Salinas Valley Health Medical Center

“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: 44577 Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 5) was given the opportunity to participate in their plan of care when Patient 5 was not provided information regarding her observation admission status. This deficient practice had violated Patient 5’s right to receive effective communication and to be informed, as well as actively participate in the plan of care. Additionally, this deficient practice had the potential to result in Patient 5’s compromised care and emotional harm. Findings: During a concurrent interview and record review on 1/27/26 at 1:30 p.m. with the Cheif Nursing Officer (CNO), the CNO reviewed the medical records (MR) of Patient 5. The MR indicated Patient 5 was seen in the Emergency Department (ED) 9/17/25, 9/24/25, 10/6/25 and 10/16/25. On 10/16/25 Patient 5 was admitted for UTI (Urinary tract infection), dehydration and failure to thrive. Location was Med/Surg 1(a medical surgical inpatient bed). Discharged 10/19/25, discharge instructions dated 1/19/26 at 12:45 p.m. indicated home care referrals included OT (Occupational therapy)/PT (Physical therapy) and RN referrals. Review of case management note dated 10/19/25 at 10:02, indicated ...met with patient who is under observation care ...discussed plan for discharge ... patient became upset stating she was told she could go the SNF (Skilled Nursing Facility) ... During an interview on 1/27/26 with the CNO, the CNO stated, [Patient 5] placed a grievance online on 10/20/25, she wanted to be discharged to a SNF but did not qualify based on observation admission, and she was sent a letter 10/22/26 closing the grievance. During a concurrent interview and record review on 2/2/25 at 10:43 a.m. with the CNO reviewing Patient 5’s signed Condition of admission (COA) dated 10/16/25 at 10:39 p.m., there is no indication that the admission was an observation admission. During an interview on 2/2/25 at 10:50 a.m. with the Director of Case Management (DCM), the DCM stated , “She should have received the information”. The DCM was not able to provide a copy of the signed document that Patient 5 was aware the admission status was observation. Concurrent review of the observation form titled “Medicare Outpatient Observation Notice” (MOON) indicated that , “Being an outpatient may affect what you pay in a hospital” ... If you need skilled nursing facility care (SNF) after you leave the hospital , Medicare Part A will only cover SNF care if you have had a 3 day minimum, medically necessary, inpatient hospital stay ...”. There was no evidence Patient 5 received the MOON documentation that made her aware it would affect her admission status payment and potential discharge to a SNF. During review of the facility’s policy and procedure (P&P) titled, “Conditions of Treatment/Admission” dated 7/1/24, indicated, “The Condition of Admissions (COA) establishes the conditions under which a patient is treated/admitted for all services ... At the time of the preadmission/registration/admission it is expected that the Registration clerk will explain the COA and obtain the appropriate signature ...”. During review of the facility’s policy and procedure (P&P) titled, “Rights and Responsibilities of Patients” dated 10/6/23, indicated, “1. Each patient has the following rights: ...have the right to effective communication and to participate in the development and implementation of your plan of care. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure ...”. During review of the facility’s policy and procedure (P&P) titled, MOON Delivery Procedure”, undated, indicated “The Medicare Outpatient Observation Notice (MOON) is a standardized notice provided to all Medicare beneficiaries when they are an outpatient receiving observation services for more than 24 hours. The MOON must be provided between the 24th hour and the 36th hour after observation services are initiated, or as soon as there is indication the patient will be in observation status for at least 24 hours. An oral explanation of the notice must be provided at the time the notice is delivered. A signature must be obtained from the Medicare beneficiary or from the individual qualified to act on their behalf, to acknowledge receipt of the notice and understanding of the information”.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 44577 Based on interview and record review, the facility failed to meet the emergency needs of two of 30 sampled patients (Patient 4 and Patient 11) in accordance with acceptable standards of care when Patient 4 and Patient 11 presented to the emergency department (ED, emergency department, also known as an emergency room (ER), is a specialized hospital facility operating 24/7 to provide immediate care for acute, life-threatening, or severe medical conditions): 1. For Patient 4; the Emergency Department (ED) failed to provide ongoing and continuing assessment (the process of gathering, analyzing, and interpreting information about a patient’s health status through assessment of their physical body and mental health) of care provided. 