel will: Clean sterilizer’s chamber...” 2. A tour of the SPD decontamination workroom was conducted on April 1, 2025, at 11:30 a.m., with the DQIP. The decontamination sink was observed to have three compartments (Sink 1, Sink 2, and Sink 3). Three surgical cleaning sponges, three toothbrush-style cleaning brushes, and two channel style (used to clean the inside of soiled instruments) cleaning brushes were observed on top of the decontamination sink. SPD Tech 1 was observed standing in front of Sink 1 and using a surgical cleaning sponge to wipe red soil and debris from a surgical instrument. SPD Tech 1 placed the instrument into Sink 2 and proceeded to pick up another instrument from Sink 1. SPD Tech 1 was observed cleaning the surface of the surgical instrument with a toothbrush-style brush and then proceeded to clean the inside of the instrument with a channel-style brush. An interview was conducted with the DQIP and SPD Tech 1 on April 1, 2025, at 11:45 a.m., in the SPD decontamination area. SPD Tech 1 stated the red soil on the instrument was blood. SPD Tech 1 stated sponges and brushes were not cleaned between cases and the cleaning products were used throughout the day and discarded at the end of the day. The DQIP stated she was not familiar with the cleaning brushes and cleaning sponges that were used in the decontamination workroom. The DQIP stated, “Let me check.” A concurrent interview and record review were conducted with the CNO, on April 1, 2025, at 3:45 p.m., in the conference room. The following documents were reviewed, -The hospital’s undated document titled, “DuraSponge, Cleaning Sponge,” indicated, “...Special Warnings and Cautions: Single use only;” and -The hospital’s undated document titled, “General Instrument Cleaning Brushes,” indicated, “Cleaning & [and] Disinfection [a cleaning process using chemicals to kill germs]: Clean brushes after each use and disinfect between cases or daily, at a minimum...” The CNO stated, according to the manufacturer’s guidelines, the brushes should have been cleaned after each use and the sponges were designed for a single use case. The CNO stated, “Let me take a picture of the guidelines.” An observation was conducted with the CNO and the DQIP on April 2, 2025, at 9:53 a.m., in the SPD decontamination workroom. Two sponges and one toothbrush-style cleaning brush were observed on top of the decontamination sink. SPD Tech 1 was observed wiping red soil and debris from instruments with a surgical cleaning sponge. During an interview, conducted with SPD Tech 1 on April 2, 2025, at 10:05 a.m., in the SPD decontamination workroom, SPD Tech 1 stated he had used the cleaning sponges today (April 2, 2025) for multiple patient cases. SPD Tech 1 stated he had not been trained nor educated to dispose of the sponge after each case. SPD Tech 1 confirmed the cleaning sponges were used for all the surgical cases throughout the day and were replaced if the sponge was damaged. During a follow-up interview conducted with the CNO on April 3, 2025, at 1:25 p.m., in the conference room, the CNO stated the hospital’s practice is to, “Meet all manufacturer’s guidelines or to exceed them (manufacturer’s IFU). The CNO stated additional education for the SPD staff was needed to ensure SPD staff followed the manufacturer’s IFU on sponge and brush products used in the decontamination workroom. The review of the hospital’s P&P tilted, “OR-Instrument Processing,” revised March 2025, indicated “...V. Procedure...Decontamination Personnel will wash, disinfect, and process all instruments, equipment, and supplies brought to this area following the manufacture’s IFU and recommendations...” 3. An observation was conducted on April 2, 2025, at 11:09 a.m., of the endoscope storage room with the Lead Gastroenterology Technician (GI Tech) and the DQIP. Scope Cabinet 2 was observed with the drip tray (a removable tray designed to collect residual moisture that may drip during the storage process) to be cracked, and the tray contained a sticky black residue. A thick pale-white material was observed on both ends of the tray. The material was not smooth nor evenly applied. The material was observed to contain black particles, thick grey fuzzy matter, and debris. Twelve scopes were observed hanging freely in the cabinet and were labeled “Clean.” An interview was conducted with the GI Tech on April 2, 2025, at 11:20 a.m., in the endoscope storage room. The GI Tech stated the drip tray had cracked, and the hospital repaired the drip tray with a caulking material. The GI Tech stated the grey fuzzy matter was dust and the black specks was debris. The GI Tech stated the material was not easy to clean and/or disinfect. The GI Tech stated he did not know why the department continued to use the damage cabinet for the storage of reprocessed endoscopes. The GI Tech stated the scope cabinet should have been taken out of service until the drip tray had been replaced to prevent the risk of cross-contamination (the unintentional transfer of harmful germs or other from one surface or object to another). The DQIP disagreed with the GI Tech and stated the drip tray could have been effectively clean and disinfected. The DQIP stated she did know not if the scope cabinet’s manufacturer had recommended the use of the caulking material that had been applied to the drip tray. The review of the manufacturer’s manual titled, “Olympus Reprocessing Manual,” dated 2014, was conducted. The manual indicated the following instructions for use, “...8.2 Storing the disinfected endoscope and accessories: Warning: Proper storage procedures are as important as proper reprocessing procedures in maintaining good infection control practices...Be sure the endoscope storage cabinet is properly maintained, clean, dry, and well ventilated...” 4. A concurrent interview and inspection of surgical trays were conducted with Lead SPDT 1 and the DQIP, on April 1, 2025, at 9:01 a.m., in the SPD clean workroom. Two surgical tray sets were inspected. Lead SPDT 1 stated the surgical tray sets contained reusable surgical instruments that had been “previously reprocessed and were ready for patient use.” The following were observed: -Tray Set 1 contained 66 surgical instruments, dated March 26, 2025. 24 of 66 sampled instruments were of concern upon inspection of the surgical tray set. Two instruments had multiple scratches; nine instruments were discolored; five instruments had multiple white spots; seven instruments had brown staining, and one instrument contained etchings; and -Tray Set 2 contained 85 surgical instruments, dated March 31, 2025. 23 of 85 sampled instruments were of concern upon inspection of the tray set. Five instruments contained pitting; 10 instruments had brown staining; one instrument contained orange/red matter, four instruments had etchings; one instrument had white residue; and two instruments contained pitting. Lead SPDT 1 stated the hospital have been discarding all instrument containing etching. Lead SPDT 1 stated the instruments with etchings should have been remove from the tray set prior to the sterilization process. Lead SPDT 1 stated the orange/red matter was “rust” and the rust was “missed” during the inspection process. Lead SPDT 1 did not provide an explanation for the multiple brown stained instruments. Lead SPDT 1 stated if one reprocessed instrument in a tray set contained rust, the tray set would not be acceptable for patient use and “The entire surgical tray set would have to be returned to the SPD’s decontamination workroom for reprocessing.” The DQIP did not provide an explanation for the identified damaged and/or stained instruments. A concurrent observation and interview were conducted with the STERIS Technician/Outside Contractor (SOC), on April 4, 2025, at 10:15 a.m., in the SPD clean workroom. The SOC was observed providing service to the hospital’s sterilizer. The SOC stated the sterilizer was not getting enough steam and a poor steam system would “definitely” affect the sterilization process and could cause sterilization failure. A review of the hospital’s P&P titled, “OR-Instrument Processing,” revised March 2025, was conducted. The P&P indicated, “...Procedure...All instruments shall be carefully inspected for flaws, damage, debris, detergent residue, and completeness before drying...” 5. A concurrent observation and interview were conducted on April 1, 2025, at 11:20 a.m., with the DQIP, Lead SPDT 1, and the Environmental Service Technician (EVS 1) in the SPD clean workroom. Black and brown scattered spots were observed throughout the floor; peeling red tape was observed on the floor at the entrance of the clean workroom; medical device stickers, and black sticky substances were observed throughout the floor; black and brown spots were observed on the wall’s baseboards; and thick grey matter was observed throughout the floor and on the wall’s baseboards. Lead SPDT 1 stated the SPD workroom should have been terminally cleaned at the end of each day. EVS 1 stated she was not sure when the SPD workroom was terminally cleaned because the process occurred at night, and she didn’t work the night shift. EVS 1 stated the medical stickers and black sticky substances would need to be “manually removed with a spatula type tool.” EVS 1 stated the debris observed on the floor could potentially transfer onto the clean surgical instruments. An interview and review of the facility’s document titled, “Terminal Cleaning Log-Surgical Services,” dated March 2025, was conducted with the EVS Supervisor (EVSS) on April 3, 2025, at 4:55 p.m., in the conference room. The terminal cleaning log indicated the SPD workroom was cleaned daily from March 1, 2025, to March 20, 2025. The EVSS stated the logs for March 21, 2025, to April 3, 2025, were missing and she could not explain why the logs were missing if the SPD workroom had been terminally cleaning after March 21, 2025. The EVSS stated the hospital recently made changes to the EVS department and the SPD workroom did not have a supervisor. The EVSS stated, “Additionally, a supervisor should have inspected the SPD workroom and signed off daily that terminal cleaning had been performed.” The EVSS stated the hospital did not have a specific P&P for performing terminal cleaning in the SPD workroom. A review of the AORN guidelines titled “Guidelines for Perioperative Practice: Environmental Cleaning,” dated 2025, was conducted. The guidelines indicated, “...6. Sterile Processing Areas: 6. Sterile Processing Areas...6.2 Terminally clean sterile processing areas each day the areas are used...” 6. A review of Patient 13’s record was conducted. A facility document titled, “History and Physical,” dated February 26, 2025, showed Patient 13 was admitted to the hospital on February 26, 2025, with the diagnosis of abdominal pain (pain felt anywhere between the chest and the pelvis area). An interview and review of Patient 13’s “Authorization for and Consent to Surgery or Special Diagnostic or therapeutic Procedures,” dated February 26, 2025, was conducted with the Manager of the Telemetry Unit (a specialized area where patients receive continuous remote electronic monitoring) and the Medical Surgical Unit (TMS Manager) on April 3, 2025, at 3:27 p.m., in the conference room. The surgical consent document showed the following: 1. Procedure to be Performed: Exploratory laparotomy repair gastrostomy tube possible bowel resection possible jejunostomy (a surgical procedure where the abdomen is opened to assess and address abdominal problems, including nutritional assess and bowel issues); and 2. Physician Certification: The consent form showed Physician 1’s signature and did not indicate the time or date that the physician’s certification process had been completed. The TMS Manager stated nursing services should have ensured the consent form was completed prior to the procedure or the procedure should have been delayed until the surgical consent process had been completed and fully documented. The TMS Manager stated during the certification process the physician should have documented the date and time that he had certified the consent process. The TMS Manager stated the hospital did not follow the policy and procedures for obtaining a surgical consent and there was room for additional education related to the hospital’s consent process. A review of the hospital’s P&P titled, “Medical Record Content &(and) Documentation,” revised April 2, 2024, was conducted. The P&P indicated, “...III. Policy: F. All entries made in the record shall be legibly signed by the person making the entry, print name (optional), date, and time. The date and time shall be the date and time that the entry was made...” A review of the hospital’s P&P titled, “Consent Informed Consent,” was conducted. The P&P indicated, “...C. Documenting Informed Consent: The doctor will complete the information in the “Consent to Surgery or Special Procedure” form or provide the information to the surgical scheduling office so the form can be completed...4. The patient’s physician must document in the patient record that he or she has conveyed the information required for an informed decision, by signing the physician certification on the “Consent to Surgery and Special Procedure” form, except in cases of emergency surgery or the procedure may not proceed unless this certification is on record. The nursing staff shall be responsible for verifying this (consent process) has been included in the chart prior to the surgery and checking this off on the Surgical Checklist...” 7. An observation was conducted with the CNO and the DQIP on April 2, 2025, at 10:14 a.m., of the manual instrument cleaning (the physical removal of visible soil and debris from instruments using hand-held brushes, detergents, and water) process, in the SPD decontamination workroom. SPD Tech 1 was observed standing at the decontamination sink and brushing debris off the surface of the surgical instrument. SPD Tech 1 walked toward the SPD’s clean supply stock, and was observed removing his soiled gloves, and placing the soiled gloves onto the transport cart. SPD Tech 1 was not observed to perform hand hygiene after he had removed his soiled gloves. SPD Tech 1 gathered the clean supplies and was observed walking back to the decontamination sink. An interview was conducted with SPD Tech 1 on April 2, 2025, at 10:20 a.m., in the SPD decontamination workroom. SPD Tech 1 stated he was performing manual instrument cleaning, and he had needed a specialized hand-held brush to clean the inner portion of the instrument. SPD Tech 1 confirmed he did not perform hand hygiene after handling soiled instruments. SPD Tech 1 stated he should have performed hand hygiene after handling soiled instruments and removing his gloves. SPD Tech 1 stated he did not know why he placed the soiled gloves onto the transport cart instead of properly disposing the gloves into the “red bin” (a waste bin specifically used to dispose of items contaminated with blood or other potentially infectious materials). A review of the hospital’s P&P titled, “Hand Hygiene Program,” revised June 2024, was conducted. The P&P indicated, “...11. A. Hand Hygiene: Hospital personnel will perform hand hygiene to prevent the spread of infections under the following conditions and circumstances...c. Before donning (the act of putting on) gloves and after doffing (taking off or removing) gloves...l. After handling blood, secretions, or excretions...D. Glove use...5. Discard gloves after each task and clean your hands-gloves may carry germs...” 8. A concurrent observation and interview were conducted with the DQIP and SPD Tech 1, on April 1, 2025, at 11:40 a.m., in the SPD decontamination workroom. The emergency eyewash station was observed attached above the decontamination sink. SPD Tech 1 confirmed the sink was used for decontaminating and cleaning potential infectious surgical instruments. SPD Tech 1 stated if he needed to use the emergency eyewash station and washed his eyes over the decontamination sink, potential infectious material could accidently splash into his eyes. The DQIP stated she was not aware that the emergency eye wash should not have been installed in locations that required SPD staff to perform emergency flushing of the eyes in the decontamination sink. The review of the AORN guidelines for Perioperative Practice (2020), Guideline for Instrument Cleaning, was conducted. The guidelines showed the following, “...recommendation...2.3 Do not clean or decontaminate instruments in the sinks where eye wash stations are located...” The review of the AAMI ST-79 ANSI/AAMI ST79:2017, “Comprehensive guide to steam sterilization and sterility assurance in health care facilities” was conducted. The standard indicated the following, “...3.3.7 Emergency eyewash/shower equipment... Eyewash stations should not be in a location that requires flushing of the eyes in a decontamination sink...” 50433 9. On April 1, 2025, at 9:45 a.m., during a tour of the Interventional Radiology (IR, an operational service that diagnoses and treats disease by inserting various small devices, such as catheters [flexible tubes] or wires into the body) procedural area conducted with the Infection Prevention Coordinator (IPC) 1 and the Interventional Radiology Manger (IRM), the sound of running water was heard in a supply room. A floor drain was observed underneath a storage shelf which was observed to contain sterile packs of supplies for patient use. Brown and black substances were observed around and in the drain. On April 2, 2025, at 2:45 p.m., during a tour of the IR procedural area conducted with Infection Prevention Coordinator (IPC) 2, the Effectiveness Coordinator (EC), the Quality Improvement Analyst (QIA), and the IRM, the floor drain was examined. The flooring was observed with bubbling and lifting of the surface material. When the flooring was pushed down, a brown crawling insect was observed to come out from under the lifted surface. On April 1, 2025, at 9:45 a.m., an interview was conducted with the IRM. The IRM stated the running water sound was from a HVAC (Heating, Ventilation, and Air Conditioning) condenser (a component of the HVAC that removes heat from the indoor air) drainage system. On April 2, 2025, at 2:45 p.m., an interview was conducted with the IRM. The IRM stated the brown and black substance around the drain, “Looks like rust.” On April 3, 2025, at 3:58 p.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated the floor drain in the IR procedural area is not consistent with expected conditions and should be on a regular cleaning and maintenance schedule. On April 4, 2025, at 12:25 p.m., an interview was conducted with the Plant Operations Director (POD). The POD stated the floor drain in IR was “dirty, rusty,” and had a condenser drainage system dripping into it. The POD stated the flooring and the floor drain should not have been in that condition. The POD stated the floor damage was caused by moisture and splashing from the condenser drainage system. The POD stated, “Maybe [name of facility] shouldn’t be storing supplies over floor drains.” The POD stated a stainless steal deflector (a device intended to turn aside the flow of something) has been installed and a flooring contracture is scheduled to repair the area around the drain. On April 4, 2025, at 2:24 p.m., an interview was conducted with the IPC 1. IPC 1 stated the facility follows the Centers for Disease Control and Prevention (CDC) “Infection Control Sterilizing Practices” guidance. IPC 1 stated sterile supplies should not be stored over a floor drain. IPC 1 stated the exposure to moisture and pests could potentially contaminate the supplies. A facility document titled, “Maintenance Work Order,” dated April 3, 2025, at 10:14 a.m., was reviewed. The document indicated, “...IR Room...floor sinks need to be restored and floor need to be repair...” A facility P&P titled, “Plant Operations Engineering Policy,” dated January 2020 was reviewed. The P&P indicated, “...A safe, clean, structurally sound environment will be achieved in the hospital ...” A facility P&P titled, “Cleaning and Sanitizing the Drains,” dated April 1992 was reviewed. The P&P indicated, “...The floor drains shall be cleaned on a regular basis...” A facility P&P titled, “Work Order System Engineering,” dated February 2024, was reviewed. The P&P indicated, “...It is the policy of the Plant Operations/Engineering department to provide preventive, corrective and predictable maintenance on the support systems, building and grounds of the facilities...” The facility provided a CDC guidance titled, “Infection Control, Sterilizing Practices,” dated November 28, 2023. The document was reviewed and indicated, “...Sterile items should not be stored...in...locations where they can become wet...” 10. A concurrent observation and interview were conducted with the Lead SPDT 1 on April 1, 2025, at 8:59 a.m., in the SPD clean workroom. One washer/disinfector was observed in use. Lead SPDT 1 stated the washer/disinfector was used to mechanically wash and disinfect surgical instruments after the manual cleaning process had been completed. Lead SPDT 1 stated the SPD staff did not provide routine maintenance or cleaning services for the washer/disinfector machine. Lead SPDT 1 stated the hospital did not have documentation to show that the washer/disinfector sump debris screen (a removable filter designed to prevent large debris, such as blood particles, tissue fragments, or broken instrument parts, from entering the piping system and pump) nor the rotary spray arms (a mechanism that rotates within the wash chamber, spraying cleaning solution and/or water onto the instruments or items being processed) were routinely cleaned and/or inspected. An interview and record review were conducted with the CNO and Lead SPDT 2 on April 2, 2025, at 8:48 a.m., in the conference room. The hospital’s document titled, “Operator Manual: Reliance Synergy Washer/Disinfector,” dated May 13, 2013, indicated “...6.2 Daily Cleaning: Each day, clean washer as follows: 1. After the last cycle of the day, allow unit to cool. 2. Open unload side door. 3. Remove sump debris screen from wash chamber and clean...6. Remove manifold sliding inlet (a system where detergent and rinse water are delivered) and inspect for debris...7. Brush off (the manifold sliding inlet) and rinse under tap water, as necessary...6.3 Weekly Cleaning: 6.3.1 Routine Cleaning Procedures: 1. Clean unit exterior...2. Clean wash chamber rotary spray arm...6.3.2 Note it is the responsibility of the Customer to perform the decontamination of their own unit once a week, as instructed. Decontaminate and descale (the removal of substances that build up inside the washer/disinfector’s heating elements, spray arms, and other parts due to hard water) chamber, using the DECOMTAM cycle expressly designed for this purpose...” Lead SPDT 2 stated she had reviewed the manufacturer’s IFU, and she was not aware that the hospital expected the SPD staff to perform daily or weekly cleaning of the washer/disinfector. Lead SPDT 2 confirmed the SPD staff were not performing daily or weekly maintenance/cleaning services for the hospital’s washer/disinfector. A review of the hospital’s P&P titled, “OR (Operating Room)-Instrument Processing,” reviewed March 2025, was conducted. The P&P indicated, “...V. Procedure...Instruments are processed through the washer decontamination unit following manufacturer’s specifications...””

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to ensure its medical staff bylaws and rules and regulations were implemented, for one of 30 sample patients (Patient 15) when the patient’s diagnostic result was missed, and patient was discharged home with an acute medical condition. This failure led to a delay in patient care and treatment and had the potential to cause harm. Findings: On February 4, 2025, at 3 p.m., an interview and review of Patient 15’s record was conducted with the Director of Education (DE). A facility document titled, “ED [Emergency Department] Physician Record,” dated January 8, 2024, was reviewed. The document indicated, “...[Patient 15] presents to the ED for evaluation of right sided abdominal pain onset last night exacerbated by deep breaths, movement, and by touch. Patient [Patient 15] states the pain worsened overnight and became localized to right lower quadrant [area of the abdomen that is on the right side below the belly button.]...endorses nausea and rates pain a 6/10 [for pain scale of 1 to 10, a pain scale of six means moderate pain] at rest...Physical Examination...GI [gastro-intestinal, pertains to the esophagus, stomach, and intestines]: soft, non-distended [not swollen or enlarged]...tender [painful] to palpation [touch] over the right lower quadrant. Positive McBurney’s point tenderness [specific location on the abdomen where tenderness may indicate an underlying medical condition, typically appendicitis, a medical emergency that occurs when the appendix, a small tube-like organ attached to the large intestine, becomes inflamed and infected]. Negative Murphy’s sign [a physical examination maneuver used to assess for inflammation of the gallbladder]...Results review...Lab [labroatory] results...WBC [white blood cells, a component of blood] 11.43 HI [High, can indicate infection, normal is between 4.0 and 11.]...” A facility document titled, “CT abdomen/Pelvis w/Contrast,” dated January 8, 2025, at 8:57 p.m. was reviewed. The document indicated, “...Stomach and bowel [a tube-like organ that is part of the digestive tract]...appendix mild dilated at 7 [seven] mm [milimeter, a unit of measurement]. Large appendicolith [a small, hard deposit that forms in the appendix] within the appendix. There is mild periappendiceal stranding [inflammation and thickening of the fat tissue surrounding the appendix.]. No bowel dilation...Impression: CT [medical imaging technique that uses x-rays to create detailed images of the body] findings of acute appendicitis. No evidence of perforation [hole]...” A facility document titled, “ED Physician Record,” dated January 8, 2024, was reviewed. The document indicated, “ED Course...Based on the patient’s [Patient 15’s] history and presentation, my workup, the differential diagnoses [list of possible medical conditions that could be causing symptoms] considered for this patient include...appendicitis...I [Medical Doctor, MD 1] reviewed the patient’s past medical history, clinical risk factors, comorbidities as per HPI as well as any relevant diagnostic studies. The patient is well-appearing and hemodynamically stable...Plan: Condition: Stable...patient given the following discharge instructions: Vomiting...abdominal pain... Disposition...time 1/8/2025 [January 8, 2025] 2219 [10:19 p.m.]...Patient is currently stable for discharge...no emergent medical condition exists...” A facility document titled, “ED Physician Record,” modified January 12, 2024, was reviewed. The document indicated, “...Addendum...on 1/12/25 [January 12, 2025] I [MD 1] called the patient and emergency contacts...received an answer from the patient’s [family member] who updated on the patient, the patient had worsening symptoms so was seen at an ED, subsequently admitted and treated for appendicitis...spoke to the patient’s [family member] regarding the CT findings during the visit on 1/8/2025 [January 8, 2025]...Patient overall had an uncomplicated course and was able to be discharged home in care of their parents...” On February 5, 2025, at 11:40 a.m., an interview was conducted with the Quality Director (QD). The QD stated the patient’s family member had filed a grievance related to the patient being discharged with appendicitis. The QD stated the Medical Director is doing an investigation to decide on any disciplinary actions for MD1 for discharging the patient with appendicitis. The QD stated the patient should not have been discharged without the correct results. On February 5, 2025, at 12:30 p.m. a concurrent interview and review of Patient 15’s recrod were conducted with the Emergency Department Director (EDD). The EDD stated there was a Midas (facilities internal reporting system) follow up which has been sent to the Medical Director for this incident. The EDD stated the ED physician receives and reviews diagnostic results as they come in. The EDD stated this was not a case of a critical value so MD 1 read the results on their own and either misread or missed the appendicitis result. The EDD stated MD 1 had the CT results prior to discharging Patient 15 but missed the impression of acute appendicitis and discharged Patient 15. The EDD further stated the result should have been read correctly prior to dicharging Patient 15. A review of the facilitydocument titled, “Medical Staff Bylaws,” dated October 2021, was conducted. The bylaws indicated, “...the ongoing responsibilities of each member of the medical staff include the following basic responsibilities...providing patients with care and coordinating care, treatment, and services...as relevant to the care, treatment, and services of each patient to ensure that all patients admitted to the hospital or treated in any outpatient department are provided with the quality of care meeting the professional standards of the medical staff of this hospital...abiding by the medical staff bylaws...rules and regulations...and other established rules and policies of the hospital...” A review of the facility policy titled, “Organization Plan for the Provision of Patient Care,” dated August 2024, was conducted. The policy indicated, “...The medical staff is responsible for the quality of medical care in the organization...the medical staff assesses and reassesses the patients physical, psychosocial, social and cultural status. The medical staff defines the scope and intensity of each service which include but may not be limited to: performing histories and physicals, ordering of diagnostic testing, timely assessments, timely reports, and discharge planning...Patient safety and stabilization is the primary consideration in the Emergency Department...””

