John F Kennedy Memorial Hospital

“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: 50433 Based on interview and record review, the facility failed to comply with the provisions in 42 CFR at §489.20, and §489.24, when it failed to stabilize and appropriately transfer one of 21 sampled patients (Patient 20) who presented to the Emergency Department with a surgical emergency (Refer to A2407 and A2409). This failure resulted in a delay of care and had the potential to result in prolonged hospitalization and death for Patient 20.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 50433 Based on observation and interview, the facility failed to ensure the rights of individuals to examination and treatment was posted in a conspicuous area likely to be noticed in the Emergency Department (ED, a department which provides round the clock immediate, unscheduled care, diagnostic services, and stabilization for seriously ill or injured patients). This failure had the potential for patients seeking care at the ED to not be aware of their rights to treatment. Findings: On March 23, 2026, at 9:51 a.m., a tour of the ED was conducted with the Quality Director (QD) and the ED Manager (EDM). During the tour, the required Emergency Medical Treatment and Labor Act (EMTALA) signage was observed to not be posted. On March 24, 2026, at 12:03 p.m., a second tour of the ED was conducted with the EDM. The required EMTALA signage was observed posted in a location in a hallway with locked double doors past the ED entrance. On March 24, 2026, at 1 p.m., an interview was conducted with the EDM. The EDM stated the location in the hallway past the ED entrance was the only location the EMTALA signage was posted in or near the ED. On March 25, 2026, at 9:44 a.m., an interview was conducted with Patient 21. Patient 21 stated she had been in the ED waiting area for four hours and did not notice nor observe the EMTALA signage posted in the hallway past the ED entrance. A facility policy and procedure (P&P) titled, “EMTALA Policy,” dated June 19, 2025, was reviewed. The P&P indicated, “...Posting Signs...The Hospital must post conspicuously, in the ‘Dedicated Emergency Departments’ and all areas in which individuals routinely present for treatment of emergency medical conditions and wait prior to examination and treatment...””

“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: 50433 Based on interview and record review, the facility failed to provide stabilizing treatment, for one of 21 sampled patients (Patient 20), when surgery was not performed for a perforated gastric ulcer (a medical emergency occurring when an untreated gastroduodenal (pertaining to the stomach or the first part of the intestine) ulcer [painful sores in the stomach lining] erodes completely through the wall of the stomach, allowing acid and food to leak into the abdomen) timely. This failure resulted in delayed treatment for Patient 20 and had the potential for an increased risk of complications, prolonged hospitalization, or death for Patient 20. Findings: On March 24, 2026, at 1:10 p.m., a review of Patient 20’s medical record was conducted with the Emergency Department Manager (EDM). A facility document titled, “ED [Emergency Department, a department which provides round the clock immediate, unscheduled care, diagnostic services, and stabilization for seriously ill or injured patients] Note - Physician - ED Note,” dated January 29, 2026, at 8:25 p.m., was reviewed. The document indicated Patient 20 presented to the ED on January 29, 2026, with a complaint of abdominal pain. The document further indicated on January 29, 2026, at 9:28 p.m., Patient 20 had “ ...intraperitoneal free air [gas in the abdominal space outside the stomach]...gallbladder [an organ in the abdomen] looked inflamed [with pain and swelling]...Case discussed with the on-call general surgeon ...for further treatment and admission...” The document indicated, on January 30, 2026, at 2:43 a.m., “...Contacted [name Facility C]...this patient will be excepted [sic] to the emergency department...” A facility document titled, “Computer Tomography [CT, an imaging procedure],” dated January 29, 2026, was reviewed. The document indicated, “ ...severe inflammatory changes [the body’s immune system responding to injury, infection, or irritation] involving the distal [lower portion] stomach and proximal [upper portion] duodenum [the small intestine located immediately below the stomach] with suspected ill defined gas and fluid collection [a pocket of fluid and air] and moderate free air [the presence of gas outside the stomach and intestines within the abdominal cavity]. Findings are suspicious for perforated gastroduodenal ulcer with suspected adjacent abscess [a swollen area within body tissue, containing an accumulation of pus]...” A facility document titled, “SURGERY AFTER HOURS/WEEKEND ADD-ONS,” dated January 29, 2026, was reviewed. The document indicated, “...Time of Initial Call...2200 [10 p.m.]...Surgery Start DATE/TIME Requested...STAT [immediately or without delay]...Surgery Type...Robotic Ulcer Repair [a minimally invasive surgical procedure used to treat severe, non-healing, or perforated stomach (gastric) and duodenal ulcers]...Notes...DaVinci robot [an advanced robotic-assisted equipment used for minimally invasive surgery] unavailable due to construction. Case cancelled and patient transferred out...” A facility document titled, “Transfer Summary,” dated January 30, 2026, at 3:12 a.m., was reviewed. The document indicated, “ ...REASON FOR TRANSFER...Requires Higher Level of Care [more intensive, structured medical or psychiatric treatment services]...BENEFITS FOR TRANSFER...Obtain level of care/service unavailable at this facility...Service: general surgery - DaVinci Robot ...” A document from Facility C titled, “Emergency Provider Report,” dated January 30, 2026, at 7:36 a.m., was reviewed. The document indicated Patient 20 was tachycardic [high heart rate, normal heart rate is 60 to 100 beats per minute (bpm)] and confused. The document further indicated, “...presented to the emergency department as a transfer from [name of Facility A] with complaint of abdominal pain with findings on CT scans concerning for a perforated gastroduodenal ulcer...I did reach out to surgery as soon as the patient arrived in the emergency department, given the CT scan findings from outside hospital describe a emergent medical condition that requires surgical intervention...They reviewed the CT scan and are planning to take the patient emergently to the OR [operating room] for operative management, given that patient is persistently tachycardic...Given that patient is having a significant abdominal surgery, he will require admission to ICU [Intensive Care Unit, a specialized department within a hospital which provides care for critically ill patients] postoperatively [after a surgery]...The high probability of sudden, clinically significant deterioration in the patient’s condition required the highest level of my preparedness to intervene urgently...” A document from Facility C titled, “General Surgery Consult Note,” dated January 30, 2026, was reviewed. The document indicated, “...On exam patient is guarding [tensing of abdominal wall muscles as a protective response to touch or pain], AMS [altered mental status, a change in brain function, such as confusion or decreased alertness], HR [heartrate] 130s...presented as a transfer from OSH [outside hospital, Facility A] for abd [abdominal] pain...CT scan showed a suspected perforated abd ulcer with pneumoperitoneum [the presence of free are or gas within the abdominal cavity, most commonly indicating a perforated abdominal organ]...and adjacent fluid collection. Surgery team consulted for evaluation and management...Plan: Admit to ICU...OR emergently for exploratory laparotomy [a major surgical procedure involving a large incision in the abdominal cavity to directly examine organs for diagnosis or treatment], repair of gastric ulcer...Patient was ...accepted from [Facility A] with free air, free fluid and sepsis [the body’s extreme life-threatening response to an infection, where the immune system overreacts and begins damaging its own tissues and organs] after a significant delay there. The reason for transfer was ‘lack of a Davinci robot’ by the consulted surgeon...I confirmed findings and recommended emergent surgery...Risk include, but are not limited to bleeding, infection...and, particularly due to the significant delay at the referring hospital, death...” A document from Facility C titled, “Operative Note,” dated January 30, 2026, was reviewed. The document indicated, “...Post-procedure [after a procedure] diagnosis: perforated ulcer...Procedures performed...exploratory laparotomy...abdominal washout [a surgical procedure which cleanses the space around the abdominal organs with warm saline solution]...repair of...ulcer...cholecystectomy [surgical removal of the gallbladder]...temporary abdominal closure with...wound vac [vacuum, a medical device applying suction to a wound to quicken healing]...” On March 25, 2026, at 11:56 a.m., an interview was conducted with General Surgeon (GS) 1. GS 1 stated he remembers Patient 20 had come into the ED with a possible perforated ulcer and he had called the House Supervisor (HS, an experienced staff who acts as the administrative representative for a facility during nights, weekends, or holidays) to prepare the Operating Room (OR) for robotic assisted repair of the ulcer. GS 1 stated he wanted to use the robotic assist because it gives the patient a faster recovery from the surgery. GS 1 stated the HS called him back to inform him the Da Vinci robot was not available. GS 1 stated the next step would be to perform an open surgery (exploratory laparotomy) and it was the only available option at the facility. GS 1 stated it was his understanding Patient 20 would be transferred to [name of Facility B] quickly, and he was not informed of the delay in transfer for Patient 20. GS 1 stated if he had been informed of the delay in the transfer, he would have performed an open surgery on Patient 20. On March 25, 2026, at 8:53 p.m., an interview was conducted with the HS. The HS stated, when he called GS 1 back to inform him the DaVinci robot was not available, he asked GS 1 if the surgery could be done without the DaVinci or if the surgery could wait until the DaVinci robot was available. The HS stated GS 1 told him the surgery needed to be performed STAT and it could only be done with the DaVinci robot. The HS stated the information was relayed to the ED Physician (ED MD) and Patient 20 was flown to [name of Facility C] later in the shift on January 30, 2026. On March 26, 2026, at 9:06 a.m., an interview was conducted with the ED MD. The ED MD stated when he initially spoke with GS 1, GS 1 recommended to admit Patient 20 and he would see the patient as a consult (a request by a treating doctor for a specialist or expert to review a patient’s case, examine them, and provide specific advice or recommendations for care). The ED MD stated he was then told GS 1 could not perform the surgery because he needed the DaVinci robot. The ED MD stated he first called (name of Facility B) and was told they did not have an on-call surgeon with privileges to use the DaVinci robot for surgery. The ED MD stated he called GS 1 back to inform him (name of Facility B) could not perform a DaVinci robot assisted surgery. The ED MD stated a perforated gastric ulcer is a surgical emergency and a delay in surgery could lead to a deterioration [worsening] of the patient and could lead to the patient’s death. On March 26, 2026, at 10:03 a.m., an interview and review of Patient 20’s medical record was conducted with General Surgeon (GS) 2. GS 2 reviewed Patient 20’s CT and stated if he was consulted to see Patient 20, he would take the patient to the OR to perform an open laparotomy [a major surgical procedure involving a large abdominal incision allowing surgeons to directly view organs], wash the abdomen, perform a closure of the perforation, and place a drain [a device used to collect fluid from the abdomen after surgery]. The facility policy and procedure (P&P) titled, “EMTALA Policy,” dated June 19, 2025, was reviewed. The P&P indicated, “...The purpose of this policy is to establish clear guidelines and procedures to ensure the Hospital’s compliance with the Emergency Medical Treatment and Labor Act (EMTALA)...If...it is determined that an individual has an emergency medical condition, the Hospital must...Within the capability and capacity of the staff and facility available at the Hospital (including coverage available through the Hospital’s on-call roster), provide treatment necessary to stabilize the individual...” The facility P&P titled, “Plan for Provision of Patient Care,” dated July 18, 2024, was reviewed. The P&P indicated, “...The plan of the Provision of Care outlines the core processes and care activities necessary to provide access to levels of care and/or disciplines necessary to meet the patients’ needs...Standards of Patient Care...Patients will receive competent, compassionate care in a safe environment...[name of Facility A] Hospital offers a complete range of ancillary services, including:...Surgical Services...Scope of Service: includes all specialties except open-heart surgery, neurology [the branch of medicine focused on the human nervous system], and transplants...””