2. For Patient 11; the Emergency Department failed to provide initial and ongoing assessments by the registered nurse (RN) therefore injuries and worsening symptoms were not assessed or escalated to the physician, potently resulting in Patient 11 needing to return to the ED. These failures in emergency room standards of care had the potential to result in increased risk of illness or injury to patients receiving care in the ED. Findings: 1. During a concurrent interview and chart review on 1/27/26 at 1:25 p.m. with the Chief Nursing Officer (CNO), the Emergency Department (ED) records dated 7/27/24 were reviewed. The ED record indicated Patient 4 was seen in the ED on 1/27/26 for vaginal bleeding, possible miscarriage. Patient 4 had labs, an ultrasound and pelvic exam completed. Review of nursing assessment indicated, Patient 4 had VS (vital signs) done at 9:17 a.m., 10:58 a.m., 12:31 p.m. and 3:28 p.m. there was no evidence of reassessment of pain or evaluation of bleeding after the pelvic exam. The EDMD (Emergency Department Medical Doctor) provider note indicated a pelvic exam was done and some products of conception were removed. The ultrasound result indicated, a heart rate of 138 and findings concerning for a miscarriage in progress. There was no evidence indicating there was a chaperone (A medical exam chaperone procedure ensures a trained staff member-acting as an impartial witness-is present during sensitive examinations e.g., breast, pelvic, genital, rectal to safeguard patient dignity, comfort, and safety. It provides emotional support, ensures professional boundaries, and allows for chaperones of a specific gender) during the pelvic exam (pelvic examination is a brief, routine physical examination of the female reproductive organs-including the vulva (female external genitals), vagina, cervix, uterus, and ovaries-used to check for infections, chronic pain, or any abnormalities) or one was offered. Review of the pathology report , dated collected 7/27/24, indicated, “products of conception identified, consists of 2 (two) feet and some limbs” During an interview and concurrent record review on 2/2/26 at 8:58 p.m. with Registered nurse (RN) C , Patient 4’s chart was reviewed. RN C stated a female chaperone [for pelvic exams] is standard, the provider and the chaperone would document. Review of Patient 4’s emergency record indicated, here was no evidence of a nurse/chaperone in the room during the pelvic exam and no evidence of a reassessment done after the pelvic exam. RN C confirmed that no reassessment was completed, stated , “with abnormal bleeding it should be done every 2 hours”. On 2/2/26 at 1:37 p.m. attempt to interview EDMD B, EDMD B refused to be interviewed about the care provided to Patient 4. During an interview on 2/11/26 at 1:18 p.m.with Registered Nurse (RN) A, RN A was advised by the Chief Legal Officer (CLO), not to answer interview questions about care provided to Patient 4 on 7/27/24. During an interview on 2/11/26 at 3:39 p.m. with RN G and RN I, RN G and RN I were advised by the Chief Legal Officer (CLO), not to answer interview questions about care provided to Patient 4 on 7/27/24. During an interview on 2/17/26 at 9:33 a.m. with RN A and RN H together with the CLO present, RN A stated she did not remember Patient 4, she was not the primary nurse. RN H stated “he was handed a cup to take to the lab, he does not know if there was a chaperone in the room. He discharged Patient 4, VS were done but no reassessment or pain assessment done on discharge following the pelvic exam. He was not the primary nurse”. During an interview on 2/17/26 at 10:05 with RN G, RN G stated, “ he does not know who the primary nurse was for Patient 4.” RN G confirmed a focused assessment including pain assessment should have been completed every 2 hours and at discharge. During an interview on 2/17/26 at 10:13 with RN I, RN I stated, “ she was not the chaperone for Patient 4, she does not remember the patient, she does not know who was the primary nurse” During an interview on 2/17/26 at 11:24 with RN J, RN J stated “she was not the chaperone or the primary nurse for Patient 4.” During an interview on 2/17/26 at 10:25 with EDMD B, EDMD B stated, “Attorney recommended not to discuss [Patient 4] with anyone”. During a concurrent interview and record review on 2/19/26 with CNO, 26 additional sample charts were reviewed with diagnosis for potential pelvic exams. During review of Patient 48’s Emergency Department record, dated 2/28/25, the EDMD B provider