“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: 48562 Based on interview and record review, the facility failed to ensure the policy for Patient Controlled Analgesia (PCA, a safe way for patients in pain to give themselves intravenous [IV] pain medicine when they need it) Pump monitoring was implemented, for three patients of 30 sample patients (Patients 2, 8, and 13). This failure had to the potential for pain treatment to be delayed which may prolong the patient’s pain. Findings: 1. On February 4, 2025, at 1:25 p.m., an interview and review of Patient 2’s record were conducted with the Director of Education (DE). The facility document titled, “History and Physical,” dated November 1, 2024, was reviewed. The document indicated, Patient 2 was admitted with a “...chief complaint of abdominal pain... Patient status post [after a procedure was done] exploratory laparoscopy [a minimally invasive surgical procedure that allows the surgeon to directly visualize and examine the abdominal organs]...” An untitled facility document, dated November 1, 2024, was reviewed. The document indicated, “...Original order...by [name of surgeon] on 11/1/2024 [November 1, 2024] at 15:35 [3:35 p.m.]...Morphine [a narcotic used to treat moderate to severe pain] PCA 1 [one] mg/ml [miligram per mililiter, units of measurement] 30ml 30mg...” An untitled facility document was reviewed. The document indicated Patient 2’s vital signs were taken on the following dates and times: - November 1, 2024, at 7:45 p.m.; - November 1, 2024, at 10:34 p.m.; - November 2, 2024, at 12:35 a.m.; - November 2, 2024, at 2:18 a.m.; - November 2, 2024, at 3 a.m.; - November 2, 2024, at 4:10 a.m.; and; - November 2, 2024, at 8:30 a.m. There was no documented evidence Patient 2’s vital signs were taken every 15 and 30 minutes in accordance with the facility’s policy and procedure. The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when the vital signs were not documented according to the policy. The DE stated staff did not document Patient 2’s vital signs every 15 and 30 minutes in accordance with the facility’s policy. 2. On February 4, 2025, at 1:45 p.m., an interview and review of Patient 8’s record were conducted with the Director of Education (DE). The facility document titled, “History and Physical,” dated February 3, 2024, was reviewed. The document indicated Patient 8 was admitted with a “...chief complaint of low back pain with radiation into the legs. Patient status post L3-4 [the 3rd and 4th vertabrae in the spine] posterior decompression and fusion [a surgical procedure that relieves pain and pressure on the spinal cord and nerves in the lower back]...” An untitled facility document was reviewed. The document indicated, “...Original order...by [name of surgeon] on 2/3/2025 [February 3, 2025] at 6:27 a.m...Morphine PCA 1 mg/ml...30ml 30mg...” An untitled facility document was reviewed and indicated the PCA pump for Patient 8 was initiated on February 3, 2025, at 2:08 p.m. An untitled facility document was reviewed and indicated Patient 8’s vital signs were taken on the following dates and times: - February 3, 2025, at 2:22 p.m.; - February 3, 2025, at 3:14 p.m.; - February 3, 2025, at 4 p.m.; - February 3, 2025, at 8 p.m.; - February 3, 2025, at 9 p.m.; and; - February 4, 2025, at 12 a.m. There was no documented evidence Patient 8’s vital signs were taken every 15 and 30 minutes in accordance with the facility’s policy and procedure. The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when vital signs were not documented according to the facility policy. The DE stated staff did not document Patient 8’s vitals for every 15 and 30 minutes in accordance with the facility’s policy. 3. On February 4, 2025, at 2:15 p.m., an interview and review of Patient 13’s record were conducted with the Director of Education (DE). The facility document titled, “History and Physical,” dated December 24, 2024, was reviewed. The document indicated Patient 13 was admitted with a “...chief complaint of neck pain with radiation to bilateral [both] arms...proceeding with surgery...cervical fusion [a surgical procedure that joins the individual bones that make up the spinal column, in the neck] C4 to C7 [the fourth to seventh vertabrea in the neck]...” An untitled facility document was reviewed and indicated, “...Order name...on 12/26/2024 [December 26, 2024] at 11:46 a.m...Morphine PCA 1 mg/ml...30 ml 30 mg...Status...Discontinued on 12/27/2024 [December 27, 2024]...” An untitled facility document was reviewed and indicated, “...Order name...on 12/27/2024 [December 26, 2024] at 11:46 a.m...Dilaudid PCA 0.2mg/ml...6 g...” An untitled facility document was reviewed and indicated Morphine PCA was started for Patient 13 on December 26, 2024, at 1:38 p.m. and was discontinued on December 27, 2024, at 10:34 a.m. The document indicated the Dilaudid PCA was started for Patient 13 on December 27, 2024, at 10:53 a.m. and was discontinued on December 28, 2024, at 10 a.m. An untitled facility document indicated Patient 13’s vital signs were taken on the following dates and times: - December 27, 2024, at 1:30 p.m.; - December 26, 2024, at 2 p.m.; - December 26, 2024, at 3 p.m.; - December 26, 2024, at 4 p.m.; - December 26, 2024, at 5 p.m.; - December 26, 2024, at 6 p.m.; - December 27, 2024, at 8:23 a.m.; - December 27, 2024, at 12:42 p.m.; - December 27, 2024, at 3:15 p.m.; - December 27, 2024, at 8:02 p.m.; and - December 28, 2024, at 12:01 a.m. There was no documented evidence Patient 8’s vital signs were taken every 15 and 30 minutes in accordance with the facility’s policy and procedure. The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when vital signs were not documented according to the policy. The DE stated Patient 13’s vital signs should have been documented according to the facility’s policy for the initiation of the Morphine and Dilaudid PCA pumps. The DE stated staff did not document Patient 13’s vital signs for every 15 and 30 minutes in accordance with the facility’s policy. The facility policy and procedure titled, “Patient Controlled Analgesia (PCA) Policy,” revised October 2019, was reviewed. The policy indicated, “...Patient Monitoring- Once PCA is initiated, vital signs will be assessed and documented, at a minimum, as follows...every 15 minutes x2 [two times]...every 30 minutes x2...every 1-hour x2...every 4 [four] hours during PCA therapy...assess the patient’s respiratory rate, level of pain, level of sedation every 4 hours...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedure was implemented, when education regarding the process for magnetic resonance cholangiopancreatography (MRCP, a non-invasive magnetic resonance imaging [MRI, an imaging procedure] procedure which produces detailed images of the biliary and pancreatic systems) procedure was not provided to one of 30 sample patients (Patient 5). This failure resulted in a delay in Patient 5’s MRCP, and had the potential to cause delay in the provision of care and treatment to Patient 5. Findings: On November 4, 2024, at 9:59 a.m., a tour of the Medical/Surgical/Telemetry (MST, unit where patients’ heart rates and rhythms are continuously monitored remotely) 2 unit was conducted with the MST Director (MSTD), Scribe 1, and Scribe 2. An observation was conducted on November 4, 2024, at 9:59 a.m., at Patient 5’s room. Patient 5 was observed sitting in bed with a grimace on his face. During a concurrent interview, Patient 5 stated the care is good but he was upset because of the poor communication between the nurses and the physicians. Patient 5 stated, “I was scheduled to have an MRI of the abdomen but now I have to wait three hours because I ate breakfast.” Patient 5 stated, “Nobody told me that I shouldn’t [eat breakfast]. If I knew then I would not have eaten.” An interview was conducted on November 4, 2024, at 10:28 a.m., with Registered Nurse (RN) 3. RN 3 stated she didn’t inform Patient 5 to not eat his breakfast because there was no physician’s order for NPO (nothing per orem, nothing by mouth) for the MRI of the abdomen procedure. RN 3 stated the MRI technician informed her the procedure will be delayed because Patient 5 ate breakfast. RN 3 further stated she is not sure if this process is in a policy. A concurrent interview and record review were conducted on November 5, 2024, at 10:54 a.m., with the MST Director (MSTD). An undated facility document titled, “Decision Support,” was reviewed. The document indicated, “...Identified Order: MRI MRCP w/o [without] Contrast...MRI screening and education form to be completed electronically...Patient must be NPO for 4-6 hours prior to the exam...” There was no documented evidence the document was provided to Patient 5. The MSTD stated the document titled, “Decision Support,” is what the nurses provide to the patient prior to a procedure. The MSTD stated there was no documentation the document was provided to Patient 5. A review of Patient 5’s record was conducted on November 5, 2024, at 10:57 a.m., with the MSTD. A facility document titled, “History and Physical,” dated November 3, 2024, was reviewed. The document indicated, “...Assessment/Plan...Acute pancreatitis [inflammation of the pancreas]...jaundice [yellowing of the skin]...liver cirrhosis [a condition with scarring of the liver]...” An undated facility document titled, “Order Information for: MRI MRCP w/o [without] Contrast,” was reviewed. The document indicated, “...original order entered and electronically signed by [Name] MRI tech [technician]...11/3/2024 [November 3, 2024] at 15:11 PST [ 3:11 p.m.]...MRI MRCP w/o Contrast...” A facility policy and procedure titled, “Patient and Family Education,” dated, October 2024, was reviewed. The policy indicated, “...To provide the patient, family and/or significant other education/training specific to the patients’ needs and abilities and as appropriate to the care, treatment and services provided...Such instructions is presented in ways understandable to the patient, family and/or significant others and includes...The plan of care, treatment and services...Adult...Multidisciplinary personnel will document patient education on an ongoing basis to who was taught, what was taught, patient teaching tools utilized, written information given to the patient...””

“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: 45431 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 30 sample patients (Patients 1, 2, 3, 6, and 7), when the external urine collection device was not changed every 12 hours in accordance with the facility’s P&P. This failure had the potential to cause infection, delay in patient care, and harm to patients using an external urine collection device. Findings: 1. A review of Patient 1’s record was conducted on November 5, 2024, at 9:36 a.m., with Medical/Surgical/Telemetry (unit where patients’ heart rates and rhythms are continuously monitored remotely) Director (MSTD) and Scribe 2. A facility document titled, “History and Physical,” dated September 7, 2024, was reviewed. The document indicated, “...Assessment/Plan Diagnoses...UTI [urinary tract infection, an infection affecting the bladder, urethra (a hollow tube which lets the urine pass out of the body), or kidneys]...AKI [acute kidney injury, a condition when the kidney suddenly lose its ability to filter waste from the blood]...” A facility document titled, “Genitourinary,” dated September 7, 2024, was reviewed and indicated an external urinary collection device was applied to Patient 1. There was no documented evidence Patient 1’s external urine collection device was changed on the following dates and shifts: - On September 8, 2024, day shift (7 a.m. to 7 p.m.); - On September 8, 2024, night shift (7 p.m. to 7 a.m.); - On September 9, 2024, day shift; and - On September 9, 2024, night shift. 2. On November 4, 2024, at 11:08 a.m., a tour of the MST 2 unit was conducted with the MSTD, Scribe 1, and Scribe 2. An observation was conducted inside Patient 2’s room, a urine collection canister was observed to be mounted on the wall. The urine collection canister was observed to not be labeled with a date. During a concurrent interview, Patient 2 stated the canister is connected to a device between his legs where he urinates. An interview was conducted on November 5, 2024, at 11:40 a.m., with Registered Nurse (RN) 7. RN 7 stated the external urinary catheter including the canister should be changed every shift and when needed. RN 7 was stated she was unable to say when Patient 2’s external urinary collection device including the urine collection cannister were changed because it was not labeled with a date. A review of Patient 2’s record was conducted on November 5, 2024, at 9:36 a.m., with the MSTD. A facility document titled, “History and Physical,” dated November 1, 2024, was reviewed. The document indicated, “...Assessment/Plan...Bilateral pulmonary embolism (blood clot in the lungs)...” There was no documented evidence Patient 2’s external urine collection device was changed on the following dates and shifts: - On November 2, 2024, day shift; - On November 2, 2024, night shift; - On November 3, 2024, day shift; - On November 3, 2024, night shift; and - On November 4, 2024, day shift. 3. On November 4, 2024, at 10:12 a.m., a tour of the MST 1 was conducted with the MSTD, Scribe 1, and Scribe 2. An observation was conducted in Patient 3’s room. An external urine collection device was observed attached to a collection canister with suction mounted on the wall which were observed to not be labeled with a date. An interview was conducted on November 4, 2024, at 10:13 a.m., with RN 3. RN 3 stated the external urine collection device including the collection cannister is changed daily and as needed. A review of Patient 3’s record was conducted on November 5, 2024, at 9:48 a.m., with the MSTD. A facility document titled, “History and Physical,” dated November 1, 2024, was reviewed. The document indicated, “...Assessment/Plan...URI [upper respiratory infection]...metabolic encephalopathy [a brain disorder caused by a chemical imbalance in the blood]...seizures...” A facility document titled, “Genitourinary,” dated November 3, 2024, indicated the external urine collection device was applied at 8:10 p.m., on November 3, 2024. There was no documented evidence Patient 3’s external urine collection device was changed during the day and night shifts on November 4, 2024. 4. On November 4, 2024, at 11:17 a.m., an observation was conducted in Patient 6’s room. A urine collection canister was observed mounted on the wall. During a concurrent interview, Patient 6’s family member stated the urine collection canister is connected to a device in between Patient 6’s legs where Patient 6 urinates. An interview was conducted on November 4, 2024, at 11:20 a.m., with RN 5. RN 5 stated Patient 6 has an external urine collection device. RN 5 stated she is unable to say when Patient 6’s external urinary collection device including the urine collection cannister was changed because it was not labeled with a date. A review of Patient 6’s record was conducted on November 5, 2024, at 11:36 a.m., with the MSTD. A facility document titled, “History and Physical,” dated, November 2, 2024, was reviewed. The document indicated, “...Assessment/Plan...Encephalopathy...” There was no documented evidence Patient 6’s external urine collection device was changed on the following dates and shifts: - On November 3, 2024, day shift; - On November 3, 2024, night shift; and - On November 4, 2024, day shift. 5. On November 4, 2024, at 10:58 a.m., an observation was conducted in Patient 7’s room. A urine collection canister mounted on the wall which was observed to not be labeled with a date. An interview was conducted on November 4, 2024, at 11 a.m., with RN 4. RN 4 stated Patient 7 has an external urine collection device which should be changed every shift. RN 4 stated she was unable to say when the external urinary collection device including the urine collection cannister was changed because it was not labeled with a date. A review of Patient 7’s record was conducted on November 5, 2024, at 11:34 a.m., with the MSTD. A facility document titled, “History and Physical,” dated November 3, 2024, was reviewed and indicated, “...Assessment/Plan...Acute respiratory failure [inefficient breathing]...” There was no documented evidence Patient 7’s external urine collection device was changed on the following dates and shifts: - On November 2, 2024, day shift; - On November 2, 2024, night shift; - On November 3, 2024, day shift; - On November 3, 2024, night shift; and - On November 4, 2024, day shift. An interview was conducted on November 5, 2024, at 9:47 a.m., with the MSTD. The MSTD stated the external urinary catheter should be changed every 12 hours in accordance with the facility’s hospital P&P. A review of the facility P&P titled, “External Urinary Catheter: Female,” dated October 2024, was conducted. The P&P indicated, “...During use...Replace device every 12 hours or if soiled with stool or bodily fluids other than urine...” There was no documented evidence a facility P&P was developed for the male external urinary catheter. An interview was conducted on November 5, 2024, at 11:40 a.m., with the Quality Director (QD). The QD stated the facility has not developed a policy for the male external urinary catheter. The QD stated the P&P for the female external urinary catheter is currently being followed for the male external urinary catheter.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) titled, “Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting 1525,” was implemented, for one of 30 sample patients (Patient 16), when Patient 16 was physically hit with a closed fist by Staff 1. This failure resulted in Patient 16 sustaining superficial scratches and swelling to his left eyebrow. Findings: On November 4, at 2:45 p.m., an interview was conducted with the Director of Behavioral Health Services (DBHS). The DBHS stated, on September 18, 2024, at approximately 5:45 a.m., Patient 16 stood up from his wheelchair and hit Staff 1, then Staff 1 hit Patient 16. The DBHS stated the facility has no tolerance for staff hitting patients and Staff 1’s employment was terminated. A facility document titled, “Physician Orders,” dated September 13, 2024, was reviewed. The document indicated, “...Per 5150 [an involuntary 72-hour hospitalization of patients who may be a threat to self or others]...He [Patient 16] endorsed suicidal ideation & [and] homicidal ideation with a plan & intent...He stated that prior to leaving his home/work...he grabbed his 380 Beretta [gun] out of his safe & debated whether he wanted to shoot himself in the head or rob another bank...Admitting Diagnosis: Major Depressive Disorder [a mood disorder which causes a persistent feeling of sadness and loss of interest], recurrent, severe, without Psychosis [a condition with impaired reality]...” A facility document titled, “Behavioral Health (BH) Psychiatric [related to mental illness and its treatment] Evaluation,” for Patient 16, dated September 13, 2024, was reviewed. The document indicated, “...review of systems...also includes antisocial personality disorder [a mental health disorder defined by a long term behavior which disregards the rights and well-being of others]...Urine Drug Screen [a test which detects evidence of recent drug use or misuse in a sample of urine] positive for alcohol, cocaine [a highly addictive drug], danger to self danger to others [sic], due to command auditory hallucinations [hearing voices, sounds that don’t exist in reality]...also gravely disabled [unable to meet basic needs due to a mental health disorder, substance use disorder, or chronic alcoholism...” A facility document titled, “Consult-Internal Medicine,” dated September 14, 2024, was reviewed. The document indicated, “...Patient [Patient 16] has been feeling very depressed recently, patient feels hopeless, helpless and worthless...Patient also had a severe pain on the right leg...The patient had very poor impulse control...” A facility document titled, “BH Progress Note-Nurse,” dated September 18, 2024, at 5:40 a.m., indicated, “...Patient [Patient 16] was agitated because staff was redirecting his peer who was wheeling him on the wheelchair to go to his own room for medication administration. This patient became upset, got up and start to hit a staff member [Staff 1] who was part of the team redirecting his peer as the staff at the point also thew punches at patient. Patient sustained superficial scratches and a little swelling to his lt [left] eyebrow...” An untitled and undated facility document was reviewed. The document indicated, “...On 9/18 [September 18, 2024] at 5:40 [a.m.] patient [Patient 16] stated he wasn’t going to take any [expletive] shots and I’ll [expletive] anyone who comes near me...and took a defensive stance toward Staff 1 then struck out with his fists and hit Staff 1, at this point Staff 1 retaliated and threw approx. [approximately] 5 [five] closed fisted blows at the patient which resulted in the patient’s left eye temple [sic] getting cut open...staff tried to redirect Staff 1 away from patient toward the medroom [medication room]...” A facility document titled, “BH Progress Note-Nurse,” dated September 18, 2024, at 6:25 a.m., was reviewed. The document indicated, “...As staff was exiting Patient 16’s room with the other male peer, Patient [Patient 16] then proceeded to posture at male medication nurse [Staff 1]. Patient began swinging at staff with closed fists, and both patient and male staff began punching each other. Patient was hit to the left side of his face with a closed fist by male staff twice...” On November 4, 2024, at 4 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated, for any physical abuse, they are supposed to separate the staff and the patient to prevent any physical altercation against the patient. RN 1 stated the staff will report the abuse to the person on call, call the psychiatrist, and call the medical physician if there are any injuries. RN 1 stated the staff is supposed to do a verbal de-escalation, use an open seclusion (placing patient in a room alone until they are calm) or offer medications as interventions to assist a patient in a crisis. A concurrent interview and review of the video recording of the incident was conducted on November 5, 2024, at 9:20 a.m., with the Chief Nurse Officer (CNO) and Quality Director (QD). In the video recording, Patient 16 was observed to be hit three times by Staff 1. CNO stated they teach de-escalation in the facility and that was not done. The CNO stated, “We want to avoid any physical contact with the patient.” A facility P&P titled, “Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting 1525,” revised April 2024, was reviewed. The P&P indicated, “...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. [Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff...””