“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: 50433 Based on interview and record review, the facility failed to provide stabilizing treatment, for one of 21 sampled patients (Patient 20), when surgery was not performed for a perforated gastric ulcer (a medical emergency occurring when an untreated gastroduodenal (pertaining to the stomach or the first part of the intestine) ulcer [painful sores in the stomach lining] erodes completely through the wall of the stomach, allowing acid and food to leak into the abdomen) timely. This failure resulted in delayed treatment for Patient 20 and had the potential for an increased risk of complications, prolonged hospitalization, or death for Patient 20. Findings: On March 24, 2026, at 1:10 p.m., a review of Patient 20’s medical record was conducted with the Emergency Department Manager (EDM). A facility document titled, “ED [Emergency Department, a department which provides round the clock immediate, unscheduled care, diagnostic services, and stabilization for seriously ill or injured patients] Note - Physician - ED Note,” dated January 29, 2026, at 8:25 p.m., was reviewed. The document indicated Patient 20 presented to the ED on January 29, 2026, with a complaint of abdominal pain. The document further indicated on January 29, 2026, at 9:28 p.m., Patient 20 had “ ...intraperitoneal free air [gas in the abdominal space outside the stomach]...gallbladder [an organ in the abdomen] looked inflamed [with pain and swelling]...Case discussed with the on-call general surgeon ...for further treatment and admission...” The document indicated, on January 30, 2026, at 2:43 a.m., “...Contacted [name Facility C]...this patient will be excepted [sic] to the emergency department...” A facility document titled, “Computer Tomography [CT, an imaging procedure],” dated January 29, 2026, was reviewed. The document indicated, “ ...severe inflammatory changes [the body’s immune system responding to injury, infection, or irritation] involving the distal [lower portion] stomach and proximal [upper portion] duodenum [the small intestine located immediately below the stomach] with suspected ill defined gas and fluid collection [a pocket of fluid and air] and moderate free air [the presence of gas outside the stomach and intestines within the abdominal cavity]. Findings are suspicious for perforated gastroduodenal ulcer with suspected adjacent abscess [a swollen area within body tissue, containing an accumulation of pus]...” A facility document titled, “SURGERY AFTER HOURS/WEEKEND ADD-ONS,” dated January 29, 2026, was reviewed. The document indicated, “...Time of Initial Call...2200 [10 p.m.]...Surgery Start DATE/TIME Requested...STAT [immediately or without delay]...Surgery Type...Robotic Ulcer Repair [a minimally invasive surgical procedure used to treat severe, non-healing, or perforated stomach (gastric) and duodenal ulcers]...Notes...DaVinci robot [an advanced robotic-assisted equipment used for minimally invasive surgery] unavailable due to construction. Case cancelled and patient transferred out...” A facility document titled, “Transfer Summary,” dated January 30, 2026, at 3:12 a.m., was reviewed. The document indicated, “ ...REASON FOR TRANSFER...Requires Higher Level of Care [more intensive, structured medical or psychiatric treatment services]...BENEFITS FOR TRANSFER...Obtain level of care/service unavailable at this facility...Service: general surgery - DaVinci Robot ...” A document from Facility C titled, “Emergency Provider Report,” dated January 30, 2026, at 7:36 a.m., was reviewed. The document indicated Patient 20 was tachycardic [high heart rate, normal heart rate is 60 to 100 beats per minute (bpm)] and confused. The document further indicated, “...presented to the emergency department as a transfer from [name of Facility A] with complaint of abdominal pain with findings on CT scans concerning for a perforated gastroduodenal ulcer...I did reach out to surgery as soon as the patient arrived in the emergency department, given the CT scan findings from outside hospital describe a emergent medical condition that requires surgical intervention...They reviewed the CT scan and are planning to take the patient emergently to the OR [operating room] for operative management, given that patient is persistently tachycardic...Given that patient is having a significant abdominal surgery, he will require admission to ICU [Intensive Care Unit, a specialized department within a hospital which provides care for critically ill patients] postoperatively [after a surgery]...The high probability of sudden, clinically significant deterioration in the patient’s condition required the highest level of my preparedness to intervene urgently...” A document from Facility C titled, “General Surgery Consult Note,” dated January 30, 2026, was reviewed. The document indicated, “...On exam patient is guarding [tensing of abdominal wall muscles as a protective response to touch or pain], AMS [altered mental status, a change in brain function, such as confusion or decreased alertness], HR [heartrate] 130s...presented as a transfer from OSH [outside hospital, Facility A] for abd [abdominal] pain...CT scan showed a suspected perforated abd ulcer with pneumoperitoneum [the presence of free are or gas within the abdominal cavity, most commonly indicating a perforated abdominal organ]...and adjacent fluid collection. Surgery team consulted for evaluation and management...Plan: Admit to ICU...OR emergently for exploratory laparotomy [a major surgical procedure involving a large incision in the abdominal cavity to directly examine organs for diagnosis or treatment], repair of gastric ulcer...Patient was ...accepted from [Facility A] with free air, free fluid and sepsis [the body’s extreme life-threatening response to an infection, where the immune system overreacts and begins damaging its own tissues and organs] after a significant delay there. The reason for transfer was ‘lack of a Davinci robot’ by the consulted surgeon...I confirmed findings and recommended emergent surgery...Risk include, but are not limited to bleeding, infection...and, particularly due to the significant delay at the referring hospital, death...” A document from Facility C titled, “Operative Note,” dated January 30, 2026, was reviewed. The document indicated, “...Post-procedure [after a procedure] diagnosis: perforated ulcer...Procedures performed...exploratory laparotomy...abdominal washout [a surgical procedure which cleanses the space around the abdominal organs with warm saline solution]...repair of...ulcer...cholecystectomy [surgical removal of the gallbladder]...temporary abdominal closure with...wound vac [vacuum, a medical device applying suction to a wound to quicken healing]...” On March 25, 2026, at 11:56 a.m., an interview was conducted with General Surgeon (GS) 1. GS 1 stated he remembers Patient 20 had come into the ED with a possible perforated ulcer and he had called the House Supervisor (HS, an experienced staff who acts as the administrative representative for a facility during nights, weekends, or holidays) to prepare the Operating Room (OR) for robotic assisted repair of the ulcer. GS 1 stated he wanted to use the robotic assist because it gives the patient a faster recovery from the surgery. GS 1 stated the HS called him back to inform him the Da Vinci robot was not available. GS 1 stated the next step would be to perform an open surgery (exploratory laparotomy) and it was the only available option at the facility. GS 1 stated it was his understanding Patient 20 would be transferred to [name of Facility B] quickly, and he was not informed of the delay in transfer for Patient 20. GS 1 stated if he had been informed of the delay in the transfer, he would have performed an open surgery on Patient 20. On March 25, 2026, at 8:53 p.m., an interview was conducted with the HS. The HS stated, when he called GS 1 back to inform him the DaVinci robot was not available, he asked GS 1 if the surgery could be done without the DaVinci or if the surgery could wait until the DaVinci robot was available. The HS stated GS 1 told him the surgery needed to be performed STAT and it could only be done with the DaVinci robot. The HS stated the information was relayed to the ED Physician (ED MD) and Patient 20 was flown to [name of Facility C] later in the shift on January 30, 2026. On March 26, 2026, at 9:06 a.m., an interview was conducted with the ED MD. The ED MD stated when he initially spoke with GS 1, GS 1 recommended to admit Patient 20 and he would see the patient as a consult (a request by a treating doctor for a specialist or expert to review a patient’s case, examine them, and provide specific advice or recommendations for care). The ED MD stated he was then told GS 1 could not perform the surgery because he needed the DaVinci robot. The ED MD stated he first called (name of Facility B) and was told they did not have an on-call surgeon with privileges to use the DaVinci robot for surgery. The ED MD stated he called GS 1 back to inform him (name of Facility B) could not perform a DaVinci robot assisted surgery. The ED MD stated a perforated gastric ulcer is a surgical emergency and a delay in surgery could lead to a deterioration [worsening] of the patient and could lead to the patient’s death. On March 26, 2026, at 10:03 a.m., an interview and review of Patient 20’s medical record was conducted with General Surgeon (GS) 2. GS 2 reviewed Patient 20’s CT and stated if he was consulted to see Patient 20, he would take the patient to the OR to perform an open laparotomy [a major surgical procedure involving a large abdominal incision allowing surgeons to directly view organs], wash the abdomen, perform a closure of the perforation, and place a drain [a device used to collect fluid from the abdomen after surgery]. The facility policy and procedure (P&P) titled, “EMTALA Policy,” dated June 19, 2025, was reviewed. The P&P indicated, “...The purpose of this policy is to establish clear guidelines and procedures to ensure the Hospital’s compliance with the Emergency Medical Treatment and Labor Act (EMTALA)...If...it is determined that an individual has an emergency medical condition, the Hospital must...Within the capability and capacity of the staff and facility available at the Hospital (including coverage available through the Hospital’s on-call roster), provide treatment necessary to stabilize the individual...” The facility P&P titled, “Plan for Provision of Patient Care,” dated July 18, 2024, was reviewed. The P&P indicated, “...The plan of the Provision of Care outlines the core processes and care activities necessary to provide access to levels of care and/or disciplines necessary to meet the patients’ needs...Standards of Patient Care...Patients will receive competent, compassionate care in a safe environment...[name of Facility A] Hospital offers a complete range of ancillary services, including:...Surgical Services...Scope of Service: includes all specialties except open-heart surgery, neurology [the branch of medicine focused on the human nervous system], and transplants...””