notes indicated a pelvic exam was performed, there was no orders or evidence a chaperone was offered or provided. During review of Patient 51’s Emergency Department record, dated 10/29/25, the EDMD B provider notes indicated a pelvic exam was preformed, there was no orders or evidence a chaperone was offered or provided. During an interview on 2/20/26 at 9:52 am with the Medical Director of Pathology (MDP), the MDP stated, “Advised not to answer questions specific to Patient 4”. During an interview on 2/20/26 with OB Hospitalist (OBH), the OBH stated, “for consults we are available to come to the ED to see a patient if needed, procedures are done in the OR if clinically indicated. During an interview on 2/20/26 at 12:00 with the Medical Director of Radiology (MDR), the MDR stated, “Can not answer specific questions about Patient 4”. During an interview on 2/20/26 at 12:32 p.m. with EDMD B, EDMD B stated. “Scribe is supposed to document chaperone; I do not know nursing documentation. There is an order for pelvic set exam/setup in general use the order or tell the nurse”. ERMD B would not answer interview questions about Patient 4. During a review of the facility’s policy & procedure titled, “Vaginal Bleeding Nursing Standardized Procedure”, dated 7/26/24, indicated, “Reassessment and reevaluation of vaginal bleeding every two hours or more frequency according to the patient severity and amount of vaginal bleeding ...” 2. During a concurrent interview and record review on 1/28/26 at 3:36 p.m. with the CNO the medical record dated 1/24/26 for Patient 11 was reviewed. The ED MR indicated Patient 11 was admitted on 1/24/26 for complaints of back pain and not able to get out of bed post (after) a fall 9 days prior. Patient 11 was seen in the ED 1/21/26. ED physician documentation indicated: pain on percussion to the thoracic spine and right posterior ribs. Tenderness over the bony prominences”. CT chest , dated 1/24/26 indicated, “ multiple rib fractures [1,7,8,9,10] and a small hemothorax (serious medical condition characterized by the accumulation of blood in the pleural cavity-the space between the chest wall and the lungs) “. Patient 11 was admitted to the Hospital. During a concurrent interview and record review on 1/29/26 at 10:43 Patient 11 ED record from 1/21/26 [1st visit] was reviewed, the ED record indicated Patient 11 was seen in the Emergency Department on 1/21/26 at 10:31 p.m. and 1/24/26 at 3:05 p.m. Review of the 1/21/26 visit indicated Patient 11’s chief complaint was high blood pressure for the last three days and a recent fall on her side. Patient 11 has a history of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), she was there with her daughter. Patient’s chest X-ray dated 1/22/26 at 2:07 a.m. indicated a moderate left sided pleural effusion (the abnormal accumulation of fluid within the pleural space, the thin cavity between the pleural layers surrounding the lungs). There was no evidence that the nursing staff completed an assessment on Patient 11 on the first visit . There was no evidence the Medical Provider evaluated Patient 11 for rib pain or tenderness on the first visit. During a concurrent interview and record review on 1/29/26 at 11:13 with Registered nurse A, the MR, dated 11/21/26 was reviewed. The nursing assessment dated 1/21/26 was not completed, RN A stated the assessment [documentation] is red indicating it was not completed. During an interview on 1/29/26 at 1:42 p.m. with Emergency Department physician (EDMD) D, EDMD D stated, “[chest] X-ray showed no fracture, I listened to her heart and lungs and do not remember if there was pain or tenderness.” There is no evidence documented that Patient 11’s rib/chest were assessment. During an interview on 2/2/26 at 8:29 a.m. with RN C and RN E, RN C stated the “front end nurse does the primary and focused assessment and once in a formal treatment are the primary nurse completes the other needed documentation”. During a concurrent review of Patient 11 ED nursing assessments dated 1/21/26, Patient 11’s chart had no indication that a primary or focused assessment was completed. During a review of the facility’s Registered Nurse Job description, dated November 1, 2024, indicated, “Primary Job Duties 1. Completes nursing assessment of patients, and documents appropriately into patient record. 2. Develops a plan of care based upon the assessment of patient, age appropriate and developmental needs of the patient. 3. Collaborates with physicians and other health team members in developing a plan of care.” During a review of the facility’s policy & procedure titled, “Standards of Care-Emergency Department”, dated 3/7/25, indicated, “Reassessment ESI level 3 every 2 hours to 4 hours or more frequency as patient condition warrants. All patients should be reassessed after interventions, ...””