“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: 45431 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedure was implemented, when education regarding the process for magnetic resonance cholangiopancreatography (MRCP, a non-invasive magnetic resonance imaging [MRI, an imaging procedure] procedure which produces detailed images of the biliary and pancreatic systems) procedure was not provided to one of 30 sample patients (Patient 5). This failure resulted in a delay in Patient 5’s MRCP, and had the potential to cause delay in the provision of care and treatment to Patient 5. Findings: On November 4, 2024, at 9:59 a.m., a tour of the Medical/Surgical/Telemetry (MST, unit where patients’ heart rates and rhythms are continuously monitored remotely) 2 unit was conducted with the MST Director (MSTD), Scribe 1, and Scribe 2. An observation was conducted on November 4, 2024, at 9:59 a.m., at Patient 5’s room. Patient 5 was observed sitting in bed with a grimace on his face. During a concurrent interview, Patient 5 stated the care is good but he was upset because of the poor communication between the nurses and the physicians. Patient 5 stated, “I was scheduled to have an MRI of the abdomen but now I have to wait three hours because I ate breakfast.” Patient 5 stated, “Nobody told me that I shouldn’t [eat breakfast]. If I knew then I would not have eaten.” An interview was conducted on November 4, 2024, at 10:28 a.m., with Registered Nurse (RN) 3. RN 3 stated she didn’t inform Patient 5 to not eat his breakfast because there was no physician’s order for NPO (nothing per orem, nothing by mouth) for the MRI of the abdomen procedure. RN 3 stated the MRI technician informed her the procedure will be delayed because Patient 5 ate breakfast. RN 3 further stated she is not sure if this process is in a policy. A concurrent interview and record review were conducted on November 5, 2024, at 10:54 a.m., with the MST Director (MSTD). An undated facility document titled, “Decision Support,” was reviewed. The document indicated, “...Identified Order: MRI MRCP w/o [without] Contrast...MRI screening and education form to be completed electronically...Patient must be NPO for 4-6 hours prior to the exam...” There was no documented evidence the document was provided to Patient 5. The MSTD stated the document titled, “Decision Support,” is what the nurses provide to the patient prior to a procedure. The MSTD stated there was no documentation the document was provided to Patient 5. A review of Patient 5’s record was conducted on November 5, 2024, at 10:57 a.m., with the MSTD. A facility document titled, “History and Physical,” dated November 3, 2024, was reviewed. The document indicated, “...Assessment/Plan...Acute pancreatitis [inflammation of the pancreas]...jaundice [yellowing of the skin]...liver cirrhosis [a condition with scarring of the liver]...” An undated facility document titled, “Order Information for: MRI MRCP w/o [without] Contrast,” was reviewed. The document indicated, “...original order entered and electronically signed by [Name] MRI tech [technician]...11/3/2024 [November 3, 2024] at 15:11 PST [ 3:11 p.m.]...MRI MRCP w/o Contrast...” A facility policy and procedure titled, “Patient and Family Education,” dated, October 2024, was reviewed. The policy indicated, “...To provide the patient, family and/or significant other education/training specific to the patients’ needs and abilities and as appropriate to the care, treatment and services provided...Such instructions is presented in ways understandable to the patient, family and/or significant others and includes...The plan of care, treatment and services...Adult...Multidisciplinary personnel will document patient education on an ongoing basis to who was taught, what was taught, patient teaching tools utilized, written information given to the patient...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure the facility’s policy on leaving against medical advice (AMA) was implemented, for one of 20 sampled patients (Patient 8). This failure had the potential for harm to and delay of care for Patient 8. Findings A concurrent interview and review of Patient 8’s record were conducted with the Emergency Room Manager (ERM) on August 23, at 3:20 p.m. The facility document titled, “ED [Emergency Department] Physician Record,” indicated Patient 8 presented to the emergency department (ED) on August 4, 2024, at 1:40 a.m., for anxiety (a mood disorder), paranoia (a thought process that involves feelings of distrust and suspicion about others), and hallucinations (an experience involving the apparent perception of something not present). The document indicated, “...Observation Note...The patient [Patient 8] was placed under Observation status at 0140 [1:40 a.m.] for ongoing evaluation and risk stratification of their bizarre behavior. Patient has not been medically cleared. Patient is pending evaluation...Disposition...Upon re-evaluation, it is determined that the patient requires ongoing observation and treatment...” A facility document titled, “Nursing Note-Text,” dated August 4, 2024, at 6:55 a.m. indicated, “...Pt [Patient 8] saying incomprehensible words, unable to assess what pt is saying...” A facility document titled, “ED Physician Record,” dated August 4, 2024, at 7:20 a.m., indicated, Patient has not been medically cleared...Patient is pending evaluation...Disposition: Patient AMA’ed at 0650 with [family member] present and agreeable to AMA[leaving against medical advice].... Patient and [family member] made aware of the risks of AMA’ing and decided to proceed...Family and patient wished to leave due to long waiting hour, patient’s [family member] wants to take him to another facility. Denies SI [suicidal ideation, thoughts of killing oneself], HI [hallucinations, an experience involving the apparent perception of something not present] at this time. Patient and family AMA...” The document further indicated, “...Addendum by [name of physician] on August 04, 2024 [August 4, 2024], at 7:49 [7:49 a.m.]...Patient and [family member] decided not to leave AMA according to the nurse at 0750 [7:50 a.m.]...upon re-eval [re-evaluation]at 0820 [8:20 a.m.], patient AMA’ed again...Upon re-eval at 0830, patient checked back in to the ED...” The document further indicated, “...Addendum by [name of physician] on August 04, 2024, at 11:20 [11:20 a.m.]...Upon re-eval at 0845 [8:45 a.m.], patient AMA’ed...” A facility document titled, “Nursing Note-Text,” dated August 4, 2024, at 8:13 a.m. indicated, “...pt wants to leave AMA. pt [sic] denies SI and denies HI. Patient a/ox4 [alert and oriented to person, place, time, and event). pt verbalized understanding of leaving AMA up to and including death. pt left with family members]...” A facility document titled, “Nursing Note-Text,” dated August 4, 2024, at 10:31 a.m., indicated, “...Patient called to move to [bed number] for psych eval [psychiatric evaluation]. No answer from patient in WR [waiting room] or outside of ED...” A facility document titled, “Nursing Note-Text,” dated August 4, 2024, at 11 a.m., indicated, “...Patient called for bed assignment...no answer from WR or outside...” A facility document titled, “Nursing Note-Text,” dated August 4, 2024, at 11: 27 a.m., indicated, “...Patient called for 3rd [third] time. Not found in WR or outside area of ER. Patient presumed to have eloped [when a patient leaves a hospital unsupervised and undetected]. Patient was last seen in [an area of the ED] with [family members] accompanying him...” The ERM stated it appears the Patient 8 came in on August 4, 2024, at 1:40 a.m., left AMA with a family member, returned to the ED again at 8:22 a.m., and left again. The ERM stated there is no documentation Patient 8 signed the AMA form. The ERM stated the patient should have signed an AMA form. An interview was conducted with Coordinator Infection Prevention (CIP) on August 23, 2024, at 3:40 p.m. The CIP stated Patient 8 should have signed an AMA form. The CIP stated there is no documentation Patient 8 signed the AMA form. A review of the facility’s policy and procedure titled, “Against Medical Advice, Elopement and Leaving Without Being Seen- ED 0500,” revised February 2022, was conducted. The policy indicated, “...Against Medical Advice (AMA): Adult patient who is oriented to person, place and date, chooses to leave the Emergency Department against the advice of the nurse or provider. This includes patients leaving prior to evaluation, completion of diagnostic testing or prior to discharge by the physician...A Patient [sic] leaving the ED AMA status is documented in the Medical Record...The patient, upon departure, signs the AMA Form for patients wishing to leave against medical advice...Patient leaving the ED AMA...Consult with ED provider immediately ...ED provider shall advise patient of risks and potential complications from leaving ...the patient is asked to sign the AMA form. The AMA form shall state the possible consequences as determined by the provider and is maintained in the medical record...Completed AMA forms are maintained in the medical record...If the patient refuses to sign the AMA form, documentation is completed on the AMA form or in the medial record stating that the patient refused to sign the form...” A review of the facility’s policy and procedure titled, “AMA Leaving Against Medical Advice 1505,” revised June 2022, was conducted. The policy indicated, “...the ‘Leaving Hospital Against Medical Advise’ (AMA) form is to be completed. This form documents that the patient was given information regarding possible risks that may result from the decision to leave, the benefits of continued hospitalization any [sic] alternatives...If the patient refuses to sign the (AMA) form a notation to this effect is to be made on the form and signed by the Licensed Nurse. These facts are also documented in the nurse’s notes...Specific statements made by the patient regarding his/her reasons for leave should be quoted in the narrative section of the nursing notes...””

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure records for a patient transferred to and from the facility was maintained, for one of 21 sampled patients (Patient 19). This failure had the potential to delay the provision of care for Patient 19. Findings: A review of Patient 19’s record was conducted with the Emergency Room Manager (ERM) on August 22, 2024, at 11:50 a.m. A facility document titled, “ED [Emergency Department] Physician Record,” dated August 15, 2024, at 4:18 p.m., indicated, “...This is a 15-year old patient [Patient 19] with a history of psychomotor seizures (a sudden, uncontrolled burst of electrical activity in the brain)...Patient was witnessed by paramedics losing consciousness and falling onto dirt ground...According to paramedics, patient had 2-3 [two to three] seizures prior to their arrival, then had another 3-4 [three to four] seizures on route [on the way to the facility]...Observation note ...On re-evaluation at 1656 [4:56 p.m.], patient had another...seizure in the ED. On re-evaluation at 1708 [5:08 p.m.], patient breaks in and out of seizures...Plan to transfer for higher level of care which I have discussed with [Name of Facility 4] and arranged transport, however, [family member] provided consent but only for transfer to [Name of Facility 5]...[Family member] arrived and was agreeable to transport. Patient transferred in stable condition...” A facility document titled, “Orders,” dated August 15, 2024, at 5:30 p.m., indicated, “...Discharge Request (Transfer Out of Facility Request)...” An interview was conducted with the ERM on August 22, 2024, at 11:50 a.m. The ERM stated the RN witnessed the discussion of Patient 19’s transfer with the ED Physician and Patient 19’s family member, but there is no documentation of the transfer form in Patient 19’s record. An interview was conducted with the Coordinator Infection Prevention (CIP) on August 23, 2024, at 2 p.m. The CIP stated there is no documentation of the transfer consent form in Patient 19’s record. A review of facility policy titled, “Transfer to Another Facility,” dated February 2023, was conducted. The policy indicated, “...Purpose...To outline the procedure to ensure the safe and appropriate transfer of an ED patient from this hospital to another facility...The individual or the individual’s acknowledgement of such notification should be reflected in appropriate signing the Patient Release Form Emergency Department Patient Treatment or Transfer Consent/Request/Refusal Form...Patient’s authorization release information is documented and signed on the Patient Release Form Emergency Department Patient Treatment or Transfer Consent/Request/Refusal Form...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 35056 Based on observation, interview, and record review, the facility failed to ensure stabilizing treatment and maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC) were provided, for four of 21 sampled patients (Patients 1, 2, 3, and 15), when: 1. For Patient 1, the patient was on a 5150 hold (an involuntary hold for 72 hours for an adult experiencing a mental health crisis) and was able to elope (when a patient leaves the facility unsupervised); 2. For Patient 2, the patient was on suicidal ideation (SI, having thoughts of killing oneself) precautions (interventions in place to prevent one from committing suicide) and was able to elope; 3. For Patient 3, the patient was on SI precautions and was able to elope; and 4. For Patient 15, the patient was on SI precautions and was able to elope. These failures resulted in Patients 1, 2, 3, and 15 being able to elope from the Emergency Department (ED) and had the potential for patients with EMC to be able to harm themselves or others. Findings: 1. The video footages for Patient 1, dated August 13, 2024, were reviewed with the Chief Nursing Officer (CNO) on August 21, 2024, at 3:10 p.m. The footages showed the following: -Video 1: A male patient was walking in a green gown with black anti-skid socks. The patient was seen to turn the corner by Fast Track chair 6 and pushed open the double door and exited the ED and 20 seconds later a male and female staff were observed pushing open the double doors and exited the ED. The female staff was observed to come back through the double doors into the ED; and -Video 2: A male patient was seen walking in a green gown with black anti-skid socks along the facility hallway outside the ED, then turned left towards the exit doors, continued walking towards the doors, pushed the door open, exited the facility, and turned left once outside. A male staff member was seen exiting the ED, then walked down the hall towards the exit, exited the facility and turned left. The male staff member was observed to use his badge to reenter the facility and back to the ED. On August 22, 2024, at 2:30 p.m., a concurrent interview and review of Patient1’s record were conducted with Clinical Supervisor (CS) 1 and the Infection Prevention (IP) staff. A facility document titled, “Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment,” dated August 13, 2024, signed at 1:20 a.m., indicated, “...To...[Name of Facility 1]...A Reporting Party Called Police...[Name of Patient 1] Attempting To Get Into His Backyard @ [at] about 0100 hours [1 a.m.]...He [Patient 1] Was Seen On Camera Going To Multiple Houses. [Name of Patient 1] Was “Looking For A Friend.” He did Not Know The Current Year, Date, & [and] Did Not Make Sense. He Is Unable To Safely Care For Himself & Is Putting Others In Danger By Trying To Enter Their Properties...” The document indicated check marks were placed after the following sections: “A danger to others” and “Gravely disabled [unable to provide for their own food, clothing, and shelter] adult...” A document titled, “1) Patient Care Report,” from AMR (an emergency transport service), dated August 13, 2024, at 1:16 a.m., indicated, “...Impediment...ED Overcrowding; Hospital Staff Delay/Transfer of Care Delay...Mental Status...Confused...Complaints...Chief-5150...Behavioral/Psychiatric...Primary Symptom...Abnormal behavior...Other Symptoms...Altered Mental Status [confusion]...Primary Impression...Behavioral/psychiatric disorder (mental disorder)...Narrative...[description of Patient 1] Who Had Been Placed On A 5150 After Being Found On Someone Else’s Property Going Through Their Trash, And Being Disoriented To Time And Event...Placed The Patient In Soft Restraints Due To The Patient’s 5150 hold...Turned Over To Hospital Staff On Transfer Of Care...08/13/2024 [August 13, 2024] 01:40:51 [1:40 a.m.] Patient Arrived at Destination...8/13/2024...03:04:12 [3:04 a.m.]...Destination Patient Transfer of Care...” A facility document titled, “ED Physician Record,” dated August 13, 2024, at 4:50 a.m., indicated Patient 1 was brought in by an ambulance for a 5150 on August 13, 2024, at 3:05 a.m. The document indicated, “...Patient’s [Patient 1] presenting complaint has moderate risk of further deterioration, and disability, and morbidity...The patient was placed under Observation status at 0445 for ongoing evaluation and risk stratification of their bizarre behavior...Disposition...Patient eloped from the ED while on a 5150 hold. Code elope was called and attempted to find the patient without success...Diagnosis...Acute psychosis [mental disorder]...Eloped from emergency department...Homicidal ideation [thoughts of killing]...” A facility document titled, “Orders” dated August 13, 2024, indicated, “...Notify Precautions...Observation Level...08/13/24 2:58:00 [2:58 a.m.]...Suicidal Risk, 1:1 [one staff assigned to observe one patient continuously] Observation at all times...Precautions...08/13/24 2:58:00...Precautions: Elopement [when a patient leaves a hospital unsupervised and undetected]...Suicide Precautions...08/13/24 2:58:00...NOW...” A facility document titled, “Involuntary Hold Patient Observation Record,” dated August 13, 2024, indicated Patient 1 was in the ED and was monitored by a sitter, whose initial appeared on the document, from 3:45 a.m. to 6:15 a.m., on 15 minute interval of documentation. A facility document titled, “Nursing Note-Text,” dated August 13, 2024, at 3:30 a.m., indicated, “...Nursing Note Entered On ...8/13/24 4:36 [4:36 a.m.]...Performed on...8/13/24 3:30 [3:30 a.m.]...Nursing Note: List of items done during initial assessment...complete safety check of room...initiated observation...placed on elopement precautions...” A facility document titled, “ED Activity Log Elopement” dated August 21, 2024, indicated “...[Name of Patient 1]...Acuity level 3-Urgent...Reason for visit...Altered [confused]...Arrival Date & Time...8/13/24 [August 13, 2024] 01:44 a.m. [1:44 a.m.]...Depart Date & Time...08/13/24 08:23 a.m. [8:23 a.m.]...Discharge Disposition...ED Elopement...” A facility document titled, “Nursing Note-Text,” dated August 13, 2024 at 6:32 a.m, indicated, “....Performed by [Name RN 1]...Nursing Note...while provide [sic] patient report to...[Name of Facility 2]...sitter [a staff who is continuously observing one patient] at bedside advised patient eloped down the hallway. sitter [sic] called operator and announced a code green [hospital code for elopement]. charge [sic] rns [registered nurses] aware...pd [police department] contacted...” There was no documented evidence Patient 1 was placed on a 1:1 observation from 3 a.m., when the physician ordered it, to 3:44 a.m. CS 1 stated on August 22, 2024, at 2:40 p.m., the nursing staff must have been busy because they put the patient in under the wrong ESI (emergency severity index, treatment based on the level of urgency and resource needs of the patient, with level 1 being the most critical, level 5 being the least critical) level. CS 1 stated the records indicated Patient 1 was 3-urgent and should have been under ESI level 2 in accordance with the facility policy. CS 1 stated when a patient comes in under 5150 they should be assigned ESI level 2. CS 1 stated the observation ordered by the provider should have been started at 3 a.m. CS 1 stated the staff should not have waited until 3:45 a.m. to start the 1:1 observation (45 minutes after the order was given). An interview was conducted with the CNO on August 22, 2024, at 3:31 p.m. The CNO stated Patient 1 was listed as altered upon admission to the Emergency department (ED) and documented discharge time as August 13, 2024, at 8:23 am. The CNO stated Patient 1 should not have been able to elope from the facility. An interview was conducted with Emergency Technician (ERT) 1 on August 23, 2024, at 5:49 a.m. ERT 1 stated he was assigned Patient 1 on a 5150 hold. ERT 1 stated he began his 1:1 observation at 3:45 a.m. ERT 1 stated he left Patient 1 in order to assist another Emergency Room Technician (ERT) and Patient 1 eloped. ERT 1 stated he was told by another staff member that his patient left. He stated he went out after Patient 1 and followed him out and was 30 or more feet away from the patient. He stated he tried to talk the patient into coming back in with no success. An interview was conducted with RN 1 on August 23, 2024, at 9:08 a.m. He stated he completed the environmental check list (list of items to remove from the room) and then placed Patient 1 in the room. He stated Patient 1 was on a 5150 hold for danger to others and grave danger to self. He stated he was busy and did not feel the need to monitor the sitter to ensure the patient was continuously observed. He stated he did not see the patient elope. An interview was conducted with Director of Emergency Department (DED) August 23, 2024, at 9:46 a.m. The DED stated ERT 1 was assigned to observe Patient 1 in Room A and a patient on hold in Room B. She stated ERT 1 should have only been watching one patient on a 1:1 observation and not the other patient in Room B. She stated they were trying to clean Room C for the other patient. She stated ERT 1 should not have left Patient 1 without finding coverage to continuously observe the patient on a 1:1. She stated the order should have been started immediately started at 3 a.m. and the staff should not have waited 45 minutes to start. A review of the facility’s video footage dated August 22, 2024, at 3:40 p.m., was conducted with the CNO. The video footage dated August 13, 2024, at 6:19 a.m., showed a male staff was at the corner of Station C in front of Rooms A and C across Room B. The male staff was observed to be at the corner of the nursing station and was observed to be moving in and out of the camera view. A male patient dressed in a green gown was observed walking out of Room A and down the hall passing by Room B. The male staff was not seen in the video at that time. On August 23, 2024, at 1:12 p.m., an observation of the ED was conducted with Nursing Supervisor (NS) 1. The placement of the chair where Patien 1 was put on was not observed to be visible from the nursing station. 2. A concurrent interview and review of Patient 2’s record were conducted with Clinical Supervisor (CS) 1 on August 22, at 10:40 a.m. Patient 2’s record indicated the patient presented at the ED on June 26, 2024, at 5:54 p.m. A facility document titled, “Triage Note,” dated June 26, 2024, at 6:05 p.m. indicated, “...Suicidal Risk Assessment: Presents with suicidal ideation ...C-SSRS [Columbia Suicide Severity Rating Scale, a tool to help determine establish a person’s immediate risk of suicide] Suicide Risk Level: Low risk...Suicide Low Risk Interventions: Notify provider of patient risk level for further evaluation...” A facility document titled, “Emergency Physician Record,” dated June 26, 2024, at 7:23 p.m., indicated, ...Chief Complaint...6/26/24 [June 26, 2024] 17:58 [5:58 p.m.]...pt [Patient 2] states he is having thoughts of hurting himself, stated he’s been homeless for about a year and a half. plan [sic] is to OD [overdose] with medications...Patient [Patient 2] states he is now having thoughts of SI through OD by fentanyl [a potent narcotic]. States he tried to hurt himself 6 months ago...Physical Examination...Psych [psychological, pertaining to thought processes: Endorses SI...Observation Status...The patient was placed under Observation status at 1808 [6:08 p.m.] on 6/26/2024 for ongoing evaluation...Patient suicide risk assessment is low...During their time in observation they received the following interventions: suicidal precautions, one-to-one monitoring, serial exams, and treatments...Disposition: Prior to DC [discharge], patient eloped from the ED without being further evaluated and treated by ED physician...” A facility document titled, “Orders,” indicated, “...Observation Level 06/26/24 18:24:00 [6:24 p.m.]...Suicidal Risk, 1:1 Observation at all times, constant order...Precautions: Elopement...Suicide Precautions...Now...” A facility document titled, “Phone Call to Consultants v2,” dated June 26, 2024, at 8:13 p.m. indicated, “...Callback #1[number]...Psychiatry...[name of physician contacted]...Time Consult Call Attempt 1 19:25 [7:25 p.m.]...Time Consult Call Returned 19:54 [7:54 p.m.]...Callback #2...Psych Intake Nurse...REACH [a mobile crisis response team) Team...Time Consult Call Attempt 1 19:42 [7:42 p.m.]...” The portion for “Time Consult Call Returned” was blank. CS1 stated Patient 2 had an order to have a 1:1 sitter. CS1 stated there is no sitter documentation in Patient 2’s record. CS1 further stated there are no nursing documentation to give information on what happened or transpired at the time the patient eloped. CS1 stated, when a patient elopes, the staff should notify the charge nurse, look for the patient, and try calling the patient if there is a number on file. CS1 stated if there is no answer after three attempts, the patient is removed from the system as an elopement. CS1 stated Patient 2 was pending a psychiatric [the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation for his SI. CS1 stated there is no documentation the staff spoke with REACH. CS1 stated if the ED is full and no rooms are available, the patient is put in front of the nurse’s station in Station A. CS1 stated the bed where Patient 2 was placed in was a chair in the hallway in front of the nurse’s station. CS1 stated, when patients are ordered a 1:1, the patient gets a sitter when the patient has been placed into a room, not when they are in the hallway. 3. A concurrent interview and review of Patient 3’s medical record was conducted with CS 1 on August 22, at 10:56 a.m. Patient 3’s record indicated the patient presented to the ED on July 22, 2024, at 4:52 p.m. A facility document titled, “Emergency Department Timeline,” indicated, “...Chief Complaint: PATIENT PRESENTS FOR 5150 WITH SUICIDAL THOUGHTS...” A facility document titled, “Emergency Physician Record,” dated July 22, 2024, at 5:33 p.m., indicated, “...presents to the ED with a chief complaint of SI. Patient [Patient 3] states she [sic] “feeling suicidal when she’s a black person stalking her”. Patient started speaking obscenities and demanded to leave the ED...ED COURSE...The patient was evaluated in the emergency department for presenting issue of psychiatric care...She left the emergency department on her own recognizance. the [sic] patient does not have appropriate insight with respect to my presenting complaint at this time...Initial medical workup was initiated...Patient elected to elope from the emergency department prior to the completion of the workup...Nursing staff and myself did conduct an initial search of the premises to no avail...Disposition: Time 7/22/2024 17:41:00 [5:41 p.m.], Eloped...” A facility document titled, “Nursing Note-Text,” dated July 22, 2024, at 6:30 p.m., indicated, “...Performed on: 7/22/2024 [July 22, 2024] 17:40 [5:40 p.m.]... Pt [Patient 3] has eloped at this time with no evaluation. MD [medical doctor] was made aware. per MD...’pt has eloped since I have not seen the patient yet.’ ...” CS1 stated Patient 3 eloped after the medical screening exam (MSE) was completed. CS1 stated Patient 3 was placed in a chair in front of the nurse’s station for monitoring. CS1 stated if the patient is not in a room, they do not have a sitter. CS1 stated when the patient is placed in a chair in front of the nurse’s station, they are being watched by the charge nurse at the station. CS1 stated the safety check and sitter would be done when the patient has a room assigned. An interview was conducted with the Director of Emergency Department (DED) on August 23, 2024, at 10:15 a.m. The DED stated patients usually come into the ED with a 5150 hold written by police or the REACH team from the county. The DED stated the length of time it takes for a patient with a psychiatric issue to be evaluated for a 5150 depends on how quickly staff can get REACH here to see the patient. The DED stated if a patient walks in and is identified as having SI they will be given an ESI level of two. The DED stated staff then would find a safe space for the patient, either in a room or in general observation and the patient might be in general observation in front of nurses’ station until a room is available. The DED stated an MD order is needed for 1:1 observation. The DED stated for patients with suicidal ideations pending a psychiatric evaluation, staff try to keep the patient in a treatment area for observation. The DED stated a patient in general observation will sit in a chair in front of the nurse’s station and staff will keep them in sight of the nurses’ station while trying to move them into a room. The DED further stated when the patient is in a chair, they don’t have a nurse continuously monitoring the patient on 1:1 and they sit the patients in front of clinical nursing supervisors in the nurse’s station who monitor the patient. The DED stated, when a patient elopes, the nurses need to document that they notified the MD and PD in the chart. An interview was conducted with the Director of Quality (DQ) on August 23, 2024, at 11:10 a.m. The DQ stated that after reviewing Patient 3’s medical record, Patient 3 does not have a suicide risk assessment completed for their ED visit on July 22, 2024. An interview was conducted with the DED on August 23, 2024, at 11:20 a.m. The DED stated if the MD ordered a 1:1 sitter for a patient, we should be carrying out the order for 1:1 and the patient is given the sitter when they get to a room. The DED stated the MD tells staff to contact REACH the unit clerk calls, and it is documented when the call is made and returned. An interview was conducted with Medical Doctor (MD) 1 on August 23,2024, at 1:10 p.m. MD 1 stated when patients come in with psych complaints or SI, they would self-identify why they are here at triage. MD 1 stated, if the patient has SI, the triage nurse will take them back to fast track in a chair at station A with staff monitoring them until they are in a room. MD 1 stated once an order for a 1:1 is placed, the nurses take over and handle the 1:1. MD 1 stated the MD does not call REACH and the unit secretary makes the call to REACH and documents when the call is made and returned. An interview was conducted with the EDM on August 23, 2024, at 1:15 p.m. The EDM stated ED staff try to get patients with SI into a room as soon as possible to put the patient with a 1:1 sitter and would be under general observation in front of the nurse’s station until in a bed is available. An interview was conducted with Nursing Supervisor (NS) 1 on August 23,2024, at 1:20 p.m. NS 1 stated the patients with SI or 5150 would be an ESI 2. NS 1 stated the charge nurse is notified when a patient has SI or a hold during check in, and the charge nurse clears a room. NS 1 stated if the ED is full, the patient is placed in a chair in front of the nurse’s station for the charge nurse to monitor while the room is made ready. NS 1 stated the charge nurse doesn’t document monitoring or fill out Q15 sheet (every 15-minute monitoring document) until the patient is in a room. An interview was conducted with Registered Nurse (RN) 2 on August 23,2024, at 1:28 p.m. RN 2 stated, when a patient comes in with SI or 5150 requiring a 1:1, they go to a bed right away if beds are available and an ED tech sits with the patient. RN 2 stated if there is no bed available, the patient is placed in a chair in front of the charge nurse at the nurse’s station until a bed is available. RN2 stated the definition of a 1:1 is that one staff has eyes on the patient for their safety. 4. A review of Patient 15’s record was conducted with the ERM and the CIP on August 22, at 1140 a.m. A facility document titled, “ED Summary,” dated July 12, 2024, indicated, “...Chief Complaint: pt [Patient 15] SI thoughts x 1 [for one week] week with plan...’ A facility document titled, “Triage Note,” indicated, “...Result date: July 12, 2024 14:18 (2:18 p.m.)...General/Screenings Adult Suicidal Risk Assessment: Presents with suicidal ideation...Suicide Risk Assessment...C-SSRS Suicide Risk Level: High Risk...Suicide High Risk Interventions...Place on elopement precautions...Place on suicide precautions...” A review of the facility document titled, “Orders,” indicated, “...Notify/Precautions Observation Level 07/12/24 [July 12, 2024] 14:19:00 [2:19 p.m.]...Suicidal Risk, 1:1 Observation at all times, Constant order...Precautions 07/12/24 14:19:00...Stat [immediately], Precautions: Elopement Suicide Precautions 07/12/24 14:19...Stat...” There was no documented evidence Patient 15 was assigned placed on 1:1 observation. A concurrent review of Patient 15’s record and interview were conducted with the ERM on August 23, 2024, at 11:40 a.m. The ERM stated Patient 15 was assigned to a room at 2:34 p.m. for observation and did not have a sitter. The ERM stated the Unit Coordinator called the REACH Crisis Team to assess Patient 15 for a 5150 hold at 2:35 p.m. The ERM stated the REACH Crisis Team arrived to the ED at 3:30 p.m., the team was unable to locate the patient and the patient had eloped. A facility document titled, “ED Physician Record,” dated July 12, 2024, at 2:19 p.m., indicated, “...Patient [Patient 15] presents to the ED for evaluation of suicidal ideation which has been ongoing for the past week. Patient states that she wants to slit her wrists...Orders...Ongoing Suicide Assessment...ED Course/Medical Decision Making: At 1530 [3:30 p.m.], REACH attempted to find the patient in the ED with no success. Patient likely eloped from the ED...Due to the patient’s complaint...PD [police department] was called and they performed a wellness check at the patient’s residence but she was not found. The patient eloped prior to completion of emergency department work-up...Impression and Plan...Diagnosis Suicidal Ideation...Condition: Guarded. Disposition: Eloped, Dispositioned by: Time 7/12/24 at 16:55:00 [4:55 p.m]...Patient has eloped from this ED before being given paperwork regarding diagnosis, treatment options, or follow-up options...” The facility policy and procedure titled, “Triage ESI Level System -ED 4700,” dated May 2021, was reviewed and indicated, “...Purpose: To provide a guideline for use of standardized system whereby patients presenting to the Emergency Department (ED) are treated in order of priority based upon acuity [severity of symptoms] utilizing the Emergency Severity Index (ESI) Five Level Triage System...from level 1 (most urgent) to level 5 (least urgent. The ESI provides a method for categorizing ED patients by both acuity and resource needs to move the patient to a final disposition such [sic] admission, transfer or discharge...ESI Level 2: Potentially life or limb threatening and could worsen without intervention. When an ESI level 2 is identified, patient placement is rapidly facilitated to be evaluated as soon as possible...Examples may include...Psychiatric complaints...” The facility policy and procedure titled, “Guidelines of the Sitter Program -1258,” dated January 2018, was reviewed and indicated, “...Definitions: Sitter: an individual either a hospital employee or a contracted worker who remains at a designated patient’s bedside with no other dutied to focused [sic] on patient’s safety...The sitter will maintain continuous visual contact with the patient that is assigned as 1:1 care...” The facility policy and procedure titled,”Safety of Patients at Risk for Suicide,” dated April 2021, was reviewed and indicated, “...The purpose of this policy is to outline the requirements for ensuring the safety of patients at {Name of facility] with actual or potential thoughts of self-harm or suicide...One-to-One Observation involves one trained and competent staff member to observe one patient only...Elopement: A patient who is aware that they should not leave but does with intent (i.e. [that is] 5150/Psychiatric hold patients in the ED...The patient will be continuously monitored by a staff member trained and competent to observe a patient at risk for suicide...” On August 23, 2024, at 3:05 p.m., the survey team identified significant concerns in the facility’s ED. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s CNO, Chief Operating Officer (COO) and the DQ. The facility’s CNO, COO, and DQ were verbally notified regarding the concerns of the facility’s failure to ensure patients who have been determined to have suicidal ideation and patients on 5150 (involuntary 72-hour hold) were continuously monitored to prevent the patients from eloping. A copy of the IJ template was provided to the DQ. On August 23, 2024, at 6:28 p.m., the DQ provided a Corrective Action Plan (CAP). On August 23, 2024, at 6:57p.m., a meeting was conducted with the CNO, COO, and the DQ to review and provide clarification for the CAP. On August 26, 2024, at 3:15 p.m., the DQ provided a revised CAP. The CAP indicated the following: - EDUCATION & Training: Immediate training for all Emergency Depatment (ED) staff regarding policies, procedures, and practices: Distributed August 23, 2024: Read and sign Huddle regarding suicidal ideations identified, 1:1 sitter/observer must always be in constant observation on the patient. All registered nurses will receive suicide risk assessment training and documentation regarding suicide risk patients, including specific actions to take, and prevention strategies while in the ED until 5150 holds cleared or discharged to another facility. Education regarding completion of the Observation Log/Environmental checklist will be completed along with the frequency. All technicians will be educated regarding the completion of the Observation log/ environmental checklist. Escalation of behavior will be communicated to the RN; - Once patient is identified as a 5150 hold or a suicide risk, then they will be brought Immediately to the treatment area and direct 1:1 observation will be initiated by emergency room technician (ED techs), Certified nurse assistants (CNAs), patient observation attendants, registered nurse, or other competent staff immediately and documented using the Observation Log/Environmental checklist. Patient placement should be room 3 or 4 whenever possible, although any treatment area will suffice provided appropriate environment and observation present; - Forms: ED Patient observation log/environmental checklist (5150 holds and patients at risk) will be completed by the sitter/observer every 15 minutes for the duration of the ED stay until discharged or 5150 hold cleared. Form will be modified to have environmental assessment completed on the back of the monitoring form. Observation documentation will commence immediately upon identification and placement in the treatment area. Competency documents (initial and annual) will be modified to include the added content focusing on identification, frequency of monitoring, and environmental safety; - Revise the following policies and procedures: Safety of Patients at Risk for Suicide #9001 - Enhance the Identification of patients at risk for suicide, implementation of monitoring and documentation every 15 minutes by a qualified observer. Code Green #1297, Against medical advice/Elopement #0500, AMA leaving against medical advice 1505, Psychiatry involuntary Holds- ED #3700, All observers/sitters will complete the sitter/observer competency assessment, Guidelines of the Sitter Program #1258 - will be modified to include the environmental assessment and the continuous every 15-minute monitoring. The Inpatient monitoring document will be modified to align with the ED document; - Monitoring: Behavioral health patients presenting to the ED will be audited to assure compliance with identified suicidal patients or patients at risk: Sample Size: 100 % of patients presenting to the ED with identified suicidal ideation; Measure:Education: The ED Director and Director of Education created a mandatory education for all ED nurses and ED technicians regarding assessment, interventions based upon identified risk, observation expectations including frequency and location, documentation, and environmental safety. Training will be conducted initially by in-person meetings, read and sign, and followed by formal learning management system class. This training began August 23rd and has been subsequently modified to include items identified above. Staff were notified about the training during huddles, and by electronic communications. Content will be added to the ED orientation and competency. Registered nurse/LVN: Numerator: number of ED RN that completed the education/training and Denominator # of RN assigned to the ED. ED Technician: Numerator: # of ED Techs that completed the education/training and Denominator # of Techs assigned to the ED. Clinical Observation: Suicidal ideation/5150 patient monitoring ; Numerator: # ED patient Observation Log/Environmental checklist completed and Denominator # patients with suicidal ideation and/or 5150 hold patient. On August 26, 2024, at 3:40 p.m., the CAP for the immediate jeopardy at the ED was reviewed and accepted. On August 26, at 3:45 p.m., the CAP was verified onsite to have been fully implemented. August 26, 2024, at 4:21 p.m., the IJ was removed in the presence of DQ, with the COO and the CNO were also on the phone call.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42512 Based on interview and record review, the hospital failed to ensure there was an effective governing body that carried out the functions required of a governing body to provide a safe and secure environment for patients as evidenced by: The facility failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients when a medical student (Med Student 1) was assisting in and performing surgical services in the operating room (OR) without authorization and was not under the direct supervision of a physician which was not in accordance with hospital policy (Refer to A-0049 and A-0347). The cummulative effect of these systemic problems resulted in the facility’s failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide a safe and secure environment for patients.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure patients or their representative, were informed of their rights when: 1. Patients 4, 12, 13, 14, and 21 were not informed in advance of their rights to appeal discharge (Refer to A-0117); 2. For Patient 8, a medical student (Med Student 1) performed a surgical procedure without supervision (Refer to A-0131); and 3. For 238 patients, the facility failed to protect patient private health information when a medical student (Med Student 1), who was not authorized to access patients’ records, had accessed the facility’s Electronic Health Record System and the patients files (Refer to A-0144). These cummulative failures had the potential to result in the patients’ rights to be violated and for patients to not be able to make informed decisions about their care.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure accountability of the medical staff when a medical student (Med Student) 1 performed surgical procedures in the operating room (OR) without authorization and without the direct supervision of a physician (Refer A-0347) The cumulative effect of this systemic problem resulted in the facility failure to ensure patient safety was maintained in the OR had the potential to affect the quality of care provided to the patients.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure case management evaluation and reassessment were completed for patients during hospitalization, for six of 32 sampled patients (Patients 3, 6, 13, 18, 20, and 22) (Refer to A-0805). In addition, the facility failed to ensure the transfer to an acute care facility was appropriate, for one of 32 sampled patients (Patient 9) (Refer to A-0813). The cumulative effect of these systemic problems had the potential for the patients’ needs to not be met after they are discharged from the facility which may result to delay in recovery and to rehospitalization.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure, for three of 32 sampled patients (Patients 2, 3, and 8), 1. Only authorized practitioner assist in and/or perform surgical procedures when a medical student (Med Student 1) was permitted to assist and perform surgical procedures in the operating room (OR) without authorization and direct supervision of a physician (Refer to A 0945); 2. Documents in the patients’ records were filled appropriately: a. For Patient 2, the facility failed to ensure the date and time when the document was signed were indicated on the consent for surgery (Refer to A-0955); b. For Patient 3, the facility failed to ensure the date and time when the document was signed were indicated on the consent for anesthesia (Refer to A-0955); and 3. For Patient 8, the operative report was documented accurately (Refer to A-0959). The cumulative effect of these systemic problems resulted in the facility’s failure to ensure surgical services were provided by authorized providers only, and had the potential for patients to not receive information about their surgery and to not give their informed consent prior to the surgery/procedure which may result in substandard care provided to patients.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47071 Based on interview and record review, the governing body failed to ensure accountability of the medical staff when a medical student (Med Student 1) was assisting in and performing surgical procedures in the operating room (OR) without authorization and direct supervision of a physician. This failure had the potential to result in harm to patients undergoing surgery. Findings: On May 15, 2024, an unannounced visit was conducted at the facility to investigate a complaint. On May 15, 2024, at 10:57 a.m., an interview with the Director of Surgery was conducted. The Director of Surgery stated Med Student 1 was coming to the OR until mid-February of 2024. The Director of Surgery stated Med Student 1 was previously a medical student at the facility and did not have full privileges at the facility. The Director of Surgery stated Med Student 1 would come into the OR to observe and assist the surgeons after her authorized rotation at the facility. The Director of Surgery stated as a medical student, Med Student 1 would not have been allowed unsupervised in the OR and should have always been supervised by a surgeon. On May 15, 2024, at 10:15 a.m., an interview with the Chief Nursing Officer (CNO) was conducted. The CNO stated Med Student 1 was observing and assisting with surgeries in the OR until possibly January or February 2024. On May 15, 2024, at 11:35 a.m., an interview with OR Nurse 1 was conducted. OR Nurse 1 stated they are familiar with Med Student 1 being in the OR, and Med Student 1 was there until February 2024, and came and assisted the surgeons. OR Nurse 1 stated the operative reports listed who is in the room, such as the surgeon, who is assisting, and other OR staff. On May 15, 2024, at 11:40 a.m., an interview with OR Tech 1 was conducted. OR Tech 1 stated Med Student 1 was a medical student in the OR until February 2024. OR Tech 1 stated Med Student 1 assisted the surgeons and sometimes helped with surgical wound dressings after. On May 15, 2024, at 1:46 p.m., a review of Med Student 1’s OR rotation documentation and a concurrent interview with the CNO was conducted. The CNO stated, when medical students are expected to be at the facility, an email was sent out from the Graduate Medical Education (GME) Program regarding the incoming medical students. The CNO stated the only information available at this time is the email which included Med Student 1. The email was reviewed with the CNO and indicated Med student 1 was incoming for a medical student rotation from September 25, 2023, through October 22, 2023. The CNO stated there is no documentation available to indicate Med Student 1 was still a medical student at the facility after October 2023. The CNO stated operative reports reviewed in February indicated Med Student 1 was in the OR as of February 2024. On May 17, 2024, at 9:57 a.m., an interview with the Anesthesiologist was conducted. The Anesthesiologist stated she is familiar with Med Student 1. The Anesthesiologist stated Med Student 1 was coming into the OR from around September 2023 until February 2024. The Anesthesiologist stated Med Student 1 was a medical student doing her rotation at the facility until October 2023, and after that was not on rotation. The Anesthesiologist stated she witnessed Med Student 1 being left unsupervised by the surgeon, who left her “to close [performing stitches on an open surgical wound to close the surgical cut]” on a patient in February 2024, and the surgeon who was supervising left the room completely and was not supervising Med Student 1. The Anesthesiologist stated Med Student 1 was present in the OR almost daily, other than on the weekends. The Anesthesiologist stated Med Student 1 was in the OR with Surgeon Group 1 thru December 2023, and after about January 2024, was present with different surgeons outside of Surgeon Group 1. On May 17, 2024, at 12:20 p.m., an interview was conducted with the Director of Surgery. The Director of Surgery stated that there is usually a list posted in the OR of current medical students on rotation. The Director of Surgery stated there was no list posted of current medical students in February 2024. On May 17, 2024, at 12:25 p.m., a review of the facility document titled, “Application for Medical/Clinical Student Rotation,” dated March 22, 2023, signed by Med Student 1, and email correspondence documents between Med Student 1, General Surgery Residency program manager, and executive assistant to the chief academic officer and GME program, dated May 17, 2024, was conducted with the CNO. The facility document titled, “Application for Medical/Clinical Student Rotation,” indicated Med Student 1 applied for emergency medicine rotation from May 1, 2023, to June 2, 2023. The email correspondence documents indicated, “...Here is the email communication between the student, GS [General Surgery Program Manager, and myself regarding the confirmation and approval of students rotation for her last roll over rotation at [name of facility] in GS on 9/25-10/22/23 [September 25 to October 22, 2023] ...” The email correspondence titled, “Anticipated Medical Students Rotating Sept. [September] 2023,” sent by the Executive Assistant of the Chief Academic Officer and GME program indicated, “...Please see added student “[Name of University]: [Name of Med Student 1] General surgery/[Name of Facility], 9/25-10/22/23...” An undated document titled, “Peri-op Case Attendees,” was reviewed. The document indicated Med Student 1 was present for 100 cases in the OR between October 2023 and March 1, 2024. There was no documented evidence Med Student 1 was authorized for a medical student rotation at the facility after October 23, 2023. During a concurrent interview, the CNO stated she spoke with the program director who stated the process they use for notifying hospital of medical students is through email. The CNO stated the email records indicated Med Student 1 was approved as a medical student on rotation at the facility from September through October 22, 2023. The CNO stated after October 22, 2023, Med Student 1 did not have approval as a medical student to rotate at the facility. The CNO stated Med Student 1 completed her medical student application for a rotation at the facility in March of 2023, and there were no applications submitted since then. The CNO stated she found out about the issue with Med Student 1 and escalated it up the chain of command. The CNO stated when she escalated it, she spoke with the Chief of staff and was told it was already being addressed. The CNO stated there has been disconnect between the medical staff, Med Student 1, and the facility since the issue was identified. The CNO stated the issue could have occurred with any medical student. The CNO stated the process used for medical students was not as structured as it should have been. The CNO stated Med Student 1’s rotation ended on October 22, 2023, and there is no evidence she was authorized to be at the facility as a medical student after October 22, 2023. The CNO stated Med Student 1 came to the hospital and still had a badge and access to the OR and the surgeons after her authorized rotation at the facility. The CNO stated it was a failure between the supervising surgeons, Med Student 1, and the facility. The CNO stated based on facility’s policy, medical students should be under constant direct supervision while assisting in the OR. On May 20, 2024, an interview was conducted with Medical Doctor 1 (MD 1). MD 1 stated the OR staff thought that Med Student 1 was a medical student, and at one point Med Student 1 told the OR staff that she was a resident (a medical school graduate and physician in training). MD 1 stated staff do not want to admit to what happened for fear of losing their jobs. MD 1 stated the Quality Department was forwarded the information and no response was given. MD 1 stated this was a big concern for patient safety. MD 1 stated they got confirmation that Med Student 1 had not been a medical student with the facility since October 22, 2023. MD 1 stated Med Student 1 was pulled from the OR and was interviewed on March 1, 2024. MD 1 stated Med Student 1 admitted she had her badge and access and would come to the hospital and pick the surgical procedures to assist in. MD 1 stated Med Student 1 admitted the facility’s Chief Executive Officer was aware she was coming to the hospital. MD 1 further stated Med Student 1 admitted that she had posed as a medical student and as a resident, and that surgeons had stepped out of the operating room many times during the surgeries she assisted in. MD 1 stated the Medical Executive Committee (MEC) was involved. MD 1 stated the MEC has a list of approximately 100 cases that Med Student 1 was involved in. A review of facility policy and procedure (P&P) titled, “Graduate Medical Education and Trainees,” revised December 2021 was conducted. The P&P indicated, “...Ultimately, the management of each patient’s care, treatment, and services is a responsibility of a licensed independent practitioner with appropriate clinical privileges...Medical students are not members of the Medical staff and are not entitled to the procedural rights provided in the Medical Staff Bylaws...Medical Students are not eligible for clinical privileges...they cannot manage patients independently and only function under the direct supervision of a Medical Staff Member...With respect to procedures performed...the Medical Staff Member must be physically present at the time of performance...Supervision of Medical Students...At all times, each Trainee Staff member remains under the supervision of the Faculty Attending Medical Staff Member to whom the Trainee is assigned...Procedures/Surgery...”physically present” means that the Faculty Attending Physician is located in the same room...as the patient...Medical students may assist in surgical procedures, but only under the direct and continuous supervision of the faculty attending physician or the resident or fellow (who is appropriately supervised as well) for the entire duration of the procedure...””