“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 one of 20 sampled patients (Patient 1), when an allegation of abuse was not investigated, in accordance with the facility’s policy and procedure (P&P). This failure had the potential for Patient 1 to experience continued abuse, and place other patients at risk for abuse. Findings: On February 26, 2026, at 7 p.m., a complaint was sent to the California Department of Public Health, (CDPH, a state agency) which indicated, “ ...I was lying on a stretcher in triage [the process of rapidly assessing patients or problems to prioritize treatment based on severity and available resources] when the nurse rudely demanded that I get up by myself. I was unable to do so because I felt completely weak. He then abruptly grabbed my left arm, hurting me so badly that I screamed and cried out, “You are hurting me,” but he completely ignored me. Never in my life have I felt so humiliated. I never imagined that this would happen to me, especially not in a hospital, a place where you are supposed to go for help and to feel better, not to leave worse than when you arrived, with trauma...” On March 23, at 9:45 a.m., a review of Patient 1’s medical record was conducted with the Director of Inpatient Services (DIS). A review of an untitled facility document, dated September 29, 2025, was reviewed. The document indicated, “...Admit DT [date time]: 9/29/25 [September 29, 2025] 19:23 [7:23 p.m.]...chief complaint description: SOB [shortness of breath or difficulty breathing]...” A facility document titled, “ED Note-Physician,” dated September 29, 2025, at 7:41 p.m., authored by MD 6, was reviewed. The document indicated Patient 1 was brought to the ED by a Family Member (FM) with a complaint of shortness of breath and weakness. A facility document titled, “Assessment - ADL [activities of daily living] “dated September 29, 2025, authored by Registered Nurse (RN) 4, was reviewed. The document indicated, “...9/29/2025 [September 29, 2025] 19:51 [7:51] PDT [Pacific Standard time] (Patient Rounding Comment) Patient [Patient 1] assisted to chair 3. Patients [Patient 1] states she is unable to walk but walked with assistance...9/29/2025 19:52 [7:52 p.m.] PDT (Patient Rounding Comment) Patient [Patient 1] attempted to throw herself back onto EKG (electrocardiogram, a quick, painless, and noninvasive test that records the electrical activity of the heart) bed was advised not to as we are going to help her into a chair. Patient [Patient 1] continues to argue...9/29/2025 19:53 [7:53 p.m.] PDT (Patient Rounding Comment) Patient [Patient 1] able to speak full sentences and is leaning back while being assisted to the chair but able to transition into chair without assist...” On March 24, 2026, at 10:50 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated, Patient 1’s grievance letter and the chart was reviewed and she did not find documentation of bruises on Patient 1’s arm or any complaints of abuse on discharge. The EDM stated, abuse is an intentional action and there was no proof RN 4 intentionally hurt Patient 1 so it was not considered abuse. On March 25, 2026, at 8:45 a.m., an interview was conducted with the Quality Director (QD). The QD stated, Patient 1 reported the incident four months later and their was no documentation in the record of the incident which appeared suspicious. The QD stated the abuse checklist form was not completed because this incident wasn’t considered abuse because there was no mention of abuse in the grievance letter. The QD stated, the incident should have been reported to the charge nurse when Patient 1 complained to RN 4 of her arm being hurt. On March 25, 2026, at 1:30 p.m., an interview was conducted with RN 4. RN 4 stated he did not remember Patient 1 but if there was an allegation of abuse it should be reported to the charge nurse and house supervisor. A review of the facility’s P&P titled, “Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault,” dated July 8, 2020, was conducted. The policy indicated, “...Abuse means any intentional action which harms another person. Abuse includes physical or sexual abuse. Assault means any non-consensual touching. Assault includes physical and/or sexual assault ...Policy: All individuals in [Name of Facility], including patients, family members of patients, visitors, and [Name of Facility] employees and contractors have the right to be free of abuse, neglect and assault. The Administrator on Call (AOC) or designee of each [Name of Facility] is responsible for immediately responding to allegations of abuse, neglect or assault occurring in the [Name of Facility] so that the appropriate investigation of alleged criminal or other inappropriate conduct may be conducted in accordance with this Policy...””

“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: 34933 Based on interview and record review, the facility failed to ensure one Registered Nurse (RN) 4 completed the Workplace Violence (Any act of violence or threat of violence that occurs at the work site) training every two years, in accordance with facility policy. This failure to complete violence training has the potential for RN 4 to be uninformed of abuse policy and cause harm to the patients. Findings: On March 25, 2026, at 1 p.m., a review of RN 4’s employee file was conducted with the Clinical Educator (CE). The Clinical Educator stated RN 4’s hire date was January 5, 2015. A facility document titled, “CPI [Crisis Prevention Institute, Nonviolent Crisis Prevention & Intervention Training focuses on prevention and equips individuals with proven strategies for safely defusing anxious, hostile, or violent behavior at the earliest possible stage],” dated November 20, 2023, was reviewed. The document indicated, RN 4 completed the CPI Workplace Violence training on November 15, 2023. The CE stated, RN 4 is delinquent and the training was due to be completed last year. On March 25, 2026, at 1:52 p.m., an interview was conducted with the Human Resources Manager (HRM). The HRM stated RN 4’s training is delinquent and is required every two years. A review of the facility’s Policy & Procedure (P&P) titled, “Workplace Violence Plan,” dated March 28, 2018, was conducted. The policy indicated, “...[Facility A] has zero tolerance to any behavior that is intentionally aggressive, offensive, intimidating and/or violent that would cause a patient, visitor, employee or staff member to fear for their safety or the safety of others...At the time of hire, and at a minimum of once annually thereafter, each employee will receive training that addresses workplace violence risks that the employee is reasonably anticipated to encounter in his/her job...For greater risk areas and positions in the Hospital, such as the Emergency Department, Behavioral Health, Security employees and House Supervisors, a behavioral education program such as Crisis Prevention (CPI) and/or Healthy Interventions will be provided on an annual basis...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44871 Based on observation and interview, the facility failed to provide a safe patient environment when there was not a functional nurse call light system in the following units: 1. In the Emergency Department (ED) there were no call light cords on all 12-patient care bays and no call light panel in the nurse’s station (Refer to A 0144); 2. In the Post Anesthesia Care Unit (PACU- a healthcare unit dedicated to the care of patients before, during, and after a surgical or medical procedure involving anesthesia) there were no call light cords on all 7-patient care bays and no call light panel in the nurse’s station (Refer to A 0144); and 3. In the Pre-Operative Unit (a designated area within a hospital or surgical center where patients are prepared for surgery) there were no call light cords available on three of four pre-op patient care bays (Refer to A 0144). The cumulative effect of this systemic failure resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient’s Rights was met. On April 29, 2025, at 3:25 p.m., the survey team identified significant concerns with the facility’s Nurse Call Light System. 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 Interim Chief Operating Officer (ICNO), Accreditation Regulatory Manager (ARM), Director Clinical Quality Improvement (DCQI), Emergency Department Director (EDD), Interim Director Medical Surgical Telemetry (IDMST), and the Operating Room Charge Nurse (ORCN). The facility’s ICNO, ARM, DCQI, EDD, IDMST and the ORCN were verbally notified regarding the concerns of the facility’s failure to ensure a safe patient environment when there was no call light system in the Emergency Department (ED), Post Anesthesia Care Unit (PACU), and Pre-Op Unit. On April 29, 2025, at 7:04 p.m., the DCQI provided a Corrective Action Plan (CAP). On April 30, 2025, at 3:01 p.m., the Chief Executive Officer (CEO) provided a revised CAP. The CAP indicated the following: - All Emergency Department (ED) beds and all Recovery Room bays have been equipped with handheld service bells as of April 29, 2025. All staff in the Emergency Department and Recovery Room areas will be trained by the unit supervisor on how to use the handheld service bells prior to providing care for any patients and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood. All staff on leave of absence, vacation, and new hires will receive education/training upon return to work, and prior to providing patient care. - A temporary wireless patient call light system will be installed in ED and Recovery Room by end of business April 30, 2025, by the vendor [Name of Vendor]. All staff in the Emergency Department and Recovery Room areas were trained in-person by the unit supervisor on how to use the temporary wireless patient call light system prior to seeing any patients and instructed to teach patients and family members how to use the bells. Staff have signed attestations that they received training and understand. - The permanent patient call light system in the Preoperative area had patient cords installed at each of the bays on April 30, 2025. The call light system was tested and deemed functional. All staff in the Preop area were trained in-person by the unit supervisor on how to use the handheld service bells prior to seeing any patients and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood. On April 30, 2025, at 3:57 p.m., the CAP for the immediate jeopardy was reviewed and accepted. On April 30, 2025, at 4:45 p.m., the CAP was verified while onsite, through observations, interviews, and record reviews, to have been fully implemented. On April 30, 2025, at 4:50 p.m., the IJ was removed in the presence of the CEO, ARM, DCQI, and the EDD.”