“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: 44577 Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: 1. The facility failed to maintain an accurate and complete patient log. (Refer to A/C 2405) 2. The facility failed to ensure that two of seven patients’ emergency transfer information were completed or included summary of the specific risks or benefits of transfer (Patients 6, and 20). (Refer to A/C 2409)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44577 Based on interviews, and record review, the hospital failed to comply with the regulatory requirements for EMTALA when: A patient that arrived at the ambulance bay (driveway) requesting assistance getting in to the Emergency Department was not placed on the Emergency Log and not provided a medical screening exam (MSE). This deficient practice can impede the facility’s ability to track the care provided to the patient who visits the ED seeking emergency medical care. Findings: During an interview on 12/12/24 at 10:27 a.m. with the Director of Accreditation and Regulatory (DAR), the DAR stated, the Patient “came to the ambulance bay, but decided not to stay when the clinical assistant (CA) went out to assist, I do not know the patient’s name. They are not on the log”. During an interview on 12/12/24 at 2:30 p.m. with the Clinical Assistant (CA) the CA stated, “Security came to the tent for help, I exited the tent, spoke to the female driver, she said we are going to Hospital B and asked for directions”. During an interview on 12/13/24 at 9:29 a.m. with the Security Officer (SO), the SO stated “They [the patient] pulled into the ambulance bay, said he was a transplant patient and needed to get to the ED”. Said he would get someone to help, went to the tent said someone outside is a transplant pt, can someone help me.” Review of the ED event timeline provided by security on 12/13/24 at 10:00 a.m. ED Event Timeline indicated the vehicle arrived on 12/2/24 at 00:59, the security officer encounter with vehicle was 49 seconds, SO then went to the tent for assistance, the SO returned with the ED staff, the ED staff encountered the vehicle at 1:01:54 a.m. The vehicle left the property at 1:02:28 a.m. 34 seconds later. During an interview on 12/13/24 at 2:02 p.m. with the Director of the Emergency Department (DED), “Charge nurse was not aware of the patient”. Review of the Hospitals policy “The Emergency Medical Treatment and Active Labor Act {EMTALA), dated 1/2024, indicated, Purpose: To define and describe how Salinas Valley Health Medical Center (SVHMC) will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... K. HOSPITAL PROPERTY means the entire main Hospital campus, including areas and structures that are located within 250 yards of the main buildings, ... Hospital property includes the parking lots, sidewalks, and driveways on the main Hospital campus.. A. SCOPE OF EMTALA: 1. EMTALA is applicable to any individual who “comes to the emergency department” seeking or needing an examination or treatment. C. CENTRAL LOG: Each dedicated emergency department of SVHMC will maintain a central log recording the names of individuals who come to the emergency department. The central logs will record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by SVHMC or whether the individual was transferred, admitted, and treated, stabilized and transferred or discharged.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44577 Based on interview, and record review the facility failed to obtain a completed transfer request on two of seven sampled transferred patient’s (patient’s 6, and 20) when: 1. Patient 6’s transfer record lacked documentation of the receiving hospital’s name, person accepting the transfer, the date and time of notification and the acknowledgment the patient was informed of the reason for transfer. 