“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: 44871 Based on interview and record review, the facility failed to ensure patients or their representatives were informed in advance of their rights to appeal discharge, for five of 32 sampled patients (Patient 4, 12, 13, 14, and 21 ). These failures had the potential for patients to not be able to appeal their discharge. Findings: 1. On July 17, 2024, at 10:15 a.m., a concurrent interview and review of Patient 4’s record were conducted with the Manager of Medical Surgical Telemetry (MST) and Infection Prevention Coordinator (IPC) 2. A facility document titled, “History and Physical [H&P],” dated July 13, 2024, at 5:12 p.m., indicated Patient 4 was admitted to the facility for 5150 hold (an involuntarily detention for 72 hours for being a danger to self or others) for visual hallucinations (an apparent perception of something not present). There was no documented evidence the document titled, “An Important Message from Medicare [IMM, a document indicating the patient’s right to appeal his discharge],” was given to Patient 4 when Patient 4 was admitted to the facility. An interview was conducted with the Regional Director of Patient Access (RPDA) on July 17, 2024, at 10:28 a.m. The RPDA stated Patient 4 was uncooperative and agitated and would not sign documents. She stated they should have attempted to get the IMM document signed. The RPDA stated she did not see any notes in the Patient 4’s record the staff attempted to get the IMM document signed by the patient. She further stated if it was not documented, it was not done. 2. On July 16, 2024, at 10:50 a.m., a review of Patient 12’s record was conducted with the Infection Prevention Coordinator (IPC) and the Clinical System Analyst (CSA). The “H&P,” dated December 7, 2023, at 3:45 p.m., indicated Patient 12 was admitted to the facility for Covid (a highly contagious disease caused by a virus) pneumonia (infection in the lungs). The facility document titled, “Order,” dated December 7, 2023, at 3:44 p.m., indicated, “...Admit to Inpatient...Hypoxia [not enough oxygen to the tissues]...” The facility document titled, “Discharge Request,” dated December 27, 2023, at 11:56 a.m., indicated, “...Discharge to SNF [Skilled Nursing Facility]...” There was no documented evidence an IMM document was given to Patient 12 when Patient 12 was admitted to the facility and 48 hours prior to discharge. An interview was conducted with the RDPA on July 16, 2024, at 2:23 p.m. The RDPA stated once an order for admission is given, a Patient Access Representative should have given the IMM document for the patient to sign. The RDPA stated she was unable to find documentation an IMM document was given to Patient 12 on admission. She further stated the facility’s process was not followed. An interview was conducted with Case Manager (CM) 1 on July 16, 2024, at 2:26 p.m. CM 1 stated Patient 12 was not given the IMM document 48 hours before discharge and the facility’s policy was not followed. 3. On July 17, 2024, at 10:12 a.m., a review of Patient 13’s record was conducted with the IPC and the CSA. The “H&P,” dated October 1, 2023, at 2:11 p.m., indicated Patient 13 was admitted to the facility for attempted suicide and was placed on a 5150 hold. The facility document titled, “Order,” dated September 30, 2023, at 8:05 p.m., indicated, “...Admit as Inpatient...vomiting/suicidal ideation [thoughts of committing suicide]...” There was no documented evidence an IMM document was given to Patient 13 when Patient 13 was admitted to the facility. An interview was conducted with the RDPA on July 17, 2024, at 10:29 a.m. The RDPA stated there was no copy of the IMM document in Patient 13’s record and a copy of the IMM document should have been given to the patient once an admission order was given. The RDPA further stated the facility’s process was not followed. An interview was conducted with the CSA on July 17, 2024, at 10:31 a.m. The CSA stated she cannot find a copy of the IMM document in Patient 13’s record. 4. On July 18, 2024, at 9:14 a.m., a review of Patient 14’s record was conducted with the IPC and the CSA. The “H&P,” dated February 13, 2024, at 9:06 a.m., indicated Patient 14 was admitted for anemia (a condition in which the blood doesn’t have enough healthy red blood cells) and chest pain. The facility document titled, “Order,” dated February 13, 2024, at 5:15 p.m., indicated, “...Admit to Inpatient...chest pain...” There was no documented evidence an IMM document was given to Patient 14 when Patient 14 was admitted to the facility. An interview was conducted with the CSA on July 18, 2024, at 9:28 a.m. The CSA stated she cannot find a copy of the IMM document in Patient 14’s record. An interview was conducted with the RDPA on July 18, 2024, at 9:41 a.m. The RDPA stated there was no IMM document in Patient 14’s record and a copy should have been given to the patient once an admission order was given. The RDPA further stated the facility’s process was not followed. 5. On July 16, 2024, at 2:44 p.m., a review of Patient 21’s record was conducted with the Director of Medical Surgical Telemetry (DMST). The “H&P,” dated July 10, 2024, at 1:51 p.m., indicated Patient 21 was admitted to the facility on July 10, 2024. A facility document titled, “Discharge Request,” dated July 15, 2024, at 12:58 p.m., indicated, “...Discharge to Skilled Nursing Facility...” A facility document titled, “Important Message from Medicare,” dated July 15, 2024, at 1:55 p.m., was reviewed. The document indicated the patient or representative signed the IMM document on July 15, 2024, at 1:55 p.m.. A facility document titled, “Discharge Summary,” indicated Patient 21 was discharged from the facility on July 15, 2024, at 6:45 p.m. (four hours and 50 minutes after receiving the IMM document). There was no documented evidence an IMM document was given to Patient 21 when Patient 21 was admitted to the facility and in two calendar days before discharge. On July 16, 2024, at 3:05 p.m., an interview with the DMST was conducted. The DMST stated Patient 21 was not given the IMM document on admission. She stated the IMM document was given to the patient four hours before discharge. A review of the facility’s policy and procedure (P&P) titled, “Important Message from Medicare,” dated April 2024, was conducted. The P&P indicated, “...All inpatients within 2 [two] calendar days of admission and no more than 7 [seven] days prior to an elective admission. A copy of the IMM must also be provided to each beneficiary within a maximum of 2 [two] calendar days and a minimum of 4 [four] hours prior to discharge. The IM must be signed by all Medicare, Medicare Advantage and Senior HMO (Health Maintenance Organization) patients or the patient’s representative to indicate receipt and understanding of the notice...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure a patient, Patient 8, was informed a medical student (Med Student 1) would perform/assist with a surgical procedure. These failures caused the patient to not make an informed decision and could possibly cause harm to Patient 8. Findings On July 17, 2024, at 1:20 p.m., an interview was conducted with Anonymous Staff (U) 1. U1 stated medical students signed a separate consent form each time they needed to observe a procedure and are required to ask for consent from the patient prior to observing the procedure. On July 17, 2024, at 1:45 p.m., an interview was conducted with Physician 2. Physician 2 stated medical students are supposed to obtain a signed consent from the patient to be an observer during a surgical procedure. Physician 2 stated it was common for the medical student to participate by holding the retractors. She stated the student consent form was a separate consent form the surgical consent. On July 18, 2024, at 10:20 a.m., an interview and review of Patient 8’s record were conducted with the Manager of Medical Surgical Telemetry (MST) and Infection Prevention Coordinator (IPC) 2. A facility document titled, “History and Physical (H&P),” dated February 23, 2024, at 12:32 p.m., indicated Patient 8 was admitted to the facility for altered mental status after surgery. There was no documented evidence the patient consent form titled, “Medical Student Presence or Participation in Surgical Procedures (Exhibit D),” was signed by the patient. The MST stated the patient consent titled, “Medical Student Presence or Participation in Surgical Procedures (Exhibit D),” was not found in Patient 8’s record. On July 18, 2024, at 11:23 a.m., an interview was conducted with the CNO. The CNO stated the document “Medical Student Presence or Participation in Surgical Procedures (Exhibit D)” was common practice and not the policy of the facility. She further stated there was no written policy about the student consent form. A facility document titled, “Medical and Clinical Student Rotations Requiring a Physician Preceptor,” dated October 9, 2017, was reviewed. The document indicated, “...A current clinical affiliation agreement between the Hospital and the Education Institution must be in place...Hospital retains ultimate responsibility for the care of its patients...Education institution Responsibilities...Students be fully knowledgeable and proficient in the areas of patients’ rights, HIPPA compliance...Preceptor Responsibilities...Any patient evaluated or treated by physician preceptor during a student rotation must be informed of the rotating student’s presence and activities...Preceptor is responsible for informing the patient...Preceptor must obtain a signed Patient Consent, Medical Student Presence or Participation in Surgical Procedures (Exhibit D)...Medical Staff Office...Ensure a clinical affiliation agreement is current...” A facility document titled, “Graduate Medical Education and Trainees,” dated May 2024, was reviewed. The document indicated, “...Medical Students...Medical students are not members of the medical staff and are not entitled to the procedural rights provided in the Medical Staff Bylaws...Medical Students must first be properly introduced to the patient and the patient’s consent to their presence...””

“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: 47071 Based on interview and record review, the facility failed to ensure the patients’ private health information were protected when an unauthorized medical student (Med Student 1) accessed the records of 238 patient. These failures resulted in a breach of 238 patients’ private health information. Findings: On July 17, 2024, at 2:14 p.m., an interview was conducted with Anonymous Staff (U) 2. U2 stated she followed up with the Director of Quality (DQ) multiple times by email questioning the possible breach of patients’ private health information. U2 further stated the DQ told her there was nothing to report. On July 17, 2024, at 3:30 p.m., an interview was conducted with Graduate Medical Education (GME) 1. GME 1 stated once a medical student finished her rotation at the facility, she is no longer authorized to be in the facility and should no longer have access to the private health information. GME 1 further stated if the medical student did not follow protocol she would be in violation of HIPAA (Health Insurance Portability and Accountability Act, a privacy law). On July 17, 2024, at 3:45 p.m., an interview was conducted with the DQ. The DQ stated no one reached out to quality and asked for this to be reported as a possible HIPAA violation. She stated a discussion about the risk of the patients was never brought up and the focus was on the process. The DQ further stated, “unfortunately we just messed up.” On July 17, 2024, at 4:20 p.m., an interview was conducted with the Systems Director HIM (SDHIM). The SDHIM stated she just found out about the situation and the possible reportable breach fifteen minutes before the interview. On July 18, 2024, at 11:23 a.m., an interview and concurrent record review was conducted with the Chief Nursing Officer (CNO). An audit of Med Student 1’s accessed records from October 23, 2023, to March 1, 2024, were reviewed. The documents indicated Med Student 1 had accessed around 238 patient records. A review of Med Student 1’s OR rotation documentation was conducted with the CNO. The CNO stated Med Student 1 accessed around 238 patient records and she shouldnt have. The CNO stated, when medical students are expected to be at the facility, an email was sent out from the Graduate Medical Education (GME) Program regarding the incoming medical students. The CNO stated the only information available at this time was the email which included Med Student 1. The email was reviewed with the CNO and indicated Med student 1 was incoming for a medical student rotation from September 25, 2023, through October 22, 2023. The review of the email indicated only two persons received the email, and this was the disconnect. The CNO stated there was no documentation available to indicate Med Student 1 was still a medical student at the facility after October 2023. The CNO stated operative reports reviewed indicated Med Student 1 participated in surgeries from October 25, 2023, to March 1, 2024. A review of a facility policy and procedure (P&P) titled, “Patients’ Rights Under HIPPA Privacy Rule,” dated May 15, 2024, was reviewed. The document indicated, “...Patients have the right to request that a Facility restrict the use or disclose of PHI of treatment, payment or health care operations: the disclosure to persons involved in their health care...Notification of Breach of Unsecured PHI...Patients are entitled to notification of a breach of their unsecured PHI in accordance with UHS Privacy 2.0 Breach Notifications...” A review of a facility P&P titled, “Patient’s Rights and responsibilities-1501,” dated September 2022, was reviewed. The document indicated, “...Patient’s rights include...Informed participation in decisions...Personal privacy and confidentiality information...Patient has the right to full consideration of privacy concerning the medical care...right to be advised as to the reason for the presence of any individual...will be conducted discreetly and individuals not directly involved in the care will not be present without permission...medical records...kept confidential...by individuals directly involved in the treatment...Staff Identity...the patient has the right to know the identity and professional relationship of all individuals providing service...are required to wear name badges identifying...””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure a medical student (Med Student 1) was authorized to assist during surgical procedures and was directly supervised by a physician while assisting in and performing surgical procedures in the operating room (OR). This failure had the potential to result in harm to patients undergoing surgery. Findings: On May 15, 2024, an unannounced visit was conducted at the facility to investigate a complaint. On May 15, 2024, at 10:57 a.m., an interview with the Director of Surgery was conducted. The Director of Surgery stated Med Student 1 was coming to the OR until mid-February of 2024. The Director of Surgery stated Med Student 1 was previously a medical student at the facility and did not have full privileges at the facility. The Director of Surgery stated Med Student 1 would come into the OR to observe and assist the surgeons. The Director of surgery stated as a medical student, Med Student 1 would not have been allowed unsupervised in the OR and should have always been supervised by a surgeon. On May 15, 2024, at 10:15 a.m., an interview with the Chief Nursing Officer (CNO) was conducted. The CNO stated Med Student 1 was observing and assisting with surgeries in the OR until possibly January or February 2024. On May 15, 2024, at 11:35 a.m., an interview with OR Nurse 1 was conducted. OR Nurse 1 stated they are familiar with Med Student 1 being in the OR, and Med Student 1 was there until February 2024, and came and assisted the surgeons. OR Nurse 1 stated the operative reports listed who is in the room, such as the surgeon, who is assisting, and other OR staff. On May 15, 2024, at 11:40 a.m., an interview with OR Tech 1 was conducted. OR Tech 1 stated Med Student 1 was a medical student in the OR until February 2024. OR Tech 1 stated Med Student 1 assisted the surgeons and sometimes helped with surgical wound dressings after. On May 15, 2024, at 1:46 p.m., a review of Med Student 1’s OR rotation documentation and a concurrent interview with the CNO was conducted. The CNO stated, when medical students are expected to be at the facility, an email was sent out from the Graduate Medical Education (GME) Program regarding the incoming medical students. The CNO stated the only information available at this time is the email which included Med Student 1. The email was reviewed with the CNO and indicated Med student 1 was incoming for a medical student rotation from September 25, 2023, through October 22, 2023. The CNO stated there is no documentation available to indicate Med Student 1 was still a medical student at the facility after October 2023. The CNO stated operative reports reviewed in February indicated Med Student 1 was in the OR as of February 2024. On May 17, 2024, at 9:57 a.m., an interview with the Anesthesiologist was conducted. The Anesthesiologist stated she is familiar with Med Student 1. The Anesthesiologist stated Med Student 1 was coming into the OR from around September 2023 until February 2024. The Anesthesiologist stated Med Student 1 was a medical student doing her rotation at the facility until October 2023, and after that was not on rotation. The Anesthesiologist stated she witnessed Med Student 1 being left unsupervised by the surgeon, who left her “to close [performing stitches on an open surgical wound to close the surgical cut]” on a patient in February 2024, and the surgeon who was supervising left the room completely and was not supervising Med Student 1. The Anesthesiologist stated Med Student 1 was present in the OR almost daily, other than on the weekends. The Anesthesiologist stated Med Student 1 was in the OR with Surgeon Group 1 thru December 2023, and after about January 2024, was present with different surgeons outside of Surgeon Group 1. On May 17, 2024, at 12:20 p.m., an interview was conducted with the Director of Surgery. The Director of Surgery stated that there is usually a list posted in the OR of current medical students on rotation. The Director of Surgery stated there was no list posted of current medical students in February 2024. On May 17, 2024, at 12:25 p.m., a review of the facility document titled, “Application for Medical/Clinical Student Rotation,” dated March 22, 2023, signed by Med Student 1, and email correspondence documents between Med Student 1, General Surgery Residency program manager, and executive assistant to the chief academic officer and GME program, dated May 17, 2024, was conducted with the CNO. The facility document titled, “Application for Medical/Clinical Student Rotation,” indicated Med Student 1 applied for emergency medicine rotation from May 1, 2023, to June 2, 2023. The email correspondence documents indicated, “...Here is the email communication between the student, GS [General Surgery Program Manager, and myself regarding the confirmation and approval of students rotation for her last roll over rotation at [name of facility] in GS on 9/25-10/22/23 [September 25 to October 22, 2023] ...” The email correspondence titled, “Anticipated Medical Students Rotating Sept. [September] 2023,” sent by the Executive Assistant of the Chief Academic Officer and GME program indicated, “...Please see added student “[Name of University]: [Name of Med Student 1] General surgery/[Name of Facility], 9/25-10/22/23...” An undated document titled, “Peri-op Case Attendees,” was reviewed. The document indicated Med Student 1 was present for 100 cases in the OR between October 2023 and March 1, 2024. There was no documented evidence Med Student 1 was authorized for a medical student rotation at the facility after October 23, 2023. During a concurrent interview, the CNO stated she spoke with the program director who stated the process they use for notifying hospital of medical students is through email. The CNO stated the email records indicated Med Student 1 was approved as a medical student on rotation at the facility from September through October 22, 2023. The CNO stated after October 22, 2023, Med Student 1 did not have approval as a medical student to rotate at the facility. The CNO stated Med Student 1 completed her medical student application for a rotation at the facility in March of 2023, and there were no applications submitted since then. The CNO stated she found out about the issue with Med Student 1 and escalated it up the chain of command. The CNO stated when she escalated it, she spoke with the Chief of staff and was told it was already being addressed. The CNO stated there has been disconnect between the medical staff, Med Student 1, and the facility since the issue was identified. The CNO stated the issue could have occurred with any medical student. The CNO stated the process used for medical students was not as structured as it should have been. The CNO stated Med Student 1’s rotation ended on October 22, 2023, and there is no evidence she was authorized to be at the facility as a medical student after October 22, 2023. The CNO stated Med Student 1 came to the hospital and still had a badge and access to the OR and the surgeons after her authorized rotation at the facility. The CNO stated it was a failure between the supervising surgeons, Med Student 1, and the facility. The CNO stated based on facility’s policy, medical students should be under constant direct supervision while assisting in the OR. On May 20, 2024, at 12:04 p.m., an interview was conducted with Medical Doctor 1 (MD 1). MD 1 stated the OR staff thought that Med Student 1 was a medical student, and at one point Med Student 1 told the OR staff that she was a resident (a medical school graduate and physician in training). MD 1 stated staff do not want to admit to what happened for fear of losing their jobs. MD 1 stated the Quality Department was forwarded the information and no response was given. MD 1 stated this was a big concern for patient safety. MD 1 stated they got confirmation that Med Student 1 had not been a medical student with the facility since October 22, 2023. MD 1 stated Med Student 1 was pulled from the OR and was interviewed on March 1, 2024. MD 1 stated Med Student 1 admitted she had her badge and access and would come to the hospital and pick the surgical procedures to assist in. MD 1 stated Med Student 1 admitted the facility’s Chief Executive Officer was aware she was coming to the hospital. MD 1 further stated Med Student 1 admitted that she had posed as a medical student and as a resident, and that surgeons had stepped out of the operating room many times during the surgeries she assisted in. MD 1 stated the Medical Executive Committee (MEC) was involved. MD 1 stated the MEC has a list of approximately 100 cases that Med Student 1 was involved in. A review of facility policy and procedure (P&P) titled, “Graduate Medical Education and Trainees,” revised December 2021 was conducted. The P&P indicated, “...Ultimately, the management of each patient’s care, treatment, and services is a responsibility of a licensed independent practitioner with appropriate clinical privileges...Medical students are not members of the Medical staff and are not entitled to the procedural rights provided in the Medical Staff Bylaws...Medical Students are not eligible for clinical privileges...they cannot manage patients independently and only function under the direct supervision of a Medical Staff Member...With respect to procedures performed...the Medical Staff Member must be physically present at the time of performance...Supervision of Medical Students...At all times, each Trainee Staff member remains under the supervision of the Faculty Attending Medical Staff Member to whom the Trainee is assigned...Procedures/Surgery...”physically present” means that the Faculty Attending Physician is located in the same room...as the patient...Medical students may assist in surgical procedures, but only under the direct and continuous supervision of the faculty attending physician or the resident or fellow (who is appropriately supervised as well) for the entire duration of the procedure...””

“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: 42512 Based on observation, interview, and record review, the facility failed to ensure the facility’s policy and procedures (P&P) were implemented, for five of 32 sampled patients (Patient 1, 6, 13, 14, and 24), when: 1. For Patient 1, pain assessment was not conducted prior to the administration of pain medication; 2. For Patient 6, the DNR (Do Not Resuscitate) form was not signed by the patient and the facility staff; 3. For Patient 13, pain reassessment was not performed after pain medication was administered; 4. For Patient 14, pain medication was not administered timely for pain assessed at a seven (pain scale 1-10, with 10 being the worst pain); and 5. For Patient 24, the heart rate was not assessed prior to medication administration in accordance with the physician’s order. These failures had the potential to cause a delay in care and may affect the quality of care delivered to the patients. Findings: 1. On July 16, 2024, at 10:30 a.m., a review of Patient 1’s record was conducted with the Manager of Medical Surgical Telemetry (MST) and Infection Prevention Coordinator (IPC) 2. A facility document titled, “History and Physical (H&P),” dated July 10, 2024, at 12:07 p.m., indicated Patient 1 was admitted to the facility for acute colitis (infection of the bowels). A facility document titled, “Vital Sign flow sheet,” indicated, “...12:55 p.m...pain...0/10...1 p.m...pain...6/10...2 p.m...pain...0/10...” A facility document titled, “Medication Administration Record,” indicated, “...hydrocodone-acetaminophen [a pain medication]...1Tabs [tablets], Tab, Oral, q [every] 4hrs, PRN [as needed]...Pain 4-6 (Moderate)...” The document further indicated, “...Hydromorphone (Dilaudid) [a pain medication] 1 mg [milligram, unit of measurement] = 1 mL [milliliter, unit of measurement], Injection, IV [intravenous, administered through the vein]...push, q4hrs...PRN Pain 7-10...(Severe)..7.14.24 (July 14, 2024)...12:41 p.m...1 mg given...” On July 16, 2024, at 10:45 a.m., an interview was conducted with the MST. The MST stated there should have been a pre-medication assessment completed prior to giving the Dilaudid 1 mg. The MST stated Patient 1’s pain was assessed at 6/10, and the pain medication which should have been administered was the hydrocodone-acetaminophen 1 tab which was ordered for pain 4-6. The MST stated the Dilaudid was ordered for pain 7-10. A review of the facility P&P titled, “Physician’s Orders 1400,” dated August 2023, was conducted. The P&P indicated, “...Physician’s orders are carried out until canceled...” A review of a facility P&P titled, “Medication Administration and Monitoring Policy-MM 0809,” dated April 2024, was conducted. The P&P indicated, “...Before administration, the individual administering the medication will confirm the following...verify that the medication selected matches the medication order...Medications will be administered on the established scheduled times or based on patient needs as specified by the ordering LIP [Licensed Independent Practitioner]...” A review of a facility P&P titled, “Pain Assessment and Management for the Hospital Patient,” dated April 2024, was conducted. The P&P indicated, “...Moderate pain...pain score within the range of 4 to 6...Severe pain...score...range...7-10 on scale...care giver will assess the patient’s pain level...pain will be reassessed after each pain management intervention...expectation is that the reassessment will be completed and documented within 120 min of pain management intervention...Pain assessment/re-assessment will be documented in EMR [Electronic Medical Record]...” 2. On July 17, 2024, at 11:11 a.m., a review of Patient 6’s record was conducted with the MST and the IPC 2. A facility document titled, “H&P,” dated October 5, 2023, at 6:10 p.m., indicated Patient 6 was admitted to the facility for dislodged cholecystostomy tube (tube to drain the gallbladder). A facility document titled, “(Name of Facility) PREFERRED INTENSITY OF CARE,” indicated, the sections for the date and time the document was signed by the Physician, the registered nurse, and the patient were blank. On July 17, 2024, at 11:14 a.m., an interview was conducted with the MST. The MST stated the DNR form should have been timed and dated. She stated the date and time would attest to when the discussion and decision occurred. On July 17, 2024, at 11:50 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated all forms should be dated and timed. She further stated it was a documentation expectation that all the forms were completed. A review of the facility’s P&P titled, “Medical Record E-201,” dated April 2022, was conducted. The P&P indicated, “...Guidelines for Documenting in the Medical Record...All entries are signed and dated...” 3. On July 17, 2024, at 10:27 a.m., a review of Patient 13’s record was conducted with IPC 1 and the Clinical System Analyst (CSA). The “H&P,” dated October 1, 2023, at 2:11 p.m., indicated Patient 13 was admitted to the facility for attempted suicide and was placed on a 5150 hold (an involuntarily detention for 72 hours for being a danger to self or others). A facility document titled, “Pain and Comfort,” indicated, “...October 1, 2023...Numeric Pain Scale...9...5:36 p.m...October 1, 2023...Numeric Scale...9...10:54 p.m...” A facility document titled, “Medications,” indicated, “...hydrocodone - acetaminophen...1 Tabs, Tab, Oral, q4H Pain 7-10...October 1, 2023...5:36 p.m...1 tabs...October 1, 2023...10:55 p.m...1 tabs...” There was no documented evidence that pain was reassessed after hydrocodone-acetaminophen was administered on October 1, 2023, at 5:36 p.m and 10:55 p.m. On July 17, 2024, at 10:47 a.m., an interview was conducted with the CSA. The CSA stated pain should have been reassessed within 120 minutes of pain management intervention. The CSA further stated the policy was not followed on October 1, 2023, for both medication administrations. The CSA stated there is no reassessment documented on Patient 13’s record. A review of the facility’s P&P titled, “Pain Assessment and Management for Hospital Patient,” dated April 2024, was conducted. The P&P indicated, “...The expectation is that the reassessment will be completed and documented within 120 minutes of pain management intervention...” 4. On July 17, 2024, at 11:32 a.m., a review of Patient 14’s record was conducted with IPC 1 and CSA. A facility’s document titled, “H&P,” dated February 13, 2024, at 9:06 a.m., indicated Patient 14 was admitted for anemia (low red blood cell count) and chest pain. An untitled facility document, dated February 13, 2024, indicated, “...12:38 a.m...Numeric...7...2 a.m...Numeric 5...4 a.m...Numeric 5...4:46 a.m...Numeric 7...” A facility’s document titled, “Medications,” dated February 13, 2024, at 4:47 a.m., indicated, “...morphine [a pain medication] 4mg = 1 ml, injection, IV push, Once, First Dose: Now, start date: February 13, 2024 at 4:33...” There was no documented evidence pain medication was administered when Patient 14 complained of pain from 12:38 a.m. to 4:46 a.m. (for 4 hours and 8 minutes). On July 17, 2024, at 10:47 a.m., an interview was conducted with the CSA. The CSA stated there is no documentation the nurse addressed Patient 14’s pain for the above times on February 13, 2024. The CSA further stated pain should have been addressed and the policy was not followed. A review of the facility’s P&P titled, “Pain Assessment and Management for Hospital Patient,” dated April 2024, was conducted. The P&P indicated, “...In the ED, a timely screening for pain is one (1) hour or less after treatment begins...The hospital will treat a patient’s pain and refer the patient for treatment consistent with the patient’s care and treatment needs. Treatment strategies should include non-pharmacologic, pharmacologic, or a combination of approaches...” 5. On July 17, 2024, at 11 a.m., a review of Patient 24’s record was conducted with the Director of Medical Surgical Telemetry (DMST). A facility document titled, “H&P” indicated, Patient 24 was admitted to the facility on June 17, 2024, for “abdominal distention since 5/24 [May 2024].” A facility document titled, “Medications,” indicated, “...Carvedilol (Coreg) [medication for high blood pressure]...3.125 mg = 1 tabs...Oral, BID [twice a day] With meals...Start date 06/18/2024 [June 18, 2024] 11:04 [a.m.]...Hold for HR [heart rate] < [less than] 55...” An untitled document indicated, “...Carvedilol...” and the portion for “Systolic Blood Pressure, Diastolic Blood Pressure, and peripheral Pulse Rate” were not filled on June 18, 2024, at 11:12 a.m., on June 18, 2024, at 6:12 p.m., and on June 19, 2024, at 9:02 a.m. There was no documented evidence Patient 24’s heart rate was monitored prior to the administration of the medication, in accordance with the physician’s order.. A review of the facility’s P&P, dated August 2023, indicated, “...To provide guidelines so that medications will be administered in safe, accurate, and consistent manner...Patients will be monitored based on parameters specified in the medication order...””