“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: 44871 Based on interview and record review, the facility failed to implement their policies and procedures, and failed to ensure a Post Anesthesia Care Unit (PACU, critical care unit where patients recover after surgery and anesthesia) Registered Nurse (RN), was qualified and annual competencies were completed, for six of 11 patients (Patient 1, 2, 8, 10, 11,and 12) when: 1. For Patients 1, 2, and 10, a fall care plan was not initiated despite being a fall risk according to Morse Fall Score (A tool used to determine a patients risk of falling, low risk score between 0-24, scores between 25-50 suggest low risk, a score of 51 and higher indicates a high risk of falling) (Refer to A-0398); 2. For Patient 1, pain was not reassessed within a clinically appropriate time frame after administration of pain medication (Refer to A-0398); 3. For Patients 2, and 11, the nurse did not administer the correct medication order for indicated pain level (Refer to A-0398); 4. For Patient 10, the nurse did not notify the physician of Patient 10’s critical lab value (Refer to A-0398); 5. For Patient 8, a fall risk assessment was not completed on admission (Refer A-0398); 6. For Patient 12, family was not notified of a fall (Refer A-0398); and 7. A PACU RN qualifications were not met when critical care courses 2023, and 2024, annual competencies were not completed (Refer A-0398). These cumulative failures had the potential to compromise patient safety, and cause possible patient harm or 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: 44871 Based on observation and interview, the facility failed to provide a safe patient environment when there was not a functional nurse call light system in the following units: 1. In the Emergency Department (ED) there were no call light cords on all 12 patient care bays and no call light panel in the nurse’s station. 2. In the Post Anesthesia Care Unit (PACU- a healthcare unit dedicated to the care of patients before, during, and after a surgical or medical procedure involving anesthesia) there were no call light cords on all 7-patient care bays and no call light panel in the nurse’s station. 3. In the Pre-Operative Unit (a designated area within a hospital or surgical center where patients are prepared for surgery) there were no call light cords available on three of four pre-op patient care bays. This failure had the potential to put a patient’s health and safety at risk when needs are not met in a timely manner. Findings: On April 29, 2025, an unannounced visit was conducted at the facility for a Complaint Validation survey. 1. A tour of the ED was conducted on April 29, 2025, at 9:05 a.m., with the Emergency Department Director (EDD) and the Interim Director of Medical-Surgical-Telemetry (IDMST). On April 29, 2025, at 9:20 a.m., during the tour of the ED, it was observed that there were no call light cords available on all 12 patient care bays for patients to utilize to call for assistance and no call light panel in the nurse’s station. On April 29, 2025, at 9:30 a.m., an interview was conducted with the Emergency Department Registered Nurse (EDRN) 1. The EDRN 1 stated that there has not been a call light system in the ED for years. EDRN 1 further stated a call light system is not necessary because there are staff around to look after the patients. On April 29, 2025, at 9:36 a.m., an interview was conducted with the EDRN 2. EDRN2 stated there are no call light buttons or cords in each ED patient care bays. EDRN 2 stated she just keeps the door open so she can see the patients. On April 29, 2025, at 9:46 a.m., an interview was conducted with the EDD. The EDD stated there is not a call light system in the ED because it is a small hospital where RNs are always near their assigned rooms. The EDD further stated the ED will be renovated soon and a call light system will be installed. 2. A tour of the PACU was conducted on April 29, 2025, at 12:42 p.m., with the Operating Room Charge Nurse (ORCN), the Director of Clinical Quality, Director Clinical Quality Improvement (DCQI), and the EDD. On April 29, 2025, at 12:43 p.m., during the tour of the PACU, it was observed that there were no call light cords available on all seven PACU patient care bays, and no call light panel in the nurse’s station. On April 29, 2025, at 12:44 p.m., an interview was conducted with the ORCN. The ORCN stated, as far as she can remember, there was a call light system used in the PACU when she began working at the facility in 2012, but she was unsure of what happened or why the call light system was removed. On April 29, 2025, at 12:45 p.m., an interview was conducted with the PACU RN 1. The PACU RN 1 stated a call light system is not needed in the PACU because “we only have two patients at a time, and we are always at the bedside.” 3. A tour of the Pre-Operative Unit was conducted on April 29, 2025, at 12:50 p.m., with the ORCN, the DCQI, and the EDD. On April 29, 2025, at 12:50 p.m., during the tour of the Pre-Operative Unit, there were no call light cords available in three of four Pre-Op patient care bays. On April 29, 2025, at 12:57 p.m., an interview was conducted with the Pre-Op RN. The Pre-Op RN stated, there is always a nurse in the area to respond to patient needs. When asked how patients call the nurse if they needed help, Pre-Op RN stated, “ It’s a small unit, and patients just needed to call, “Nurse”. On April 29, 2025, at 1 p.m., the DCQI stated the facility did not have a Call Light policy. On April 29, 2025, at 3:25 p.m., the survey team identified significant concerns with the facility’s Nurse Call Light System. 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 Interim Chief Operating Officer (ICNO), Accreditation Regulatory Manager (ARM), Director Clinical Quality Improvement (DCQI), Emergency Department Director (EDD), Interim Director Medical Surgical Telemetry (IDMST), and the Operating Room Charge Nurse (ORCN). The facility’s ICNO, ARM, DCQI, EDD, IDMST and the ORCN were verbally notified regarding the concerns of the facility’s failure to ensure a safe patient environment when there was no call light system in the Emergency Department (ED), Post Anesthesia Care Unit (PACU), and Pre-Op Unit. On April 29, 2025, at 7:04 p.m., the DCQI provided a Corrective Action Plan (CAP). On April 30, 2025, at 3:01 p.m., the Chief Executive Officer (CEO) provided a revised CAP. The CAP indicated the following: - All Emergency Department (ED) beds and all Recovery Room bays have been equipped with handheld service bells as of April 29, 2025. All staff in the Emergency Department and Recovery Room areas were and will be trained by the unit supervisor on how to use the handheld service bells prior to providing care to any patients, and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood. All staff on leave of absence, vacation, and new hires will receive education/training upon return to work, and prior to providing patient care. - A temporary wireless patient call light system will be installed in ED and Recovery Room by end of business April 30, 2025, by the vendor [Name of Vendor]. All staff in the Emergency Department and Recovery Room areas were trained in-person by the unit supervisor on how to use the temporary wireless patient call light system prior to seeing any patients and instructed to teach patients and family members on how to use the bells. Staff have signed attestations that they received training and understand. - The permanent patient call light system in the Preoperative area had patient cords installed at each of the bays on April 30, 2025. The call light system was tested and deemed functional. All staff in the Preop area were trained in-person by the unit supervisor on how to use the handheld service bells prior to seeing any patients and instructed to teach patients and family members on how to use the bells. Staff signed attestations that they received training and understand. On April 30, 2025, at 3:57 p.m., the CAP for the immediate jeopardy was reviewed and accepted. On April 30, 2025, at 4:45 p.m., the CAP was verified while onsite, through observations, interviews, and record reviews, to have been fully implemented. On April 30, 2025, at 4:50 p.m., the IJ was removed in the presence of the CEO, ARM, DCQI, and the EDD.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to ensure the Post Anesthesia Care Unit Registered Nurse (PACU RN) was qualified and competent to care for post-surgery patients. This failure had the potential for unsafe patient care of surgical patients. Findings: On May 1, 2025, at 9:51 a.m., a record review was conducted with the Human Resources Manager (HRM).The employee file of PACU RN was reviewed and indicated the PACU RN was initially hired on October 7, 2022. There was no documented evidence PACU RN completed a critical care course within 1 year of employment as required by the job description. There was no documented evidence PACU RN completed the 2023, and 2024, competencies as required by the job description. On May 1, 2024, at 10:50 a.m., a concurrent interview and record review were conducted with ORCN. The PACU RN job description was reviewed. The ORCN stated PACU RN has not met the requirements indicated in the job description. A facility document titled,”[Name of Hospital] 7027- Registered Nurse (RN II) Job Description,” dated October 7, 2022, indicated,”...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year...” A facility document titled,”[Name of Hospital] 7027- Registered Nurse (RN II) Job Description,” dated August 24, 2023, indicated,”...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year...” A facility document titled,”[Name of Hospital] 7027- Registered Nurse (RN II) Job Description,” dated December 12, 2024, indicated,”...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year...””