2. Patient 20’s transfer record lacked documentation that indicated the medical condition had been stabilized or not stabilized, risks and benefits, receiving facility, person accepting, reason for transfer including dates and times and mode of transport. These deficient practices placed the health of patients at risk. Findings: Review of Patient 6’s ED notes, dated 9/27/24, indicated Patient 6 was brought to the Emergency Department for suicidal ideations (wanting to harm themselves) and using drugs. They were medically cleared, placed on a 5150 legal hold and transferred to an inpatient psychiatric facility. Review of Patient 6’s transfer documents, dated 9/27/24, had no indication that they were informed of the reasons for the transfer. Review of Patient 20’s Emergency Department notes, dated 12/11/24, indicated Patient 20 was brought to the Emergency Department (ED) for shortness of breath. Patient 20 was evaluated and treated, it was determined that Patient 20 needed to be transferred to a higher level of care for admission. Review of Patient 20’s Transfer documents, dated 12/11/24, had no indication of the patient’s status, risks, and benefits, receiving facility, person accepting, reason for transfer including dates and times and mode of transport. During an interview with Director of the Emergency Department (DED), on 12/13/24 at 2:15 p.m. the DED acknowledged, “all of the transfer documents were to be completed prior to the patient being transferred to another facility.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46939 Based on interview and record review the hospital failed to implement care plan interventions for two of 30 sampled patients (Patient 1 & Patient 12) when: 1. Staff failed to document required repositioning of Patient 1 from 10/5/24 2038-10/6/24 2038 (24 hour period) 2. Staff failed to document implementation of Patient 12’s Sequential Compression Device (SCD-a mechanical device that helps prevent blood clots and improve circulation in the legs) until over 13 hours after the order was placed by the Physician These failures had the potential for Patient 1’s pressure injury (is localized damage to the skin and underlying soft tissue, caused by prolonged or intense pressure, shear, or friction forces) to worsen, and had the potential for Patient 12 to develop blood clots in the lower legs. Findings: 1. During a review of Patient 1’s “Wound Care Instruction” dated 9/25/24, instruction indicated, Patient 1 had multiple pressure injuries. Instruction indicated, “Location #1 Coccyx [the last bone at the bottom of the spine] . . .OFF LOAD [a method of preventing and treating pressure injury/ulcers by reducing or removing weight from a wounded area by repositioning] AT all times”. During a review of Patient 1’s Plan of Care dated 9/25/24, Plan of Care indicated, “Skin-Care . . . Turn Q 2 [every 2] Hours”. During a review of Patient 1’s Flowsheet titled “Reposition Patient Every 2 Hrs” dated 9/25/24-10/8/24 flowsheet indicated, no documentation Patient 1 was turned after 10/5/24 at 1838. During a review of Patient 1’s “Physical Therapy Evaluation” dated 10/4/24 Evaluation indicated, “Overall Bed Mobility Ability: Moderate assistance, Maximum Assistance”. Evaluation indicated, “How much difficulty does the pt [patient] have now -Turning over in bed: A lot (Max/Mod Assist) [maximum to moderate assistance required]”. During an interview on 11/6/24, at 10:15 a.m., with Chief Nursing Officer (CNO) CNO stated, there was no documentation Patient 1 was turned every 2 hours on 10/6/24 or after. During an interview on 11/7/24, at 9:11 a.m., with the Accreditation & Regulatory Coordinator (ARC) , the ARC stated, there was no documentation that Patient 1 refused to be turned at any time on 10/6/24 or after. During a review of the hospitals policy and procedure (P&P) titled, “Skin Assessment, Pressure Injury-Identification, Prevention and Treatment” dated 2024, the P&P indicated, “. Turn patient and document positioning at least every two hours”. 2. During a review of Patient 12’s Care Plan dated 11/6/24, Care Plan indicated, “Mobility impaired. . .outcome optimize mobility. . .Intervention VTE Mechanical Device [SCDs]”. During a review of Patient 12’s Order titled, “VTE Mechanical Device” dated, 11/6/24 at 19:14, order indicated, Patient 12’s Physician made an order for the use of “Sequential Stockings [SCDs}”. During a review of Patient 12’s “Care Assessment” flowsheet dated 11/7/24, flowsheet indicated, the SCD device was not applied to Patient 12 until 11/7/24 at 08:58 (over 13 hours after ordered by Physician). During an interview on 11/7/24, at 10:16 a.m., with the ARC, the ARC stated, the first documentation of the SCD being placed on Patient 12 was on 11/7/24 at 0858. ARC stated, the order for the SCD was placed on 11/6/24 at 1914. The ARC confirmed, there was no documentation that Patient 12 refused the SCD. During a review of the hospitals procedure titled “VTE Prevention” undated, procedure indicated, “VTE Mechanical devices should be on continually except when ambulating or bathing”.”