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure case management evaluation and reassessment were completed for patients during hospitalization, for five of 32 sampled patients (Patient 3, 6, 13, 20, and 22). This failure had the potential to delay continuity of care and discharge planning in the facility. Findings: 1. On July 16, 2024, at 1:55 p.m., a review of Patient 3’s record was conducted with the Manager of Medical Surgical Telemetry (MST) and Infection Prevention Coordinator (IPC) 2. A facility document titled, “History and Physical (H&P),” dated July 12, 2024, at 4:31 p.m., indicated Patient 3 was admitted to the facility for epigastric (stomach) abdominal pain. The face sheet indicated Patient 3 was discharged on July 16, 2024, at 12:30 p.m. There was no documented evidence a case manager completed an initial assessment and discharge planning within two days of admission for Patient 3. On July 16, 2024, at 2:05 p.m., an interview was conducted with the MST. The MST stated there was no initial case management assessment conducted for Patient 13. She further stated there should have been an initial case management assessment completed on or before July 14, 2024. On July 16, 2024, at 2:10 p.m., an interview was conducted with Case Manager (CM) 1. CM 1 stated she reviewed Patient 3’s electronic file and did not see documentation an initial case management assessment was completed. She further stated the assessment should have been completed within two days of admission and the facility’s policy was not followed. 2. On July 17, 2024, at 11:11 a.m., a review of Patient 6’s record was conducted with the MST and the IPC 2. A facility document titled, “H&P,” dated October 5, 2023, at 6:10 p.m., indicated Patient 6 was admitted to the facility for dislodged cholecystostomy tube (tube to drain the gallbladder). The face sheet indicated Patient 6 was discharged on October 14, 2023. A facility document titled, “Discharge Planning Assessment,” dated October 6, 2023, indicated discharge planning was conducted for Patient 6. There was no documented evidence that a case manager completed a reassessment on Patient 6 on or before October 11, 2023 (five days after the initial assessment on October 6, 2023), in the EMR An interview was conducted with the MST on July 17, 2024, at 11:25 a.m. The MST stated there was no reassessment completed by a case manager for Patient 6 on or before October 11, 2023. An interview was conducted with CM 1 on July 17, 2024, at 11:40 a.m. CM 1 stated she reviewed Patient 6’s record and did not find documentation a reassessment was completed per the facility’s policy. She further stated the case management reassessment should have been completed on or before October 11, 2023. CM 1 stated the facility’s policy was not followed. 3. On July 17, 2024, at 10:12 a.m., a review of Patient 13’s record was conducted with Infection Prevention Coordinator (IPC) 1 and the Clinical System Analyst (CSA). The “H&P,” dated October 1, 2023, at 2:11 p.m., indicated Patient 13 was admitted to the facility for attempted suicide and was placed on a 5150 hold (an involuntary 72 hold for person who are a danger to self or to others). The face sheet indicated Patient 13 was discharged on October 11, 2023. There was no documented evidence a Case Manager completed an assessment for Patient 13. On July 17, 2024, at 11:07 a.m., an interview and review of Patient 13’s record were conducted with the CSA. The CSA stated there was no case Management evaluation found in the chart. The CSA stated the facility’s process was not followed. On July 17, 2024, at 11:21 a.m., an interview and review of Patient 13’s record were conducted with CM 1. CM 1 stated she did not find documentation a case management evaluation was conducted. CM1 stated a case management evaluation was not done in accordance with the facility’s policy. 4. On July 16, 2024, at 1:20 p.m., a review of Patient 20’s record was conducted with the DMST. A facility document titled, “H&P,” dated July 12, 2024, at 2:10 p.m. indicated Patient 20 was admitted to the facility for right upper quadrant [area of the abdomen] and epigastric abdominal pain. The document indicated Patient 20 had a past history of pre-diabetes [condition with abnormal blood sugar] and gall stones. There was no documented evidence a case management assessment was completed for Patient 20. The DMST stated the case manager should have seen this patient within two days of admission. She stated when a patient was admitted, they should have been seen by case management for an evaluation in accordance with the facility’s policy. On July 16, 2024, at 2:30 p.m., an interview was conducted with CM 1. CM 1 stated a case management assessment was not done for Patient 20 and according to the facility policy, one should have been done within two days of admission. CM 1 stated the case management department did not have enough staff to complete one for each patient admitted and the department only prioritized the “neediest cases.” 5. On July 17, 2024, at 10:14 a.m., a review of Patient 22’s record was conducted with the DMST. Records for Patient 22 were reviewed. A facility document titled, “H&P,” dated June 25, 2024, at 2:38 p.m., indicated Patient 22 was admitted to the facility for low back pain. There was no documented evidence a case management assessment was completed for Patient 22. The DMST stated the case manager should have seen this patient within two days of admission. She stated when a patient was admitted, they should have been seen by case management for an evaluation. A review of a facility policy and procedure (P&P) titled, “Discharge Planning and Social Service Needs- D01,” dated April 2024, was conducted. The P&P indicated, “...All patients admitted to inpatient services will be evaluated by Case Management within one to two (1-2) working day of admission to determine continuum of care needs and availability of community resources...Patients are reassessed every five days for appropriateness of the discharge plan, further social service needs, after being ransferred to another unit, or when there is a change in condition.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure a patient was transferred appropriately to an acute care facility, in accordance with the facility’s policy and procedure (P&P), for one of 32 sampled patients (Patient 9). This failure had the potential to cause harm and delay care to Patient 9 and to the patients who would be transferred to another facility. Findings: On July 15, 2024, at 2:02 p.m., an interview and review of Patient 9’s record were conducted with the Director of Behavior Health (DBH). A facility document titled, “Initial Evaluation Note,” indicated Patient 9 was admitted to the facility on September 20, 2023, for assistance with medical management and was already placed on a 5150 hold (an involuntarily detention for 72 hours for being a danger to self or others) by a police officer for being a danger to others. A facility document titled, “Lab Review,” dated September 22, 2023, at 1:46 p.m., indicated, “...SARS-CoV-2 Ag [A rapid test to detect Covid, a higly contagious disease caused by a virus]...Positive...” A facility document titled, “BH [Behavioral Health] progress note-Nurse,” dated September 22, 2023, at 8:40 p.m., indicated, “...[Name of Physician 1] notified about patients positive Covid result, DR: gave orders to have the patient sign voluntary status and transfer patient to [Name of acute care facility Patient 9 was transferred to]...” There was no documented evidence an inter-facility transfer form titled, “Patient Transfer and Referral Record,” was completed for Patient 9. There was no documented evidence of an accepting physician for Patient 9 at the receiving facility. There was no documented evidence a complete patient report was given by the nurse assigned to Patient 9 directly to the nurse at the receiving facility. On July 15, 2024, at 2:24 p.m., an interview and record review were conducted with the DBH. The DBH stated the facility had to transfer the patient out due to a positive COVID result. The DBH further stated there was no transfer form nor accepting physician documented in the chart. The DBH stated the facility’s process was not followed. On July 16, 2024, at 10:38 a.m., an interview and record review were conducted with the Chief Nursing Officer (CNO). The CNO stated it was an inappropriate/incomplete transfer. The CNO further stated there was no documentation a transfer form was filled out and a physician accepted the patient. She stated the facility’s policy for transferring a patient was not followed. The facility P&P titled, “Interfacility and interhospital Transfer,” dated November 2023, was reviewed. The policy indicated, “...All transfers require an accepting physician and report from the sending physician to the accepting physician...When the patient has been accepted by the receiving hospital and the receiving physician and nursing unit have been assigned, the transfer of clinical information will take place as follows...will assist with obtain the names and telephone numbers of both the accepting physician and the nursing unit if not already provided by the receiving hospital...nurse assigned to the patient will speak directly with the receiving RN or unit charge nurse, providing a complete patient report...An inter-facility transfer form, “Patient Transfer and Referral Record,” is completed...””

“SURGICAL PRIVILEGES CFR(s): 482.51(a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure only authorized practitioner assist in and/or perform surgical procedures when a medical student (Med Student 1) was assisting in and performing surgical procedures in the operating room (OR) without authorization and direct supervision of a physician. This failure had the potential to result in harm to patients undergoing surgery. Findings: On May 15, 2024, an unannounced visit was conducted at the facility to investigate a complaint. On May 15, 2024, at 10:57 a.m., an interview with the Director of Surgery was conducted. The Director of Surgery stated Med Student 1 was coming to the OR until mid-February of 2024. The Director of Surgery stated Med Student 1 was previously a medical student at the facility and did not have full privileges at the facility. The Director of Surgery stated Med Student 1 would come into the OR to observe and assist the surgeons after her authorized rotation at the facility. The Director of Surgery stated as a medical student, Med Student 1 would not have been allowed unsupervised in the OR and should have always been supervised by a surgeon. On May 15, 2024, at 10:15 a.m., an interview with the Chief Nursing Officer (CNO) was conducted. The CNO stated Med Student 1 was observing and assisting with surgeries in the OR until possibly January or February 2024. On May 15, 2024, at 11:35 a.m., an interview with OR Nurse 1 was conducted. OR Nurse 1 stated they are familiar with Med Student 1 being in the OR, and Med Student 1 was there until February 2024, and came and assisted the surgeons. OR Nurse 1 stated the operative reports listed who is in the room, such as the surgeon, who is assisting, and other OR staff. On May 15, 2024, at 11:40 a.m., an interview with OR Tech 1 was conducted. OR Tech 1 stated Med Student 1 was a medical student in the OR until February 2024. OR Tech 1 stated Med Student 1 assisted the surgeons and sometimes helped with surgical wound dressings after. On May 15, 2024, at 1:46 p.m., a review of Med Student 1’s OR rotation documentation and a concurrent interview with the CNO was conducted. The CNO stated, when medical students are expected to be at the facility, an email was sent out from the Graduate Medical Education (GME) Program regarding the incoming medical students. The CNO stated the only information available at this time is the email which included Med Student 1. The email was reviewed with the CNO and indicated Med student 1 was incoming for a medical student rotation from September 25, 2023, through October 22, 2023. The CNO stated there is no documentation available to indicate Med Student 1 was still a medical student at the facility after October 2023. The CNO stated operative reports reviewed in February indicated Med Student 1 was in the OR as of February 2024. On May 17, 2024, at 9:57 a.m., an interview with the Anesthesiologist was conducted. The Anesthesiologist stated she is familiar with Med Student 1. The Anesthesiologist stated Med Student 1 was coming into the OR from around September 2023 until February 2024. The Anesthesiologist stated Med Student 1 was a medical student doing her rotation at the facility until October 2023, and after that was not on rotation. The Anesthesiologist stated she witnessed Med Student 1 being left unsupervised by the surgeon, who left her “to close [performing stitches on an open surgical wound to close the surgical cut]” on a patient in February 2024, and the surgeon who was supervising left the room completely and was not supervising Med Student 1. The Anesthesiologist stated Med Student 1 was present in the OR almost daily, other than on the weekends. The Anesthesiologist stated Med Student 1 was in the OR with Surgeon Group 1 thru December 2023, and after about January 2024, was present with different surgeons outside of Surgeon Group 1. On May 17, 2024, at 12:20 p.m., an interview was conducted with the Director of Surgery. The Director of Surgery stated that there is usually a list posted in the OR of current medical students on rotation. The Director of Surgery stated there was no list posted of current medical students in February 2024. On May 17, 2024, at 12:25 p.m., a review of the facility document titled, “Application for Medical/Clinical Student Rotation,” dated March 22, 2023, signed by Med Student 1, and email correspondence documents between Med Student 1, General Surgery Residency program manager, and executive assistant to the chief academic officer and GME program, dated May 17, 2024, was conducted with the CNO. The facility document titled, “Application for Medical/Clinical Student Rotation,” indicated Med Student 1 applied for emergency medicine rotation from May 1, 2023, to June 2, 2023. The email correspondence documents indicated, “...Here is the email communication between the student, GS [General Surgery Program Manager, and myself regarding the confirmation and approval of students rotation for her last roll over rotation at [name of facility] in GS on 9/25-10/22/23 [September 25 to October 22, 2023] ...” The email correspondence titled, “Anticipated Medical Students Rotating Sept. [September] 2023,” sent by the Executive Assistant of the Chief Academic Officer and GME program indicated, “...Please see added student “[Name of University]: [Name of Med Student 1] General surgery/[Name of Facility], 9/25-10/22/23...” An undated document titled, “Peri-op Case Attendees,” was reviewed. The document indicated Med Student 1 was present for 100 cases in the OR between October 2023 and March 1, 2024. There was no documented evidence Med Student 1 was authorized for a medical student rotation at the facility after October 23, 2023. During a concurrent interview, the CNO stated she spoke with the program director who stated the process they use for notifying hospital of medical students is through email. The CNO stated the email records indicated Med Student 1 was approved as a medical student on rotation at the facility from September through October 22, 2023. The CNO stated after October 22, 2023, Med Student 1 did not have approval as a medical student to rotate at the facility. The CNO stated Med Student 1 completed her medical student application for a rotation at the facility in March of 2023, and there were no applications submitted since then. The CNO stated she found out about the issue with Med Student 1 and escalated it up the chain of command. The CNO stated when she escalated it, she spoke with the Chief of staff and was told it was already being addressed. The CNO stated there has been disconnect between the medical staff, Med Student 1, and the facility since the issue was identified. The CNO stated the issue could have occurred with any medical student. The CNO stated the process used for medical students was not as structured as it should have been. The CNO stated Med Student 1’s rotation ended on October 22, 2023, and there is no evidence she was authorized to be at the facility as a medical student after October 22, 2023. The CNO stated Med Student 1 came to the hospital and still had a badge and access to the OR and the surgeons after her authorized rotation at the facility. The CNO stated it was a failure between the supervising surgeons, Med Student 1, and the facility. The CNO stated based on facility’s policy, medical students should be under constant direct supervision while assisting in the OR. On May 20, 2024, an interview was conducted with Medical Doctor 1 (MD 1). MD 1 stated the OR staff thought that Med Student 1 was a medical student, and at one point Med Student 1 told the OR staff that she was a resident (a medical school graduate and physician in training). MD 1 stated staff do not want to admit to what happened for fear of losing their jobs. MD 1 stated the Quality Department was forwarded the information and no response was given. MD 1 stated this was a big concern for patient safety. MD 1 stated they got confirmation that Med Student 1 had not been a medical student with the facility since October 22, 2023. MD 1 stated Med Student 1 was pulled from the OR and was interviewed on March 1, 2024. MD 1 stated Med Student 1 admitted she had her badge and access and would come to the hospital and pick the surgical procedures to assist in. MD 1 stated Med Student 1 admitted the facility’s Chief Executive Officer was aware she was coming to the hospital. MD 1 further stated Med Student 1 admitted that she had posed as a medical student and as a resident, and that surgeons had stepped out of the operating room many times during the surgeries she assisted in. MD 1 stated the Medical Executive Committee (MEC) was involved. MD 1 stated the MEC has a list of approximately 100 cases that Med Student 1 was involved in. A review of facility policy and procedure (P&P) titled, “Graduate Medical Education and Trainees,” revised December 2021 was conducted. The P&P indicated, “...Ultimately, the management of each patient’s care, treatment, and services is a responsibility of a licensed independent practitioner with appropriate clinical privileges...Medical students are not members of the Medical staff and are not entitled to the procedural rights provided in the Medical Staff Bylaws...Medical Students are not eligible for clinical privileges...they cannot manage patients independently and only function under the direct supervision of a Medical Staff Member...With respect to procedures performed...the Medical Staff Member must be physically present at the time of performance...Supervision of Medical Students...At all times, each Trainee Staff member remains under the supervision of the Faculty Attending Medical Staff Member to whom the Trainee is assigned...Procedures/Surgery...”physically present” means that the Faculty Attending Physician is located in the same room...as the patient...Medical students may assist in surgical procedures, but only under the direct and continuous supervision of the faculty attending physician or the resident or fellow (who is appropriately supervised as well) for the entire duration of the procedure...””

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure the date and time were indicated on patient documents, for two of 32 sampled patients (Patient 2, and 3), when: 1. For Patient 2, the date and time the document was signed were not indicated on the consent for surgery; and 2. For Patient 3, the date and time the document was signed were not indicated on the consent for anesthesia. These failures had the potential for patients to not receive information about their surgery and to not give their informed consent prior to the surgery/procedure. Findings 1. On July 15, 2024, at 10:20 a.m., a concurrent interview and review of Paient 2’s record were conducted with the Manager of Medical Surgical Telemetry (MST), Infection Prevention Coordinator (IPC) 2, and the Director of Education/Interim Director of the ICU (DOE). A facility document titled, “History and Physical (H&P),” dated October 5, 2023, at 6:10 p.m., indicated Patient 2 was admitted to the facility for severe right flank (the areas on the back between the lower ribs and hips) pain. A facility document titled, “Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” indicated, “...To: [Name of Patient]...Date: ____ Time: ___...Patient/Patient Representative Acknowledgement...Date: ____ Time: ____...” There were no entries for the sections for the date and time. There was no documented evidence the dates and times were indicated on the facility document titled, “Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures.” The DOE stated when the doctor signed and dated the consent, it was not necessary for the patient to date and time their signature. When asked if it was important for the patient to date and time the consent to indicate the signature happened before the surgery, the DOE agreed and stated the patient should have signed, dated, and timed. She further stated the staff should have indicated the date and time on page one of the consent when completing the form. 2. On July 15, 2024, at 10:35 a.m., a review of Patient 3’s record review was conducted with the MST, IPC 2, and the CS. A facility document titled, “H&P,” dated October 5, 2023, at 6:10 p.m., indicated Patient 3 was admitted to the facility for epigastric (upper abdominal region) abdominal pain. A facility document titled, “ANESTHESIA CONSENT INFORMED CONSENT FOR ANESTHESIA SERVICES,” were conducted. “...General Anesthesia...Major/Minor Nerve Block...Patient Signature...Date...Time...” There was no documented evidence the date and time when Patient 3 signed the consent was completed. On July 15, 2024, at 10:43 a.m., an interview with the CS was conducted. The CS stated it was important to have the date and time to know when the patient signed the consent for surgery and discussed the risks and benefits with the doctor before the surgical procedure. The date and time was not placed on the document when the patient signed the consent.”