“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 interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 11 sampled patients (Patient 1, 2, 8, 10, 11, and 12 ) when: 1. For Patients 1, 2, and 10, a fall care plan was not initiated despite being a fall risk according to Morse Fall Score (A tool used to determine a patients risk of falling, low risk score between 0-24, scores between 25-50 suggest low risk, a score of 51 and higher indicates a high risk of falling); 2. For Patient 1, pain was not reassessed within a clinically appropriate time frame after administration of pain medication; 3. For Patients 2, and 11, the nurse did not administer the correct medication order for indicated pain level; 4. For Patient 10, the nurse did not notify the physician when Patient 10 had a critical lab value; 5. For Patient 8, a fall risk assessment was not completed on admission; and 6. For Patient 12, family was not notified of a fall. These failures had the potential to compromise patient safety, resulting in poor pain management, unqualified staff, and delays in medical care and/or death. Findings: 1a. A review of Patient 1’s record was conducted on April 30, 2024, at 9:17 a.m., with the Accreditation Regulatory Manager (ARM). A facility document titled, “History and Physical,” dated April 30, 2025, at 11:28 a.m., was reviewed and indicated Patient 1 was admitted to the facility on April 28, 2025, for an ankle fracture. A facility document titled, “MORSE FALL RISK,” dated April 28, 2025, through April 29, 2025, was reviewed. The document indicated, “...April 28, 2025, at 9 a.m...MORSE FALL SCORE...15, April 28, 2025, at 9 p.m...MORSE FALL SCORE...35...April 29, 2025, at 9 a.m...MORSE SCORE...60...April 29, 2025, at 9 p.m...MORSE SCORE...80...” A facility document titled,”Operative Note,” dated April 29, 2025, at 7:07 p.m., was reviewed. The document indicated, “...PROCEDURE PERFORMED...Open reduction internal fixation left trimalleolar [a serious ankle fracture that includes all three malleoli bones in the ankle]...” There was no documented evidence in the Patient 1’s electronic medical record (EMR), that a fall care plan was implemented for Patient 1. On April 30, 2025, at 10:30 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the patient was a fall risk on admission and a fall care plan was not implemented per facility policy. 1b. A review of Patient 2’s record was conducted on April 30, 2024, at 10 a.m., with the ARM. A facility document titled, “History and Physical,” dated April 28, 2025, at 12:45 p.m., was reviewed and indicated Patient 2 was admitted to the facility on April 28, 2025, for pneumonia (an infection of the lungs). A facility document titled, “MORSE FALL RISK,” dated April 28, 2025, through April 29, 2025, was reviewed the document indicated, “...April 28, 2025, at 10 a.m...MORSE FALL SCORE...35, April 28, 2025, at 10 p.m...MORSE FALL SCORE...60...April 29, 2025, at 10 a.m...MORSE SCORE...35...April 29, 2025, at 10 p.m...MORSE SCORE...30...” There was no documented evidence in Patient 2’s EMR, that a fall care plan was implemented for Patient 2. On April 30, 2025, at 10:56 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the patient was a fall risk and a fall care plan was not implemented for this patient. The ARM further stated the policy was not followed; a care plan should have implemented. 1c. A review of Patient 10’s record was conducted on April 30, 2025, at 10:42 a.m., with the Operating Room Charge Nurse (ORCN). A facility document titled, “History and Physical,” dated April 28, 2025, was reviewed and indicated Patient 10 was admitted to the facility on April 28, 2025, for DKA (diabetic ketoacidosis - a serious complication of diabetes [diabetes, high blood sugar in the body]), altered mental status and urinary retention (inability to empty bladder completely). A facility document titled, “MORSE FALL RISK,” dated April 28, 2025, was reviewed and the document indicated, Patient 10’s Morse Fall Risk score on admission was 60. According to the MORSE FALL RISK SCORE the patient was a “high fall risk.” There was no documented evidence that a fall risk care plan was implemented for Patient 10. On April 30, 2025, at 10:55 a.m., an interview was conducted with the ORCN. The ORCN stated the policy was not followed when the fall risk care plan was not initiated on admission. A facility P&P titled, “STANDARD OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS,” dated July 18, 2024, indicated, “...All patients will receive nursing care based on principles of patient centered care and utilization of assessment and reassessments of the patient’s needs, by the registered nurse...The plan of care that is mutually set with the patient is culturally and age specific to the individual patient/family. The complete patient assessment establish the foundation for the diagnosing/analyzing of patient problems, formulating a plan of care and determining appropriate referrals and reassessments...Focused...A partial review of physical, psychological, spiritual/cultural, social, and educational needs based on...Patient’s needs and patient’s response to interventions...physician orders...Patient’s diagnosis...Care setting and unit specific guidelines...The patient’s plan of care is initiated on admission and reviewed on admission and reviewed a minimum of every shift based on patient’s response to their specific assessed need for care and treatment...The electronic medical record suggested care plans based on the patient’s problem list and are to be customized to the patient’s specific needs...Patient care goals, needs, interventions, and response to care are reviewed (and updated as needed) and documented every shift...The patient’s goal and needs guide the consultation and collaboration relative to planning, implementing, and formulating the patient’s plan of care...Consultation and collaboration, as appropriate to patient’s needs...” 2. A review of Patient 1’s record was conducted on April 30, 2024, at 9:17 a.m., with the ARM. A facility document titled, “History and Physical,” dated April 30, 2025, at 11:28 a.m., was reviewed and indicated Patient 1 was admitted to the facility on April 28, 2025, for an ankle fracture. A facility document titled, “Operative Note,” dated April 29, 2025, at 7:07 p.m., was reviewed and the document indicated, “...PROCEDURE PERFORMED...Open reduction internal fixation left trimalleolar...” A facility document titled, “IVIEW/I&O (Input and output),” dated April 29, 2025, at 10:10 a.m., was reviewed and the document indicated, “...Numeric Rating Pain Scale...8/10 [a tool used to measure the intensity of pain, with 1 representing very mild pain and 10 representing the worst pain]...” A facility document titled, “MAR [Medication Administration Record] Summary,” dated April 29, 2025, at 10:12 a.m., indicated, “...morphine...2 mg [milligram, unit of measurement] = [equals] 1 ml [milliliter, unit of measurement]...injection, IV [Intravenous] Push...Q4H [every four hour], PRN [as needed]...For: Pain Severe...” There was no documentation in Patient 1’s electronic medical record (EMR) that Patient 1’s pain was reassessed in a clinically appropriate time frame after administration of pain medication. On April 30, 2025, at 9:56 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the task comes up in the computer as an overdue task and this is red, it does not look like pain was reassessed after pain medication was administered. The ARM further stated the policy was not followed. A facility P&P titled, “PAIN MANAGEMENT,” dated July 18, 2024, indicated, “...A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatients and following any intervention intended to lessen the patient’s pain (e.g. administration of pain medication...)...This reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame...Documentation of pain assessment and reassessment must occur by the end of the shift...” 3a. A review of Patient 2’s record was conducted on April 30, 2024, at 10 a.m., with the ARM. A facility document titled, “History and Physical,” dated April 28, 2025, at 12:45 p.m., was reviewed and indicated Patient 2 was admitted to the facility on April 28, 2025, for pneumonia. A facility document titled, “Pain Assessment,” dated April 28, 2025, at 10:37 a.m., was reviewed and indicated, “...Numeric Rating Pain Scale...6/10...” A facility document titled, “Order,” dated April 28, 2025, at 11:20 a.m., was reviewed and indicated, “...acetaminophen-HYDROcodone [medication to manage severe pain] (Norco 325 mg [milligram, unit of measurements]- 5 mg [milligram, a unit of measurement] oral tablet)...2 [two...tab [tablet]...oral...Q6hr [every six hours]...PRN reason...Pain Severe...” A facility document titled, “MAR [Medication Administration Record] Summary,” dated April 28, 2025, at 11:51 a.m., indicated,”...acetaminophen-HYDROcodone...(Norco 325 mg - 5 mg oral tablet)...2...tab...oral...Q6hr...PRN reason...Pain Severe...” There was no order found in the EMR for pain medication indicated for pain level 5-7/10, moderate pain. There was no documentation found in the EMR that the nurse called the physician requesting medication for a moderate pain level medication. On April 30, 2025, at 11:26 a.m. a concurrent interview and record review were conducted with the ARM. The ARM stated the nurse gave a medication intended for severe pain and did not call the physician for clarification. The ARM further stated the policy was not followed. 3b. A review of Patient 11’s record was conducted on April 30, 2025, at 1:12 p.m., with the ORCN. A facility document titled, “History and Physical,” dated April 24, 2025, was reviewed and indicated Patient 11 was admitted to the facility on April 24, 2025, for a left hip fracture. A facility document titled, “Pain Assessment Detail,” dated April 24, 2025, indicated,”...Numeric Pain Acceptable Intensity Score...0 - no pain...” A facility document titled, “Order,” dated April 24, 2025, indicated,”...Morphine [medication for severe pain]...2 mg = 1ml...injection, IV, Push...Q4hrs, PRN...For Severe Pain...” A facility document titled, “Order Activity Flowsheet,” dated April 24, 2025, through April 28, 2025, indicated Morphine was given to Patient 11 for pain levels 5 through 7 (moderate pain) on the following dates: - April 25, 2025, at 5:33 a.m., with a numeric rating pain scale of 7; - April 25, 2025, at 1:33 p.m., with a numeric rating pain scale of 7; - April 26, 2025, at 1:17 a.m., with numeric rating pain scale of 6; - April 26, 2025, at 1:17 a.m., with numeric rating pain scale of 6; - April 26, 2025, at 5:51 p.m., with numeric rating pain scale of 7; - April 27, 2025, at 3:34 a.m., with numeric rating pain scale of 6; - April 27, 2025, at 10:12 a.m., with numeric rating pain scale of 7; and - April 27, 2025, at 6:29 p.m., with numeric rating pain scale of 7. A facility document titled, “MAR Summary,” dated April 24, 2025, through April 26, 2025, indicated, “...Dilaudid [medication for severe pain]...1 mg = 1ml injection...IV, Push...Q 6hrs...PRN...For: Pain Severe...” A facility document titled, “Order Activity Flowsheet,” dated April 25, 2025, through April 28, 2025, indicated Dilaudid was given to Patient 11 for pain levels 5 through 7 (moderate pain) on the following dates: - April 25, 2025, at 8:54 p.m., with numeric rating pain scale of 7; - April 26, 2025, at 4:37 a.m., with numeric rating pain scale of 6; - April 26, 2025, at 3:28 p.m., with numeric rating pain scale of 6; - April 26, 2025, at 10:43 p.m., with numeric rating pain scale of 6; and - April 27, 2025, at 6:47 a.m., with numeric rating pain scale of 6. There was no order found in the EMR for pain medication indicated for pain level 5-7/10, moderate pain. There was no documentation found in the EMR that the nurse called the physician requesting medication for a moderate pain level medication. On April 30, 2025, at 3:44 p.m., an interview was conducted with the ORCN. The ORCN stated the pain medication order was not followed and the nurse should have called the physician for clarification. ORCN further stated the facility policy was not followed. A facility P&P titled, “MEDICATION ORDERS: REQUIREMENTS FOR SAFE ORDER WRITING,” dated May 24, 2020, indicated, “...Orders written for “PRN pain” must be accompanied by specific information indicating the level of pain the medication ordered is intended to treat. The hospital uses a 0-10 scale to rate the severity of pain...If orders are written using the pain rating of mild, moderate and severe, the following conversions apply...pain scale...mild...1-4...moderate...5-7...severe...8-10...physician orders without an assigned pain scale for multiple “PRN” pain medication orders will be clarified with the prescribing physician and the order placed in the patients chart...” 4. A review of Patient 10’s record was conducted on April 30, 2025, at 10:42 a.m., with the ORCN. A facility document titled, “History and Physical,” dated April 28, 2025, was reviewed and indicated Patient 10 was admitted to the facility on April 28, 2025, for DKA, altered mental status and urinary retention. A facility document titled, “Results Details,” dated April 30, 2025, was reviewed. The document indicated, “...WBC (white blood cells-type of blood cell made in your bone marrow and found in the blood) 28 10e9/L (10 raised to the power of 9/ Liter - unit of measurement) (CRIT) [critical]...Normal low: 4.2...Normal high 10.8...Result Comment...April 30, 2025...05:56 US (United States)/Central...CRITICAL RESULTS have been phoned with read back to PREV CRITICAL NOT CALLED...” A facility document titled, “Results Review,” dated April 30, 2025, was reviewed. The document indicated, “...Physician Notification...” There was no documented evidence that the critical lab result was reported to the physician. On April 30, 2025, at 11:14 a.m., an interview was conducted with the ORCN. The ORCN stated the policy was not followed when the WBC critical lab value was not reported to the physician within an hour. A review of the facility’s P&P titled, “CRITICAL TESTS AND CRITICAL VALUES AND RESULTS,” revised date April 18, 2024, indicated, “...At [Name of Hospital] a one-hour time frame is established for reporting the results, when available, of critical tests and routine tests with critical abnormal findings...” 5. On April 29, 2025, at 9:42 a.m., a tour of the Intensive Care Unit (ICU, a special department of the hospital that provides intensive care) was conducted with the Interim Director Medical-Surgical-Telemetry (IDMST) and the Director for Clinical Quality and Improvement (DCQI). On April 29, 2025, at 9:57 a.m., an interview was conducted in Patient 8’s room. Patient 8 was observed in bed awake, and stated he was in the Emergency Department on April 28, 2025, at 6 p.m. and stayed there while waiting for an available bed in ICU. On April 30, 2025, at 10 a.m., Patient 8’s medical record was reviewed with the ORCN. A facility document titled, “[Name of Hospital] ADMISSION FACESHEET,” dated April 28, 2025, was reviewed and indicated, Patient 8 was admitted on April 28, 2025, at 6:35 p.m. A facility document titled, “History and Physical,” dated April 29, 2025, was reviewed. The document indicated, “...CHIEF COMPLAINT...snake bite to right index finger...Assessment/Plan...Toxic effect of rattlesnake venom...” A facility document titled, “Orders,” undated, was reviewed. The document indicated, “...Plan Information...Admission order...Initiated and Signed by [Name of Physician]...04/28/2025 [April 28, 2025]...21:59 [9:59 p.m.]...” A facility document titled, “Results Review,” undated, was reviewed. There was no documented evidence that the initial fall risk assessment was completed on admission. An interview was conducted on April 30, 2025, at 10:02 a.m., with the ORCN. The ORCN stated the admitting orders should be initiated within 60 minutes including the fall risk assessment. An interview was conducted on April 30, 2025, at 10:25 a.m., with the ORCN. The ORCN stated the policies were not followed when the fall risk assessment was not completed on admission. A review of the facility’s P&P titled, “ FALLS PREVENTION AND RESOURCES,” revised dated July 18, 2024, indicated, “... Initial Fall Risk Assessment...Upon entry into the hospital system or through emergency services, a registered nurse will complete the Morse Fall Risk Screening tool in electronic documentation as part of the initial assessment per facility policy...” A review of the facility’s P&P titled, “STANDARD OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS,” dated July 18, 2024, indicated, “...Initial Assessment...Level of Care...Intensive Care Unit...Physical Assessment Initiated within...1 hour...Assessment comprise three elements...Data collection includes, but not limited to...Fall Risk score...” 6.On May 1, 2025, at 9 a.m., Patient 12’s medical record was reviewed with the ORCN. A facility document titled, “History and Physical,” dated November 30, 2024, was reviewed and indicated Patient 12 was and admitted to the facility on November 30, 2024, with a diagnosis of left Pleural Effusion (buildup of excess fluid in the space between the lungs and the chest wall). A facility document titled, “Results Review,” dated November 30, 2024, was reviewed. The document indicated, “...Morse Fall Risk Score...15...” A facility document titled,”Nursing Note,” dated December 4, 2024, was reviewed. The document indicated, “...Rapid response paged at 0802 [8:02 a.m.] for patient fall...” A facility document titled, “Rapid Assessment Team Record,” dated December 4, 2024, was reviewed. The document indicated,”...RAT [Rapid Assessment Team] Team Activated Time 12/04/2024 [December 4, 2024] 08:02 [a.m.]...RAT Staff Concern...Other...Fall...” A facility document titled, “Results Review,” dated December 4, 2024, was reviewed. The document indicated, “Physician Communication...Name of Physician Contacted...[Name of Physician]...” There was no documented evidence that the emergency contact was notified of the fall. On May 1, 2025, at 9:12 a.m., an interview was conducted with the ORCN. The ORCN stated the facility policy was not followed when Patient 12’s family was not notified of the fall. A review of the facility’s P&P titled, “Fall Prevention and Resources,” revised date July 18, 2024, indicated, “...Notification of fall...physician...emergency contact...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44871 Based on observation, interview, and record review the facility failed to ensure all available supplies and equipment were ready for use when: 1.15 expired silk suture kits were found in a medication/storage room in the Intensive Care Unit (ICU, a specialized department of the hospital that provides intensive care) ready for use; and 2. Two Stryker Chairs (used for evacuating non ambulatory patients during an emergency) were hung in a locked patio without quick accessibility and staff were not trained on how to use the equipment. These failures had the potential to delay patient care and services or cause patient harm/death. Findings: 1. A tour of the Intensive Care Unit (ICU) was conducted on April 29, 2025, at 9:46 a.m., with the Patient Care Coordinator (PCC), and the Operating Room Charge Nurse (ORCN). During the tour of the ICU, in the ICU medication/supply room, 15 expired silk suture kits ready for use, were observed with the following expiration dates: -ETHICON PERMA-HAND SILK 2-0 - expiration date January 31, 2025, (8 total); -ETHICON PERMA-HAND SILK 3-0 - expiration date December 31, 2024; -ETHICON PERMA-HAND SILK 4-0 - expiration date November 30, 2020, (2 total) and expiration date July 31, 2024, (2 total); and -ETHICON PERMA-HAND SILK 6-0 - expiration date May 31, 2022, (2 total). On April 29, 2025, at 9:59 a.m., an interview with the ORCN was conducted. The ORCN stated the above mentioned suture kits were expired and should not be in there. On April 29, 2025, at 10:01 a.m., an interview was conducted with the PCC. The PCC stated the suture kits are expired and should not be in there. The PCC further stated the nurses should be checking for expired items, and removing them from the area. A review of the facility’s policy and procedure (P&P) titled, “Procurement and Supply Chain,” dated June 21, 2023, indicated, “...All supply items should be reviewed weekly and upon issuance in respect to expiration dates. All expired items will be immediately removed from the storage location and placed in a holding area until proper disposition can be made...” 2. A tour of the facility’s Surgical Tower (a second-floor unit), was conducted on April 29, 2025, at 12 p.m., with the Director of Clinical Quality and Improvement (DCQI), the Emergency Department Director (EDD), and Interim Director of Medical/Surgical/Telemetry (IDMST). During the tour of the Surgical Tower, to the left of the elevators was a locked door leading to a patio. On the patio were two Stryker Chairs hanging on the patio wall. The key was requested to open the patio door and the IDMST stated security has the key. After waiting approximately five minutes the tour was continued. At 12:17 p.m., a staff member (security guard), was observed opening the locked door. It took approximately 17 minutes for the locked door to be opened to have access to the emergency evacuation equipment. The unit did not have a key to open the locked door. Upon completion of the unit tour, there were no other emergency evacuation equipment observed. An interview was conducted on April 29, 2025, at 12:25 p.m., with the DCQI. The DCQI stated there was no documented evidence of staff training, in-services, or education, on how to use the emergency equipment. The DCQI further stated there was not a policy and procedure for the use of the Stryker Chairs available to staff on the unit. On April 29, 2025, at 12:24 p.m., an interview was conducted with the IDMST. The IDMST stated, “my staff, and I have not been trained on how to use the Stryker Chair, the security has to open the door, we do not have a key on the unit.” The IDMST further stated, “I have been here since 2018, and I have never seen that door opened”. A review of the facility P&P titled, “Safe Patient Handling,” dated September 1, 2020, indicated, “...The Safe Patient Handling policy is applicable to all employees working at [Name of facility] whose job tasks require direct hands-on patient care...Provide training to healthcare workers that perform direct hands-on patient care which includes...The use of lifting devices to handle patients safely...Employees participate actively in training and demonstrate competency in the safe and appropriate use of assistive and mechanical lifting devices...” A facility Operational Manual titled, “Evacuation Chair, Stryker,” dated August 8, 2023, indicated, “...Always read and strictly follow the warnings and cautions listed on this page. Service only by qualified personnel...Do not allow untrained helpers to assist in the operation of the product. Untrained helpers may cause injury to the occupant or themselves. Always transport an occupant....with a minimum of two trained operators...Set methods and procedures to educate and train your staff on the safe operation or maintenance of this product...””