“OPERATIVE REPORT CFR(s): 482.51(b)(6) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure the post operative note was completed accurately and in a timely manner, for one of 32 sampled patients (Patient 8), when the surgeon did not document who completed the closure of the surgical procedure. These failures had the potential to delay patient care and may cause physical harm to the patient. Findings: On July 18, 2024, at 10:20 a.m., a review of Patient 8’s record was conducted with the Manager of Medical Surgical Telemetry (MST), Infection Prevention Coordinator (IPC) 2, and the Director of Education/Interim Director of the ICU (DOE). A facility document titled, “History and Physical (H&P),” dated February 23, 2024, at 12:32 p.m., indicated Patient 8 was admitted to the facility for altered mental status (confusion) after surgery. A facility document titled, “[Name of Facility] Operative Reports Final Report,” dated February 24, 2024, was reviewed. The document indicated, “...Surgeon: [Surgeon 1]...The wound was closed in 2 [two] layers. The deep layer was closed with 3-0 Vicryl (type of suture) running fashion. The skin was closed with 4-0 Monocryl (type of suture) in subcuticular fashion. Dermabond (strong bonding agent for skin) was placed over the skin this included the counter incision at the bicep (muscle in the arm)...signature line...Electronically signed by...” The document did not reflect Med Student 1 being part of or involved in Patient 8’s surgical procedure. On July 17, 2024, at 1:45 p.m., an interview and record review were conducted with the Anesthesiologist (Physician 2). Physician 2 stated she was in the Operating Room (OR) on February 24, 2024, during Patient 8’s surgery. Physician 2 stated Surgeon (Surgeon 1) and Medical Student (Med Student 1) started the surgical procedure together. Physician 2 stated Surgeon 1 got up and walked out of the OR and did not return. She stated Surgeon 1 left Med student 1 to close the surgical incision unsupervised. Physican 2 stated Surgeon 1 did not return to the OR and Med Student 1 should have had direct supervision at all times. On July 18, 2024, at 10:55 a.m., an interview and record review were conducted with the Interim Director of Medical Staff (IDMS). The IDMS stated, looking at this note (referring to the Operative Reports Final Report, dated February 24, 2024), one would assume Surgeon 1 was the person who closed the surgical wounds of Patient 8. After discussing Physician 2’s statement about Surgeon 1 leaving Med Student 1 unsupervised to close Patient 8’s surgical incision, the IDMS stated Surgeon 1 should not have left the operating room, leaving the student alone. She further stated the note would be considered falsified or inaccurate if Surgeon 1 did not perform the closure of the wound on Patient 8. On July 18, 2024, at 11:23 a.m., an interview and record review were conducted with the Chief Nursing Officer (CNO). The CNO stated this note (referring to the Operative Reports Final Report, dated February 24, 2024) indicated Surgeon 1 closed the surgical wounds on Patient 8 and it did not mention the medical student (Med Student 1) in the note. The CNO further stated Med Student 1 should have ended her rotation and not been able to come back into the facility. The CNO stated Med Student 1 was left alone to complete the surgery when Surgeon 1 stepped out of the room and did not return. A facility document titled, “Name of Facility General Rules and Regulations,” dated October 2021 was reviewed. The document indicated, “...Operative reports will be completed immediately following surgery and a comprehensive operative note must be entered in to the progress note immediately after completion of surgery...The note shall contain a description...name of primary surgeon and any assistants...””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure the facility’s policy and procedure (P&P) was implemented within the facility when: 1. Patients 28 and 29 were not provided a Chlorhexidine Gluconate bath (CHG, bathing product that kills germs and reduces the spread of infection in hospitals). 2. For Patient 29, the facility did not report suspected neglect when Patient 29 was found with multiple wounds on admission including pressure injuries Stage three (full thickness tissue loss). 3. Patient 29 was not evaluated by a case manager and social services did not follow up. 4. For Patient 16, the facility did not administer a blood pressure medication when the patient met parameters. 5. For Patient 11, the facility did not report two critical blood pressures readings in a timely manner. 6. For Patients 1, 2, 4, 5, 9, 10, 24, and 31 the facility did not review, sign and/or place the telemetry strips in the physical chart on the unit. 7. For Patient 19, the facility did not scan the telemetry strips into the hard chart. 8. For Patient 11, the facility did not administer pain medication when Patient 11 was on comfort care with pain level of 6/10. 9. For Patient 5, the facility did not remove a home medication from Patient 5’s bedside table. 10. For Patients 8 and 19, the facility did not report an adverse event when Patients 8 and 19 died. These systemic failures could have resulted in a delay of care, infection and or death. Findings: 1. The following records were reviewed with the Director of Education (DOE) on March 19, 2024, at 9:14 a.m. a. Patient 28’s face sheet and history and physical (H&P), indicated Patient 28 was admitted to the facility on October 17, 2023, for pneumonia (infection in lungs). There was no documented evidence Patient 28 was allergic to Chlorhexidine Gluconate (CHG). A review of Patient 28’s activity of daily (ADL) hygiene (Chlorhexidine Bath Care Completed) flow sheet, dated October 22, 2023, to October 28, 2023, indicated no documented evidence that Patient 28 was provided a CHG bath on October 22, 2023, October 23, 2023, October 24, 2023, October 25, 2023, October 26, 2023, October 27, 2023, and October 28, 2023. A review of Patient 28’s Body Systems Assessment II (two) Genitourinary flow sheet, dated October 22, 2023, at 12:48 p.m., indicated a foley catheter was placed with urine output of 60 ml (milliliters-unit of measurement). An interview and record review were conducted with the Infection Prevention Coordinator (IPC) on March 19, 2024, at 11:37 a.m. The IPC stated the nurse should have done a CHG bath daily per facility policy. An interview and record review were conducted with the DOE on March 19, 2024, at 11:39 a.m. The DOE stated for the above dates there were no documented evidence that the patient was given a CHG bath. b. The following records for Patient 29 were reviewed with the Manager of Medical Surgical Telemetry (MMST) on March 21, 2024, at 2:50 p.m. Patient 29’s face sheet and H&P, indicated Patient 29 was admitted to the facility on January 9, 2024, for slurred speech, rule out CVA (Cardiovascular Accident). There was no documented evidence Patient 29 was allergic to Chlorhexidine Gluconate. A review of Patient 29’s activity of daily (ADL) hygiene (Chlorhexidine Bath Care Completed) flow sheet, dated January 16, 2024, to January 18, 2024, indicated no documented evidence Patient 29 was provided a CHG bath on January 16, 2024, January 17, 2024, and January 18, 2024. A review of Patient 29’s Body Systems Assessment II (two) Genitourinary flow sheet, dated January 16, 2024, at 11:00 a.m., indicated a foley catheter was placed with urine output of 40 mls. An interview and record review were conducted with the MMST on March 21, 2024, at 4:13 p.m. The MMST stated there is no documented evidence that Patient 29 received an CHG bath on the days listed above. A review of the facility’s (P&P) titled, “Infection Prevention and Control Plan,” dated March 2023, indicated, “...Process Review: Prevalence studies to include line necessity, dressings, tubing, CHG dressing/device, scrub-the-hub and daily CHG bathing in non-critical care units, every shift CHG bathing for critical care units...” 2. The following records were reviewed with the MMST on March 21, 2024, at 3:14 p.m. Patient 29’s face sheet and H&P, indicated Patient 29 was admitted to the facility on January 9, 2024, for Slurred speech, rule out CVA, Severe Sepsis (life threatening emergency when your body’s response to an infection), Bilateral (relating to two sides) lower extremity infected calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues), Peripheral Artery Disease (a circulation condition), Non-ST elevation Myocardial Infarction (a type of heart attack that happens when your heart’s need for oxygen can’t be met), End Stage Renal Failure, peritoneal dialysis (filters waste for advanced kidney failure). A facility document titled, “Abuse/Neglect Assessment,” dated January 9, 2024, was reviewed. The document indicated, “...Abuse Neglect Assessment...Abuse and Neglect Types: None...” The facility document titled, “Wound Care Note,” dated January 12, 2024, at 4:39 p.m., was reviewed. The document indicated, “...Bilateral Lower Extremities Atypical Wounds: Bilateral lower extremities are noted with poorly defined, open wound beds exposing pink moist tissue with scattered white fibrous tissue and wet tan/brown/grey/black necrotic tissue extending from the calf to the ankle...Moderate green drainage with foul odor ...Right Posterior Upper Arm Atypical Wound: Suspected bulbous lesion...Bilateral Coccyx Pressure Injuries Stage 3 (POA) present on admission...” An interview and record review were conducted with the Manager of Case Management (MCM), on March 21, 2024, at 4:46 p.m. The MCM stated, “looking at the pictures presented to me, yes this should have been reported to APS”. An interview and record review that included the wound photos were conducted with the Academy of Certified Social Worker (ACSW), on March 21, 2024, at 4:49 p.m. The ACSW stated if this patient came from home with these wounds this should have been reported. An interview and record review were conducted with the Emergency Department Director (EDD) and the Emergency Department Manager (EDM), on March 21, 2024, at 5:24 p.m. The EDD stated the expectation would be for all staff to report an allegation of abuse or neglect. The EDD further stated this was not reported to APS. There was no documented evidence that any mandated reporters including nurses, physicians, social workers, case managers, reported to the appropriate Chain of Command, hospital administration and APS immediately for possible abuse/neglect for Patient 29, who was a Dependent Adult. The facility P&P titled, “Reporting Abuse Neglect Allegations policy 0648,” dated March 2024, was reviewed. The document indicated, “...Neglect (A form of abuse): The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...Policy: It is the policy and the responsibility of (Name of the facility) to report all allegations of abuse/neglect appropriately. All employees of (Name of facility) shall adhere to the standards set forth in this policy directive. If an employee observes, abuse, mental abuse, or neglect has occurred; the employee shall escalate reporting of the allegations to the appropriate Chain of Command and to hospital administration immediately...If appropriate, provide notification to Social Services for follow-up, assessment, and potential APS/CPS reporting...” The P&P titled, “Recognizing and Reporting Elder Abuse Neglect 1525,” dated March 2020, was reviewed. The document indicated, “...The law specifies that all mandated reporters including nurses, physicians, non-medical practitioners, psychiatrists, psychologists, social workers, marriage and family therapists (MFT’s), residents, interns, and any other person currently licensed under the Business and Professional capacity or within the scope of his or her employment...Elder abuse should be reported if an observation is made that an elder or dependent adult has sustained physical injuries, which appear to have been inflicted upon him/her by other than accidental means by any person. Additional forms of Elder Abuse can include abandonment, abduction, deprivation, financial abuse, isolation, neglect/self-neglect...” 3. The following records were reviewed with the MMST on March 21, 2024, at 4:20 p.m. The facility document titled, “Discharge Planning Assessment,” dated January 10, 2024, at 3:54 p.m., was reviewed. The document was authored by social worker (SW), the document indicated, “...Pt confirmed residing in a mobile home which has both stairs and a ramp for entry, w/ [with] his wife, [name of wife and phone number], who pt [patient] stated is having increased difficulty managing his care needs at home. He is w/chair [wheelchair] dependent and needs assistance transferring in and out of w/chair to the toilet and recliner...Will try to reach pt’s [patients] wife for more details and inquire re: [regarding] community resource needs...” The facility document titled, “Consult to Case Management,” dated January 11, 2024, at 7:59 a.m. was reviewed. An interview and record review were conducted with MMST, on March 21, 2024, at 4:28 p.m. The MMST stated I cannot find a case management evaluation. An interview and record review were conducted with the MCM, on March 21, 2024, at 4:50 p.m. The MCM stated, “I do not see a case management evaluation, this should be done 24 hours to 48 hours of admission, then a reassessment should have been done every five days”. There was no documented evidence that a Case Manager evaluated Patient 29 per medical doctor (MD) order during his hospitalization. There was no documented evidence that the SW followed up with Patient 29 within five days per policy. The P&P titled, “Discharge Planning and Social Services Needs- D01,” dated November 2023, was reviewed. The documented indicated, “...All patients admitted to inpatient services will be evaluated by Case Management within one working day of admission to determine continuum of care needs and availability of community resources ...patient will be evaluated for Social Service interventions...Reporting to various abuse agencies...Adult Protective Services...All inpatient are screened for discharge needs and social issues by case managers or the social worker within one working day. High risk patients are interviewed and must have a documented discharge plan or social service notes in the medical record prior to discharge...Patient are reassessed every five days for appropriateness of the discharge plan, further social service needs, after being transferred to another unit, or when there is a change in condition...” 4. On March 19, 2024, at 9:30 a.m., a concurrent interview and record review were conducted with the Director of Medical Surgical/Telemetry (DMST) for Patient 16. Patient 16 was admitted on March 12, 2024, for atrial fibrillation with rapid ventricular response (a type of arrythmia, or abnormal heartbeat caused by rapid contractions of the atria [a chamber in the heart] that causes the heart to beat quickly). A review of Patient 16’s vital signs dated March 16, 2024, indicated Patient 16’s blood pressure at 6 a.m. was 172/68. The document further indicated Patient 16’s blood pressure at 5 p.m. was 188/83. There was no documented evidence Patient 16 was given a PRN (as needed) blood pressure medication per physician orders. The DMST stated the Registered Nurse (RN) should have given the PRN medication as ordered by the physician. The facility document titled, “ORDER SHEET,” dated March 14, 2024, at 00:38 (12:38 a.m.) was reviewed. The documented indicated, “...Hydralazine 20 mg/ML vial...10 mg 0.5 ml [milliliter-unit of measurement], IV [intravenous] Push, q4h [every four hours] PRN...Comment FOR SBP [systolic blood pressure] GREATER THAN 160 mmHg [unit of measurement].” A review of the P&P titled, “Medication Administration and Monitoring Policy,” dated August 2023, was conducted. The P&P indicated, “...To provide guidelines so that medications will be administered in a safe, accurate and consistent manner...Patients will be monitored based on parameters specified in the medication order...Medication will be administered on the established scheduled times or based on patient need...” 5. On March 21, 2024, at 3:20 p.m., a concurrent interview and record review were conducted with MST and CNM. Patient 11 was admitted on February 1, 2024, for gastrointestinal hemorrhage and hypertension (elevated blood pressure). A review of Patient 11’s vital signs flow sheet, dated February 4, 2024, at 7:30 a.m., indicated, “...a blood pressure of 187/94...” The high blood pressure was reported to the physician at 9:47 a.m. A concurrent interview was conducted with MST at 4:25 p.m. The MST stated the nurse reported the lab values but reported it late. The RN should have reported the high blood pressure to the physician within 30 minutes. A review of Patient 11’s vitals sign flow sheet, dated February 5, 2024, at 4:39 a.m. indicated, “...blood pressure of 189/92...” There was no documented evidence the RN reported the elevated blood pressure to the physician. A concurrent interview was conducted with the MST at 4:27 p.m. The MST stated the RN did not report the high blood pressure to the physician. She further stated the RN should have reported the high blood pressure within 30 minutes. A review of the untitled document dated February 1, 2024, at 5:48 a.m., indicated “...hydrALAZINE...10 mg, 0.5 mL...Dose 10 mg...0.5 mL...IV push...Frequency q4 [every 4 hours] ...PRN [as needed] ...Reason...Blood Pressure...Comment FOR SBP GREATER THAN 160 mmHg [unit of measurement] ...” A review of the P&P titled, “Critical Values and Abnormal Signs Reporting...,” dated December 2022, was conducted. The P&P indicated “...Notification to the physician will be done within 30 minutes of receiving the critical result...” 6. For Patients 1, 2, 4, 5, 9, 10, 24, and 31, the facility did not review, sign, and/or place the telemetry strips in the physical chart on the unit. The following records were reviewed: For Patient 1, a record review was conducted on March 19, 2024, at 10:10 a.m., with the MMST and Clinical Nutrition Manager (CNM). Patient 1’s face sheet, history and physical (H&P), indicated Patient 1 was admitted to the facility on March 17, 2024, for Non-ST elevated myocardial infarction (heart attack). A review of Patient 1’s hard chart on the unit was conducted, the telemetry strips dated March 17, 2024, at 8 a.m., and March 18, 2024, at 4 a.m. were in the chart, not signed. An interview was conducted with the Nurse Manager (NM) on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every 4 hours per the facility’s policy. For Patient 2, a record review was conducted on March 19, 2024, at 10:10 a.m., with MMST and CNM. Patient 2’s face sheet and H&P indicated Patient 2 was admitted to the facility on March 13, 2024, for Urinary Tract Infections (infection in the urinary tract) and Severe Sepsis. A review of Patient 2’s hard chart on the unit was conducted, the telemetry strips dated, March 17, 2024, at 8:00 p.m., March 18, 2024, at 12:00 a.m., and March 18, 2024, at 4:00 a.m. were in the chart not signed. An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility’s policy. For Patient 4, a record review was conducted on March 19, 2024, at 10:35 a.m., with the MMST and CNM. Patient 4’s face sheet and H&P indicated Patient 4 was admitted to the facility March 17, 2024, for acute urinary tract infection. A review of Patient 4’s hard chart on the unit was conducted, the telemetry strip for admission on March 17, 2024, at 12:00 a.m., and March 18, 2024, at 4:00 a.m., was not in the chart. An interview was conducted on March 19, 2024, at 2:20 p.m., with the MMST. The MMST stated when the patient was admitted to the unit on telemetry the nurse should have completed an admission telemetry strip, reviewed, signed, and placed in the hard chart. She further stated the registered nurse did put the 4 a.m., telemetry strip in the chart and it was not signed. For Patient 5, a record review was conducted on March 19, 2024, at 2:20 p.m., with the MMST and CNM. Patient 5’s face sheet and H&P indicated Patient 5 was admitted to the facility on March 13, 2024, for respiratory failure and diabetes (a disorder in which the body cannot control sugar levels). A review of Patients 5’s records were conducted. The telemetry strips for March 13, 2024, at 11:44 p.m., and March 14, 2024, at 3:45 a.m. were dated but not signed by the nurse. The telemetry strips for March 18, 2024, 8:00 a.m., and March 18, 2024, 12:00 p.m., were missing from the patients’ chart. An interview was conducted on March 19, 2024, at 3:05 p.m. with the MMST. The MMST stated the strips for March 18, 2024, 8:00 a.m., and 12:00 p.m., were missing from the patient’s chart and the telemetry strips for March 14, 2024, at 3:45 a.m., and March 13, 2024, at 11:44 p.m., were dated but not signed by the nurse. She stated the nurse did not follow the facility’s policy for telemetry monitoring, signing telemetry strips and placing the strips in the patient’s chart. For Patient 9, a record review was conducted on March 18, 2024, at 9:59 a.m., with the MMST and CNM. Patient 9’s face sheet and H&P indicated Patient 9 was admitted to the facility March 13, 2024, for acute hypoxic respiratory failure (low levels of oxygen in the blood). A review of Patient 9’s hard chart on the unit was conducted. The telemetry strips for March 18, 2024, 12 a.m., and March 18, 2024, 4 a.m., were not placed in the patient’s chart. An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility’s policy. For Patient 10, a recorded review was conducted on March 18, 2024, at 9:59 a.m., with the MMST and CNM. Patient 10’s face sheet and H&P indicated Patient 10 was admitted to the facility on March 8, 2024, for wide ventricular depolarization (an irregular heart rhythm). A review of Patient 10’s hard chart on the unit was conducted. The telemetry strips for March 17, 2024, at 4 a.m., and March 18, 2024, at 12 a.m., were in the chart but not signed. An interview was conducted with the NM on March 18, 2024, at 10:06 a.m. The NM stated the primary nurse did not sign the telemetry strips as per policy. She stated the primary nurse is responsible for reviewing and signing the telemetry strips every four hours per the facility’s policy. For Patient 24, a record review was conducted on March 19, 2024, at 1:37 p.m., with the IPC and the DOE. Patient 24’s face sheet and H&P indicated Patient 24 was admitted to the facility March 12, 2024, for congestive heart failure (heart unable to pump blood as well as it should) to the telemetry unit. A review of Patient 24’s hard chart on the unit was conducted. The telemetry strip for March 14, 2024, at 8 a.m., was in the chart but not signed. An interview and record review were conducted with the DOE on March 20, 2024, at 9:55 a.m. The DOE stated the expectation for the RN would be to review and sign the telemetry strip. The DOE further stated the telemetry strip for March 14, 2024, at 8 a.m., should have been signed by the RN, the strip was not signed. For Patient 31, a record review was conducted on March 19, 2024, at 10:35 a.m., with the MMST and CNM. Patient 31’s face sheet and H&P indicated Patient 31 was admitted to the facility March 10, 2024, for incarcerated ventral hernia (blood supply to the intestine is blocked). A review of patients 31’s hard chart on the unit was conducted. The telemetry strips for March 17, 2024, at 8 p.m., and March 18, 2024, at 12 a.m., were in the chart but not signed. An interview was conducted with the MMST on March 18, 2024, at 10:35 a.m. The NM stated the nurse did not sign the telemetry strips and placed them in the patient’s chart. The NM stated the nurse should have signed each strip and then put them in the chart. A review of the facility’s (P&P) titled, “Telemetry Monitoring Remote”, Dated May 2022, was reviewed. The document indicated “...Each Monitor Technician will monitor 30 to 60 monitors and will analyze, run, and input the rhythm...as applicable, into the medical record for every patient, excluding ICU... step down and telemetry level of care, monitor technicians will run the strips and interpret them with initials. Monitor Technicians or Registered Nurses document the rhythm...as applicable, in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips. The strips should be documented and placed in the medical record within 90 minutes of due time. An admission and discharge strip shall be run, interpreted with initials, and documented in electronic medical record. Registered Nurses must sign off strips that are analyzed...” 7. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the DMST. The “History and Physical,” dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention. On March 19, 2024, at 10:24 a.m., Patient 19’s telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m. were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient’s chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19’s electronic health record: -February 24, 2024, at 1600 (4 p.m.); -February 24, 2024, at 2000 (8 p.m.); and -February 25, 2024, at 0000 (12 a.m.). On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. The TT 1 stated telemetry strips are delivered to the unit every four hours, at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The TT 1 further stated the RN will review, sign, and place the strips in the patient’s chart. On March 21, 2024, at 9:45 a.m., an interview was conducted with the Charge Nurse (CN) 2. CN 2 stated the registered nurses are expected to review the telemetry strips every four hours that are brought up by the telemetry technicians. On March 21, 2024, at 10:59 a.m., an interview was conducted with the Charge Nurse (CN) 1. CN 1 stated the telemetry technicians print the patient’s telemetry strips every four hours at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.) then deliver the strips to the unit for the registered nurse to review, sign and place in the patient chart. A review of the policy and procedure (P&P) titled, “Telemetry Monitoring Remote,” dated November 2023, was conducted. The P&P indicated, “...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient’s nurse of any dysrhythmias. Rhythm strips will be entered in the patients’ medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm...as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400...” 8. On March 21, 2024, at 3:20 p.m., a concurrent interview and record review were conducted with MST and CNM. Patient 11 was admitted on February 1, 2024, for gastrointestinal hemorrhage and hypertension (elevated blood pressure). A review of Patient 11’s pain assessment was conducted with the MST and CNM. The document indicated “...February 2, 0224...9 a.m... Pain 6/10...” There was no documented evidence Patient 11 was given pain medication. A review of the facility untitled document dated February 1, 2024, indicated “...acetaminophen (Tylenol) 650 mg, 2 tabs...oral...q4 hours...pain 1-3/fever...” A review of the facility untitled document dated February 1, 2024, indicated “...morphine 2 mg, 1 mL...injection IV push...frequency q4...pain 7-10 (severe)...” On March 21, 2024, at 4:30 p.m., an interview with the MST was conducted. The MST stated Patient 11 should have been given pain medication per the pain scale. She further stated the registered nurse should have followed the medication order. On March 21, 2024, at 5:25 p.m., an interview with the Director of Pharmacy (DOF) was conducted. The DOF stated by the nurse not giving the medication the doctor ordered would be considered a medication error. A review of the P&P titled, “Medication Administration and Monitoring Policy,” dated August 2023, was conducted. The P&P indicated, “...Medications will be administered on established times or based on patient needs as specified by the ordering LIP (Licensed Independent Practitioner) ...” 9. On March 18, 2024, at 10:53 a.m., an observation and concurrent interview was conducted with MMST. Patient 5 was admitted on February 13, 2024, for respiratory failure with acute hypoxia. One medication was observed on the bedside table. The medication was Albuterol 90 mcg (unit of measurement). A concurrent interview with Patient 5 was conducted. Patient 5 stated he liked to keep it at bedside so he could use it when he felt short of breath. He further stated he used it a few hours ago and the nurses knew he had it at bedside. On March 18, 2024, at 11 a.m. an interview with the MMST was conducted. The MMST stated the policy of the hospital is that no outside medications are allowed at the bedside. She further stated Patient 5 should not have had the medication at the bedside. A review of the P&P titled, “Medication Administration and Monitoring Policy,” dated August 2023, indicated “...Medications may not be left at the patient’s bedside for self-administration...Patient self-administration is not allowed...” 10. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the DMST. The “History and Physical,” dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD, lower extremity edema, shortness of breath on exertion and abdominal distention. The facility document titled, “Modified Early Warning Score,” dated February 24, 2024, at 23:02 (11:02 p.m.) was reviewed. The documented indicated, “...4 (HI)... (score of 3-4 requires extra attention)” The DMST stated a score of 4 was high and indicated the patient met a higher risk to deteriorate. The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 00:00 (12 a.m.) was reviewed. The documented indicated, “...Rounded on patient around 0000 d/t elevated MEWs score...Rapid response and code blue was called approximately 1 hour after d/t patient being found unresponsive...” The facility document titled, “CARDIOPULMONARY RECORD,” dated February 25, 2024, was reviewed with the DMST. The document indicated, “...Time of Arrest Noted: 0104 (1:04 a.m.) ...Time of first assisted ventilation: 0105 (1:05 a.m.) ...compressions 0106 (01:06 a.m.) ...Rhythm...0129 (1:29 a.m.) ...code ended...pea (pulseless electrical activity) ...” The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 2:57 was reviewed with the DMST. The document indicated, “...0104 (1:04 a.m.) ...Call received from monitor tech patient heart rate dropping to 30’s. Was attending to another patient charge Nurse Mary went to the room and found patient not breathing and initiated CPR (cardiopulmonary resuscitation) ...0105 am (1:05 a.m.): Code Blue (patient requiring resuscitation [reviving someone from apparent death]) called and team at bedside...” The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 (2 of 3) documented February 24, 2024, from 01:04:10 (1:04 & 10 seconds) to February 24, 2024, at 01:05:00 (1:05 a.m.), page 3/3 (3 of 3) documented February 24, 2024, at 01:05:10 (1:05 & 10 seconds) to February 24, 2024, at 01:05:40 (1:05 & 40 seconds a.m.). There was no documented evidence of Patient 19’s cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 (1 of 3) was not scanned into Patient 19’s medical record. The DMST stated pages 1/3 were not scanned and could not be recovered. On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19. On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed. On March 20, 2024, at 1 p.m., a record review and concurrent interview of Patient 8’s medical record was conducted with MST and CNM. The “History and Physical,” dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker, hypertension, and abdomen pain. On March 21, 2024, at 10:24 a.m., Patient 8’s telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was off telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm PT OFF TELE and on February 20, 2024, at 13:10 (1:10 pm) note on strip “PT PUT BACK ON TELE” and on February 20, 2024, at 13:41 (1:41 pm) HR 0. The Facility Document titled “CARDIOPULMONARY RECORD” dated February 20, 2024, was reviewed with MST. The document indicated, “...Time Arrest Noted 1310...Breathing Assisted...Time of first assisted ventilation 1318 ...Intubation time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole ...Epinephrine ...1314 ...VTACH ... 1317 ...PEA ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ...” The Facility Document titled “[Facility Name] Expiration Record” dated February 20, 2024, was reviewed with the MST. The document indicated, “...Notification of Death...Date/Time Death 0220/24 13:55 ...Pronounced By... [Name of Physician] ...Autopsy...No...” The facility Document titled “Progress Note-Nurse” dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, “...@1240 primary RN left the room...patient was complaining about left neck pain and LLE [left Lowe extremity] pain...@1256...tele monitor record, the monitor was off from the patient ...RN or charge nurse did not receive phone call or notification from telemetry...@1305...went in to room because family...noticed something was wrong...patient was barely responding...@1308 Called code rapid...@1310 called code blue...@1335 daughter asked to stop chest compressions...declared of patient’s decease...” On March 21, 2024, at 9:30 a.m., an interview was conducted with the MST. The MST stated the nurse was at the bed side and Patient 8 was restless and wanting to be turned. Stated the Patient 8’s leads were off as noted on the strip. On March 20, 2024, at 2:19 p.m., and interview was conducted with the Telemetry Technician (TT) 2. The TT 2 stated they are responsible for watching 60 or more patients at a time. TT 2 stated that she just finished printing the 12 p.m. strips and was documenting the information in the computer. TT 2 stated that can take an hour to hour and half to print and put in the computer. The TT 2 stated she was distracted doing the strips and probably did not notice Patient 8 was off when she glanced over at the monitors. The TT 2 stated while putting the information in the computer she glances over at the screens every few minutes to make sure no one is off. The TT 2 stated she did not call the nurse or call a rapid response for Patient 8. A review of the P&P titled, “Event Reporting and HPR Policy,” dated September 2023, indicated “...PURPOSE ...Ensure prompt reporting of serious events...mitigate identified risk issues associated with events...Adverse Event. Any event caused by medical management rather than the patient’s underlying disease or condition...All sentinel, serious and never events...will have a root cause analysis [RCA] performed...””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47071 Based on observation and interview the hospital failed to ensure supplies and equipment were unexpired, clean and ready for use when: 1. Expired supplies were found in a cart in the Operating Room (O.R.) area; This failure has the potential to result in complications causing patient harm. 2. Unit 2’s drain in the nutrition room was found with debris and black/grey build-up. This failure has the potential for the drain to become a breeding ground for bacteria and germs leading to foul odor and/or health hazards. Findings: 1. During a tour of the O.R. conducted on March 18, 2024, at 1:22 p.m., with the Director of Surgery (DOS), a supply cart which contained a box of da Vinci Xi (EndoWrist Stapler 45 Reload, count six- stapler used for surgery with smart technology) was observed with an expiration date of September 30, 2023. An interview was conducted on March 18, 2024, at 1:59 p.m., with the DOS. The DOS verified the expiration date was September 30, 2023 and stated the expired staplers should not have been in the cart, and should have been discarded. An interview was conducted on March 20, 2024, at 9:00 a.m., with the Director of Supply Chain (DOSC). The DOSC stated the robot cart [da Vinci Xi, EndoWrist Stapler 45 Reload, six count] expired on September 30, 2023. The DOSC further stated the Operating Room Material Coordinator (ORMC) is supposed to check for expiration dates weekly. The ORMC stated if an expired product is found, it is removed, and all expired non-refundable products are discarded. The DOSC stated there is no policy/procedure (P&P) or log for this process at this time. 2. A tour of Unit 2 was conducted on March 18, 2024, at 11:15 a.m., with the Manager Medical Surgical/Telemetry (MMST). The floor drain in the Nutrition Room (T2013) was observed to have dark gray/black colored thick grime and debris in the drain. An interview was conducted on March 18, 2024, at 11:20 a.m., with the MMST. The MMST stated the drain was dirty and should have been cleaned. An interview was conducted on March 18, 2024, at 11:20 a.m., with the Director of Plan Operations (DPO). The DPO stated, “I can say that looks pretty bad. Yes, that is pretty dirty.” The DPO also stated his department was not responsible for cleaning the drain, they are responsible for snaking the drain when it is plugged. The DPO stated there was no policy for his department to clean the drain. An interview was conducted on March 18, 2024, at 2:45 p.m., with the Director of Quality (DOQ). The DOQ stated engineering should be the one to clean the drains in the nourishment room. The DOQ further stated that Environmental Services (EVS) should have cleaned the drain as well. An interview was conducted on March 20, 2024, at 9:11 a.m., with the Director of Environmental Services (DEVS). The DEVS stated he saw the drain with the DPO and it was dirty. The DEVS stated that he was not sure when the drain was last cleaned, but to his knowledge the drain had not been cleaned since he has been at the facility for the last six months. The DEVS stated there was no policy for the drains to be reviewed or cleaned.”

“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: 44871 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for two of 31 sampled patients (Patients 8 and 19), when: 1. Patient 8 was not continuously monitored on the telemetry and not recognizing and reporting cardiac changes. This failure resulted in a delay of treatment for Patient 8 and could have contributed to Patient 8’s death. 2. Patient 19 had multiple episodes of low heart rate which were not addressed. This failure resulted in the delay of treatment for Patient 19 and could have contributed to patient 19’s death. Findings: 1. On March 20, 2024, at 1 p.m., a record review and concurrent interview was conducted with the Medical/Surgical/Telemetry Registered Nurse (MST) and the Charge Nurse Manager (CNM). The facility document titled, “History and Physical,” dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker (regulate heart rate and rhythm), hypertension (high blood pressure) and abdomen pain. On March 21, 2024, at 10:24 a.m., Patient 8’s telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was from telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm, “PT [patient] OFF TELE” and on February 20, 2024, at 13:10 (1:10 pm) note on strip, “PT [patient] PUT BACK ON TELE” and on February 20, 2024, at 13:41 (1:41 pm) HR (heart rate) 0. The facility Document titled “CARDIOPULMONARY RECORD,” dated February 20, 2024, was reviewed with the MST. The document indicated, “...Time Arrest [heart stopped pumping] Noted 1310 ...Breathing Assisted ...Time of first assisted ventilation [breathing] 1318 ...Intubation [tube for breathing] time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole [heart stopped pumping] ...Epinephrine ...1314 ...VTACH [irregular heart beat] ... 1317 ...PEA[pulseless electrical activity] ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ...” The facility Document titled “[Facility Name] Expiration Record” dated February 20, 2024, was reviewed with the MST. The document indicated, “...Notification of Death...Date/Time Death 0220/24 13:55...Pronounced By... [Medical Physician Name] ...Autopsy...No...” The facility Document titled “Progress Note-Nurse,” dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, “...1240 primary RN [Registered Nurse] left the room...patient was complaining about left neck pain and LLE [left lower extremity] pain...@1256...tele monitor record, the monitor was off from the patient...RN or charge nurse did not receive phone call or notification from telemetry...1305 [1:05 p.m.]...went in to room because family noticed something was wrong...patient was barely responding...1308 [1:08 p.m.] Called code rapid...1310 [1:10 p.m.] called code blue...1335 [1:35 p.m.] daughter asked to stop chest compressions...declared of patient’s decease...” On March 20, 2024, at 2:19 p.m., an interview was conducted with the Telemetry Technician (TT) 2. TT 2 stated they are responsible for watching 60 or more patients at a time. The TT 2 stated she just finished printing the 12 p.m. strips and was documenting the information in the computer. The TT 2 stated it can take an hour to an hour and a half to print and put in the computer. The TT 2 stated she was distracted while doing the strips and probably did not notice Patient 8 was off when she glanced over at the monitors. The TT 2 stated while putting the information in the computer she glances over at the screens every few minutes to make sure no one is off. The TT 2 stated she did not call the nurse or call a rapid for Patient 8. On March 21, 2024, at 9:30 a.m., an interview was conducted with the Manager of Med/Surg/Tele (MOMST). The MOMST stated the nurse was at the bed side and Patient 8 was restless and wanting to be turned. The MOMST stated Patient 8’s leads were off as noted on the strip. 2. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the Director of Med/Surge/Tele (DMST). The “History and Physical,” dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention. The facility document titled, “Modified Early Warning Score ([MEWS] -parameters to identify patients at an increased risk of catastrophic deterioration),” dated February 24, 2024, at 23:02 (11:02 p.m.), was reviewed. The documented indicated, “...4 (HI)... (score of 3-4 requires extra attention)” The DMST stated a score of four was high and indicated the patient met a higher risk of deterioration. The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 00:00 (12 a.m.), was reviewed. The documented indicated, “...Rounded on patient around 0000 [12 a.m.] d/t [due to] elevated MEWs score...Rapid response and code blue (patient requiring resuscitation [reviving someone from apparent death]) was called approximately 1 [one] hour after d/t patient being found unresponsive...” On March 19, 2024, at 10:24 a.m., Patient 19’s telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m., were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient’s chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19’s electronic health record: -February 24, 2024, at 1600 (4 p.m.), -February 24, 2024, at 2000 (8 p.m.), -February 25, 2024, at 0000 (12 a.m.). The facility document titled, “CARDIOPULMONARY RECORD,” dated February 25, 2024, was reviewed with the DMST. The document indicated, “...Time of Arrest Noted: 0104 (1:04 a.m.) ...Time of first assisted ventilation(breathing): 0105 (1:05 a.m.) ...compressions 0106 (01:06 a.m.) ...Rhythm...0129 (1:29 a.m.) ...code ended...pea (pulseless electrical activity) ...” The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 2:57 a.m., was reviewed with the DMST. The document indicated, “...0104 [1:04 a.m.] ...Call received from monitor tech patient [Patient 19] heart rate dropping to 30’s. Was attending to another patient [Charge Nurse Name] went to the room and found patient not breathing and initiated CPR [cardiopulmonary resuscitation] ...0105 am [1:05 a.m.] ...Code Blue [patient requiring resuscitation-reviving someone from apparent death] called and team at bedside...” The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 documented February 24, 2024, from 01:04:10 [1:04 & 10 seconds] to February 24, 2024, at 01:05:00 [1:05 a.m.], page 3/3 documented February 24, 2024, at 01:05:10 [1:05 & 10 seconds] to February 24, 2024, at 01:05:40 [1:05 & 40 seconds a.m.]. There was no documented evidence of Patient 19’s cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 was not scanned into Patient 19’s medical record. The DMST stated pages 1/3 were not scanned and could not be recovered. On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19. On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. TT 1 stated one telemetry technician can be responsible for monitoring up to 60 patients at one time. The TT 1 stated the telemetry monitors are set to show bradycardia (slow heart rate) at 50 beats per minute (BPM) or less. The TT 1 stated the registered nurse is alerted of any sudden changes. The TT 1 stated if a patient’s heart rate went from 101 to 30 there was something wrong, there is a gap, the strip page 1/3 should have been printed and placed in the chart. The TT 1 stated the old log was simple, and the TT 1 only logged when the patient was off telemetry and not when cardiac changes were identified. The TT 1 further stated if a patient’s rhythm was Atrial Fibrillation (A Fib [irregular heartbeat]) then changed to bradycardia, the RN would be called and if they did not answer the TT would call a rapid response because this event is not normal. On March 21, 2024, at 9:45 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she received a call but was in an isolation room and did not answer it. She further stated after the phone call she heard the rapid response called overhead for Patient 19. She stated Charge Nurse (CN) 2 responded to the rapid response then called a code blue. On March 21, 2024, at 10:59 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated telemetry technician (tele tech) logs prior to March 2024 were vague and only identified when the patient was off telemetry, batteries were low, or when the patient was moved from one room to another. She further stated the log did not identify any patient cardiac changes. CN 1 stated the tele tech logs were discarded after a few days. On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed. A review of the policy and procedure (P&P) titled, “Management of Telemetry Alarms - 1293,” dated November 2023, was conducted. The P&P indicated, “...The telemetry monitor technician will monitor and respond to the telemetry monitor alarms for all cardiac monitored inpatient areas...All alarms are considered high risk and the telemetry monitor technician will immediately notify the registered nurse, who must respond immediately...Life-threatening rhythms...the monitor tech will initiate a Code Blue...then document the rhythm and notification on the telemetry band...Non-life-threatening rhythms:...telemetry tech will follow the Tele-escalation process...and document rhythm and notification on the telemetry band...” A review of the policy and procedure (P&P) titled, “Telemetry Monitoring Remote,” dated November 2023, was conducted. The P&P indicated, “...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient’s nurse of any dysrhythmias. Rhythm strips will be entered in the patients medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm and HR and PRI, QRS, and QT measurements, as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips...Monitor Technicians will monitor response time of staff in responding to telemetry alarms every shift utilizing the Response Time to Telemetry Alarm Audit Tool...The telemetry technician will follow the Telemetry Escalation Process anytime a patient...a lethal rhythm is identified, and/or alarms warrant notification of the RN...” Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for two of 31 sampled patients (Patients 8 and 19), when: 1. Patient 8 was not continuously monitored on the telemetry and not recognizing and reporting cardiac changes. This failure resulted in a delay of treatment for Patient 8 and could have contributed to Patient 8’s death. 2. Patient 19 had multiple episodes of low heart rate which were not addressed. This failure resulted in the delay of treatment for Patient 19 and could have contributed to patient 19’s death. 1. On March 20, 2024, at 1 p.m. a record review and concurrent interview was conducted with the MST and CNM. The facility document titled, “History and Physical,” dated February 17, 2024, indicated Patient 8 was admitted to the facility February 17, 2024, with diagnoses of newly placed pacemaker (regulate heart rate and rhythm), hypertension (high blood pressure) and abdomen pain. On March 21, 2024, at 10:24 a.m., Patient 8’s telemetry strips for February 20, 2024, at 12:56 p.m. to February 20, 2024, at 13:41 (1:41 p.m.) were reviewed with the MST. The strips indicated Patient 8 was off of telemetry from 12:56 a.m. to 1:10 pm. Strips indicated on February 20, 2024, at 12:56 pm, “PT [patient] OFF TELE” and on February 20, 2024, at 13:10 (1:10 pm) note on strip, “PT [patient] PUT BACK ON TELE” and on February 20, 2024, at 13:41 (1:41 pm) HR (heart rate) 0. The Facility Document titled “CARDIOPULMONARY RECORD” dated February 20, 2024, was reviewed with the MST. The document indicated, “...Time Arrest [heart stopped pumping] Noted 1310 ...Breathing Assisted ...Time of first assisted ventilation [breathing] 1318 ...Intubation [tube for breathing] time 1318 ...1311 ...Breathing Assisted ...Pulse ...Compressions ...Rhythm ...Asystole [heart stopped pumping] ...Epinephrine ...1314 ...VTACH [irregular heart beat] ... 1317 ...PEA[pulseless electrical activity] ...1329 ...Breathing ...Assisted ...Blood Pressure 136/75 ...Rhythm ST ...1334 ...Rhythm Asystole ...1335 ...Rhythm Asystole ...” The Facility Document titled “[Facility Name] Expiration Record” dated February 20, 2024, was reviewed with the MST. The document indicated, “...Notification of Death...Date/Time Death 0220/24 13:55...Pronounced By...[Medical Physician Name]...Autopsy...No...” The facility Document titled “Progress Note-Nurse” dated February 20, 2024, at 1830 (6:30 p.m.) was reviewed with the MST. The document indicated, “...1240 primary RN left the room...patient was complaining about left neck pain and LLE [left lower extremity] pain...@1256...tele monitor record, the monitor was off from the patient...RN or charge nurse did not receive phone call or notification from telemetry...1305 [1:05 p.m.]...went in to room because family noticed something was wrong...patient was barely responding...1308 [1:08 p.m.] Called code rapid...1310 [1:10 p.m.] called code blue...1335 [1:35 p.m.] daughter asked to stop chest compressions...declared of patient’s decease...” On March 20, 2024, at 2:19 p.m., an interview was conducted with the Telemetry Technician (TT) 2. TT 2 stated they are responsible for watching 60 or more patients at a time. The TT 2 stated she just finished printing the 12 p.m. strips and was documenting the information in the computer. The TT 2 stated it can take an hour to an hour and a half to print and put in the computer. The TT 2 stated she was distracted while doing the strips and probably did not notice Patient 8 was off when she glanced over at the monitors. The TT 2 stated while putting the information in the computer she glances over at the screens every few minutes to make sure no one is off. The TT 2 stated she did not call the nurse or call a rapid for Patient 8. On March 21, 2024, at 9:30 a.m., an interview was conducted with the Manager of Med/Surg/Tele (MOMST). The MOMST stated the nurse was at the bed side and Patient 8 was restless and wanting to be turned. The MOMST stated Patient 8’s leads were off as noted on the strip. 2. On March 19, 2024, at 9:30 a.m., an interview and concurrent record review of Patient 19 was conducted with the Director of Med/Surge/Tele (DMST). The “History and Physical,” dated February 25, 2024, indicated Patient 19 was admitted to the facility on February 23, 2024, with diagnoses of hypertension, CKD (chronic kidney disease), lower extremity edema (swelling of legs), shortness of breath on exertion and abdominal distention. The facility document titled, “Modified Early Warning Score ([MEWS] -parameters to identify patients at an increased risk of catastrophic deterioration),” dated February 24, 2024, at 23:02 (11:02 p.m.), was reviewed. The documented indicated, “...4 (HI)...(score of 3-4 requires extra attention)” The DMST stated a score of four was high and indicated the patient met a higher risk of deterioration. The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 00:00 (12 a.m.), was reviewed. The documented indicated, “...Rounded on patient around 0000 [12 a.m.] d/t [due to] elevated MEWs score...Rapid response and code blue (patient requiring resuscitation [reviving someone from apparent death]) was called approximately 1 [one] hour after d/t patient being found unresponsive...” On March 19, 2024, at 10:24 a.m., Patient 19’s telemetry strips for February 24, 2024, at 12 a.m. to February 25, 2024, at 01:29:10 a.m. were reviewed with the DMST. The DMST stated telemetry strips were printed, reviewed, signed, and placed in the patient’s chart by the registered nurse at 0000 (12 a.m.), 0400 (4 a.m.), 0800 (8 a.m.), 1200 (12 p.m.), 1600 (4 p.m.), 2000 (8 p.m.). The following strips were not found in Patient 19’s electronic health record: -February 24, 2024, at 1600 (4 p.m.), -February 24, 2024, at 2000 (8 p.m.), -February 25, 2024, at 0000 (12 a.m.). The facility document titled, “CARDIOPULMONARY RECORD,” dated February 25, 2024, was reviewed with the DMST. The document indicated, “...Time of Arrest Noted: 0104 (1:04 a.m.)...Time of first assisted ventilation(breathing): 0105 (1:05 a.m.)...compressions 0106 (01:06 a.m.)...Rhythm...0129 (1:29 a.m.)...code ended...pea (pulseless electrical activity)...” The facility document titled, “Progress Note-Nurse,” dated February 25, 2024, at 2:57 a.m., was reviewed with the DMST. The document indicated, “...0104 [1:04 a.m.]...Call received from monitor tech patient [Patient 19] heart rate dropping to 30’s. Was attending to another patient [Charge Nurse Name] went to the room and found patient not breathing and initiated CPR [cardiopulmonary resuscitation]...0105 am [1:05 a.m.]...Code Blue [patient requiring resuscitation-reviving someone from apparent death] called and team at bedside...” The DMST stated the telemetry strips were printed when cardiac events or change of rhythm occurred. The telemetry strips for February 25, 2024, prior to code blue were reviewed. There were three pages of strips printed prior to Patient 19 coding. Page 2/3 documented February 24, 2024, from 01:04:10 [1:04 & 10 seconds] to February 24, 2024, at 01:05:00 [1:05 a.m.], page 3/3 documented February 24, 2024, at 01:05:10 [1:05 & 10 seconds] to February 24, 2024, at 01:05:40 [1:05 & 40 seconds a.m.]. There was no documented evidence of Patient 19’s cardiac rate decline prior to 1:04 and 10 seconds a.m. Page 1/3 was not scanned into Patient 19’s medical record. The DMST stated pages 1/3 were not scanned and could not be recovered. On March 20, 2024, at 3:03 p.m., an interview was conducted with the DMST. The DMST stated the telemetry monitor technician logs for February 24, 2024, through February 25, 2024, have not been found. The DMST stated any time a patient is not a DNR (do not resuscitate) the death would be considered unexpected. The DMST further stated any death not expected would be reviewed by the unit director. The DMST further stated a root cause analysis (RCA) was not completed for Patient 19. On March 21, 2024, at 9 a.m., an interview was conducted with Telemetry Technician (TT) 1. TT 1 stated one telemetry technician can be responsible for monitoring up to 60 patients at one time. The TT 1 stated the telemetry monitors are set to show bradycardia (slow heart rate) at 50 beats per minute (BPM) or less. The TT 1 stated the registered nurse is alerted of any sudden changes. The TT 1 stated if a patient’s heart rate went from 101 to 30 there was something wrong, there is a gap, the strip page 1/3 should have been printed and placed in the chart. The TT 1 stated the old log was simple, and the TT 1 only logged when the patient was off telemetry and not when cardiac changes were identified. The TT 1 further stated if a patient’s rhythm was Atrial Fibrillation (AFib [irregular heart beat]) then changed to bradycardia, the RN would be called and if they did not answer the TT would call a rapid response because this event is not normal. On March 21, 2024, at 9:45 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she received a call but was in an isolation room and didn’t answer it. She further stated after the phone call she heard the rapid response called overhead for Patient 19. She stated Charge Nurse (CN) 2 responded to the rapid response then called a code blue. On March 21, 2024, at 10:59 a.m., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated telemetry technician (tele tech) logs prior to March 2024 were vague and only identified when the patient was off telemetry, batteries were low, or when the patient was moved from one room to another. She further stated the log did not identify any patient cardiac changes. CN 1 stated the tele tech logs were discarded after a few days. On March 21, 2024, at 12:05 p.m., an interview was conducted with the Director of Quality (DOQ) and the Chief Nursing Officer (CNO). The DOQ stated there was no root cause analysis completed for Patient 19. The DOQ stated no telemetry log was available because they were discarded after a few days. She further stated the logs that were in place prior to March 2024, only had information of when the patient was off telemetry or when the patient was moved to another room or went off the floor. The CNO stated an event review would have been beneficial, but it was not done. She further stated it should have been done after Patient 19 died to see if there was a trend that was missed. A review of the policy and procedure (P&P) titled, “Management of Telemetry Alarms - 1293,” dated November 2023, was conducted. The P&P indicated, “...The telemetry monitor technician will monitor and respond to the telemetry monitor alarms for all cardiac monitored inpatient areas...All alarms are considered high risk and the telemetry monitor technician will immediately notify the registered nurse, who must respond immediately...Life-threatening rhythms...the monitor tech will initiate a Code Blue...then document the rhythm and notification on the telemetry band...Non-life-threatening rhythms:...telemetry tech will follow the Tele-escalation process...and document rhythm and notification on the telemetry band...” A review of the policy and procedure (P&P) titled, “Telemetry Monitoring Remote,” dated November 2023, was conducted. The P&P indicated, “...To ensure patient safety and to provide a clear process for monitoring of patients on telemetry...The Monitor Technician will alert the patient’s nurse of any dysrhythmias. Rhythm strips will be entered in the patients medical record...Each Monitor Technician will monitor 30-60 monitors and will analyze, run and input the rhythm and HR and PRI, QRS, and QT measurements, as applicable into the medical record for every patient...Rhythm Strips & Documentation - For step down and telemetry level of care, monitor technicians will run the strips and interpret them...Monitor Technicians or Registered Nurses documents the rhythm...in the electronic medical record the 0800/2000, 1200/0000, and 1600/0400 strips...Monitor Technicians will monitor response time of staff in responding to telemetry alarms every shift utilizing the Response Time to Telemetry Alarm Audit Tool...The telemetry technician will follow the Telemetry Escalation Process anytime a patient...a lethal rhythm is identified, and/or alarms warrant notification of the RN...””