“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: 38479 Based on interview and record review, the facility failed to ensure Patient 8 was provided care in a safe environment, when a renal biopsy (procedure where a small sample of kidney tissue is removed for examination under a microscope) was performed on Patient 8 that was indicated for another patient. This failure resulted in Patient 8 having a renal biopsy procedure performed, in which Patient 8 experienced a subcapsular perirenal hematoma (SPH, a collection of blood that forms beneath the kidney’s outer layer and around the kidney), and had the potential for patient harm and/or death. Findings: On April 7, 2025, at 8 a.m., an unannounced visit was conducted at the facility for a complaint investigation survey. On April 9, 2025, at 9:11 a.m., Patient 8’s medical record was reviewed with the Chief Quality Officer (CQO). The record indicated, Patient 8 was admitted to the facility on March 8, 2025, for complaints of fatigue and weakness for one week, diagnosed with severe anemia (a condition where the body has a deficiency of red blood cells or hemoglobin, resulting in a decreased ability to carry oxygen) and thrombocytopenia (a condition that occurs when the platelet count in your blood is too low). The facility document titled, “Final Report,” electronically signed on March 12, 2025, at 11:06 p.m., was reviewed on April 9, 2025, at 9:20 a.m. It indicated, “Reason for Exam: abdominal pain s/p [status post, after a procedure] right kidney biopsy...Impression: Large right renal subcapsular hematoma with several foci [plural form of focus- a point or area of interest]...Findings are likely the sequela of recent renal biopsy...” On April 9, 2025, at 10:01 a.m., a review of Patient 8’s renal biopsy consent was reviewed with the Accreditation and Regulatory Manager (ARM). The consent was labeled with Patient 31’s identification sticker, which included Patient 31’s name, date of birth, and medical record number. The consent contained Patient 8’s signature. The ARM stated the procedure was supposed to be performed on Patient 31, not Patient 8. On April 9, 2025, at 9:15 a.m., an interview with the CQO was conducted. The CQO stated Patient 8 was being evaluated for abdominal pain and low hemoglobin. The CQO stated the hematologist (medical doctor specializing in the diagnosis, treatment, and prevention of blood disorders, including blood cancers) felt Patient 8 needed a bone biopsy. When the order was clarified, it was determined a bone biopsy should be done at (Name of hospital 2). The CQO stated Patient 8 was transferred to (Name of hospital 2) on March 11, 2025, for a bone biopsy, and transferred back to (Name of hospital 1) after the bone biopsy was completed. The CQO further stated, the morning after the procedure on March 12, 2025, Patient 8’s name appeared on the Interventional Radiology (IR, a medical specialty that uses imaging techniques to guide minimally invasive procedures, to diagnose and treat various conditions) worklist. The CQO stated, the procedure was supposed to be manually deleted because it was already completed at an outside facility. The CQO stated, the “TICKET TO RIDE” (a request to pick up and transport a patient) was completed by the nurse and transporter. The transporter then took Patient 8 to IR. The CQO stated, while Patient 8 was in IR, they were expecting another patient (Patient 31) for a renal biopsy scheduled for the day. The CQO further stated the nurses, physician, and staff did a chart review for Patient 31 during the “TIMEOUT” (a brief pause by the entire medical team to confirm critical details before a procedure, like patient identity, the correct procedure, and surgical site) and there was a “presumptive assumption” that the patient inside the room was Patient 31. The CQO stated the Medical Doctor (MD) consented Patient 8 inside the procedural room in Spanish, and Patient 8 consented for a renal biopsy. On April 9, 2025, at 11:10 a.m., the Physician Assistant (PA) was interviewed. The PA stated she was working with the primary team and was asked by the Charge Nurse (CN) to speak with the patient and family regarding the renal biopsy that was “inadvertently” done on the patient [Patient 8]. The PA further stated, “It [renal biopsy] was never ordered but was done inadvertently”. On April 9, 2025, at 11:28 a.m., the Interim Director of Quality (IDQ) was interviewed. The IDQ stated, “Next time, ensure time out is completed for the right patient, right procedure, and right time”. The IDQ further stated, “The wrong procedure can cause harm to the patient and on extreme case may result in permanent disability”. On April 9, 2025, at 1:15 p.m., the Interventional Radiology Medical Doctor 1 (IRMD) was interviewed. The IRMD 1 stated, “It was a disaster”. The IRMD 1 further stated, the “TIMEOUT” was done for Patient 31. The Information was read for Patient 31. Patient 31 had a normal platelet count. Patient 8’s platelet count was 41. The IRMD 1 stated, “I would not have done the renal biopsy if I had known”. IRMD 1 stated, “I assumed verification was done”. They read the name of Patient 31, read his labs and not Patient 8’s. The IRMD 1 stated, “Everybody agreed the patient in the room was [Name of Patient 31].” The IRMD 1 stated, the patient in the room was not included in the “Timeout”, and the patient in the room was not asked his name. A review of facility policy titled, “SUMMARY OF STATE REPORTING REQUIREMENTS”, dated, April 25, 2014, indicated, “An Adverse Event means... Surgery performed on a wrong body part that is inconsistent with the documented informed consent for that patient...Surgery performed on the wrong patient...The wrong surgical procedure performed on a patient, which is a surgical procedure performed on a patient that is inconsistent with the documented informed consent for that patient...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to implement their restraint (device that limits a patient’s movement to keep them safe and prevent them from harming themselves or another person) policy, when restraint assessments and documentation was not performed, for one of 31 sampled patients (Patient 23). This failure had the potential to result in serious patient harm and/or death. Findings: On April 8, 2025, at 1:50 p.m., a review of Patient 23’s medical record was conducted with the Operating Room Charge Nurse (ORCN). The facility’s undated, and untitled, document was reviewed. The document indicated Patient 23 was admitted to the facility on January 31, 2025, for seizures (a condition caused by uncoordinated changes to electrical signals in the brain that results in uncontrollable body twitching). A facility document untitled, dated February 9, 2025, at 9:25 a.m., was reviewed. The document indicated, “...Patient Rounding Comment: Pt [patient] pulled out NG [Naso-Gastric] tube (a thin, flexible tube inserted through the nose and into the stomach)...Date/Time: February 09, 2025, 09:25 [9:25 a.m.] Verify by [Name of Registered Nurse (RN) 2]...” A facility document untitled, dated February 9, 2025, at 9:40 a.m., was reviewed. The document indicated, “...Patient Rounding Comment: MD [Medical Doctor] notified of tube removal...Date/Time: February 09, 2025 09:40 [9:40 a.m.] Verify by [Name of RN 2]...” A facility document untitled, dated February 9, 2025, at 2:20 p.m., was reviewed. The document indicated, “...Patient Rounding Comment: New NG tube order and (sic) restraint order...Date/Time: February 09, 2025 1420 [2:20 p.m.] Verify by [Name of RN 2]...” An undated facility document titled, “Order Sheet,” was reviewed. The document indicated, “...Order entry D/T [Date/Time]: 02/09/25 [February 9, 2025] 18:56 [6:56 p.m.]...Ordering Doctor: [Name of MD] Restraint Initiation Non-violent...interferes with medical device...soft limb restraints...bilateral upper extremity [both upper arms]...” During the record review there was incomplete documentation of restraints assessment from February 12, 2025, 8 a.m., to February 13, 2025, at 6 p.m. There was no documented evidence of restraint removal and restraint assessment after restraints were removed. On April 8, 2025, at 2:43 p.m., an interview with the ORCN was conducted. The ORCN stated there were incomplete restraint assessments for Patient 23 from February 12, 2025, 8 a.m., to February 13, 2025, 6 p.m. The ORCN stated there was no documentation of restraint removal, and assessment after restraint removal. The ORCN stated RN 2 should have assessed Patient 23 for difficulty breathing, skin assessment, range of motion, Nutrition/hydration, hygiene/elimination, discontinuation are you OK Readiness attempts, pain restraints, and patient safety from February 12, 2025, 8 a.m. to February 13, 2025, 6 p.m. The ORCN stated an RN should have documented removal of restraints and performed an assessment of Patient 23 after removal of the restraints. The ORCN stated it is done for patient safety. On April 8, 2025, at 3:14 p.m., an interview with the Interim Director Of Quality (IDQ) was conducted. The IDQ stated it is important to complete restraint assessments for patients as it is for “the well-being of the patients.” A review of the facility policy titled, “Restraints Violent/Non-Violent,” dated, August 19, 2009, indicated, “...the purpose of this policy is to define the hospital’s approach to the application of restraints for patients in a way that protects the patient’s health and safety, and preserves his or her dignity [self-respect], rights and well-being...monitoring must include but is not limited to...Ability to clear airway...Circulation...Heart rate...Respirations...Skin integrity [condition of the skin]...Sensation...””

“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: 50304 Based on observation, interview, and record review, the facility failed to implement their Infection Prevention Policy for two of 31 sampled patients (Patients 24, and 25) when hand hygiene was not performed. This failure had the potential for the transmission of infections to be spread to Patient 25. Findings: On April 7, 2025, at 9:32 a.m., a tour of facility was conducted with the Emergency Department Director (EDD), the Operating Room Charge Nurse (ORCN), and the Interim Quality Director (IQD). On April 7, 2025, at 11:07 a.m., during the tour of the Emergency Department, Registered Nurse (RN) 1 was observed coming out of Isolation Room 1 (Patient 25’s room) and did not perform hand hygiene. RN 1 was observed going back into Isolation Room 1 without performing hand hygiene. On April 7, 2025, at 11:08 a.m., during the tour of the Emergency Department, Emergency Room Medical Doctor (ERMD) was observed coming out of Isolation Room 1 (Patient 25’s room), and going into Isolation Room 2 (Patient 24’s room), without performing hand hygiene. The ERMD was observed coming out of Isolation Room 2, and going back into Isolation Room 1, without performing hand hygiene. On April 9, 2025, at 11:11 a.m., a review of Patient 24’s medical record was conducted with the ORCN. It indicated Patient 24 was admitted on April 7, 2025, for diarrhea. An undated facility document titled, “Order Sheet,” was reviewed. The document indicated, “...Isolation...04/07/2025 [April 7, 2025] 9:56 [9:56 a.m.]...Continuous, enteric precautions...Pt name: [Name of Patient 24]...” On April 7, 2025, at 11:12 a.m., an interview was conducted with the ERMD. The ERMD stated she did not perform hand hygiene when she came out of Isolation Room 1 (Patient 25’s room) and went into Isolation Room 2 (Patient 24’s Room), and before going back into Isolation Room 1 after coming out of Isolation Room 2, because she was busy. The ERMD stated she should have performed hand hygiene before and after going into the isolation rooms. The ERMD stated she broke infection control. On April 7, 2025, at 11:18 a.m., an interview was conducted with the EDD. The EDD stated the ERMD and RN 1 should have performed hand hygiene before entering patient rooms, and after leaving patient rooms. The EDD stated it is important to do this for infection control. On April 10, 2025, at 11:23 a.m., an interview was conducted with IP 2. IP 2 stated infection control practices should be followed to prevent and control Hospital Acquired Infection (HAI -infections that patients develop while receiving care in a hospital). The facility’s undated, policy titled, “isolation procedures,” was reviewed. The facility policy indicated, “...This policy is designed to prevent the transmission of infectious [likely to be passed to people] agents...These measures are to be used when providing care to all patients...hand hygiene...Placing a patient in isolation...order is placed in the electronic medical record with the type of isolation precaution...an appropriate isolation sign must be placed outside patient’s room so the sign is visible to staff and visitors...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to follow its Infection Surveillance Prevention Program and Plan when: 1. An Infection Preventionist (a trained personnel that focuses on preventing and controlling the spread of infection) was not physically present to conduct observations on infection prevention control practices in the facility from November 4, 2024, through April 10, 2025. 2. An Infection Preventionist was not physically present to complete Hospital Acquired Infection/ Conditions (HAI/HAC -infections that patients develop while receiving care in a hospital) reports for February and March 2025. These failures resulted in inadequate surveillance and monitoring of infection control practices and data which can potentially hinder efforts to reduce HAIs and improve patient safety. Findings: 1. On April 7, 2025, at 9:32 a.m., a tour of facility was conducted with the Emergency Department Director (EDD), the Operating Room Charge Nurse (ORCN), and the Interim Director of Quality (IDQ). The IDQ stated the Infection Preventionist (IP) 1, is currently on leave since November 4, 2024. The IDQ further stated IP 2 is covering for IP 1 and is assisted by the Quality/Performance Improvement Analyst (QPIA). On April 10, 2025, at 11:12 a.m., an interview was conducted with the QPIA. The QPIA stated her primary responsibility is physician peer review. The QPIA stated she did not do observations on infection prevention and control practices in the facility from November 4, 2024, to present. The QPIA stated she did not conduct any inspections in the OR to ensure medical equipment cleaning, disinfecting and sterilizing guidelines were being followed. On April 4, 2025, at 11:20 a.m., an interview was conducted with the IDQ. The IDQ stated observations on infection prevention control practices in the facility from November 4, 2024, to present, should have been conducted. The IDQ stated inspections in the OR should have been conducted to ensure sterilizing (to kill all bacteria and viruses) guidelines were being followed. The IDQ further stated it is important to do observations and surveillance to provide adequate patient care and prevent hospital acquired infection. On April 10, 2025, at 11:33 a.m., an interview was conducted with the IP 2. The IP 2 stated she is an IP consultant for the facility. The IP 2 stated she can not do observations on infection prevention and control practices because she is not present onsite. The IP 2 stated it should be done to prevent and control HAIs. 2. On April 7, 2025, at 9:32 a.m., a tour of facility was conducted with the Emergency Department Director (EDD), the Operating Room Charge Nurse (ORCN), and the Interim Director of Quality (IDQ). The IDQ stated the Infection Preventionist (IP) 1, is currently on leave since November 4, 2024. The IDQ further stated IP 2 is covering for IP 1 and is assisted by the Quality/Performance Improvement Analyst (QPIA). The facility HAC report dated January 2025, was reviewed with the IDQ and QPIA. There was no documented reports for February 2025, and March 2025. On April 10, 2025, at 1: 38 p.m., an interview was conducted with the QPIA. The QPIA stated her primary responsibility is physician peer review. The QPIA stated she only completed the January 2025, HAC report, and did not complete the February and March 2025, HAC reports. The QPIA further stated she should have completed the February and March 2025, reports, however, it was only her “doing everything”. On April 10, 2025, at 2:07 p.m., an interview was conducted with the IDQ. The IDQ stated it was important the facility do their due diligence in ensuring that preventing and treating infections promptly were done “to keep patients and staff safe.” A review of the facility infection prevention policy titled, “Infection Prevention Program and Plan, dated January 22, 2009, indicated, “...the aim of our program is to deliver safe, cost effective care to our patients...the program is designed to prevent and reduce hospital associated infections...the IP is responsible for implementing this plan...the facility’s IP will conduct daily infection prevention rounds with follow up required by the survey department...ensuring medical equipment cleaning, disinfecting [to kill bacteria] and sterilizing [to kill all bacteria and viruses]of medical equipment...” A review of the facility infection prevention policy titled, “Post Discharge [after the patient left the hospital] Hospital Acquired Infection Surveillance,” dated October 20, 2005, indicated, “...efforts shall be made to determine the infection rate for discharged patients presenting with an infection within thirty (30) and ninety (90) days of surgery...To document that infection and maintain a retrievable (capable of being regained) form of record keeping to be used in preparing the Monthly Surveillance Report...””

“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: 38479 Based on interview and record review, the facility failed to ensure the patient or patient’s legal representative was informed in writing, the need for the patient to be transferred to another facility for four of 20 sampled patients (Patients 1,3,7, and 9). This failure resulted in Patients 1, 3, 7, and 9, being transferred to another facility without consent from the patient or the patients responsible party, and the potential for the patients to not understand where they are going and why they are being transferred to another facility. Findings: On January 15, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for an Emergency Medical Treatment and Labor Act (EMTALA) survey. 1 a. A review of Patient 1’s medical record was conducted on January 15, 2025, at 2 p.m., with the Accreditation Regulatory Manager (ARM). The facility document titled, “ED [Emergency Department] Triage Form”, dated January 1, 2025, at 6:06 p.m., indicated, Patient 1 was admitted on January 1, 2025, on a 5150 (an involuntary hold, detained for mental health assessment of patients exhibiting psychiatric/behavioral symptoms or a status post attempted suicide event), after being found in an alley and gravely disabled after being discharged from a local hospital on December 31, 2024. Review of a facility document, titled, “ED Discharge Form,” dated January 4, 2025, at 8:32 a.m., indicated, “...ED Disposition: Transfer...Discharge Comment: Pt [patient] alert and awake...” The facility’s undated document titled, “Transfer Summary,” was reviewed and indicated Patient 1 was discharged to another local hospital on January 4, 2025. There was no patient signature on this form. The facility’s undated document titled, “Transfer Contact Documentation form,” was reviewed and indicated, “...Transferred Date and Time: 1/4/25 [January 4, 2025] at 0843 [8:43 a.m.]...” 1 b. A review of Patient 3’s medical record was conducted on January 15, 2025, at 2:30 p.m., with the ARM. The facility undated document titled, “ED Triage Form,” was reviewed and indicated Patient 3 was brought in by ambulance after attempted suicide and was placed on a 5150 hold. The facility’s undated document titled, “Transfer Form,” was reviewed and indicated Patient 3 was transferred to another local hospital for foreign body ingestion on January 1, 2025, at 8:25 p.m. There was no signature of the patient or the patient’s responsible party noted on this form. 1 c. A review of Patient 7’s medical record was conducted on January 15, 2025, at 2:50 p.m., with the ARM. The facility’s undated document titled, “ED Note-Physician” was reviewed and indicated Patient 7 was admitted on January 4, 2025, on a 5150 hold for danger to self. It further indicated Patient 7 was alert and oriented. The facility’s undated document titled, “Transfer Summary,” was reviewed and indicted, Patient 7 was transferred to another facility for 5150 (psychiatric services). This form did not include the patient’s or a responsible party signature. The facility’s document titled, Transfer Contact Documentation form,” was reviewed and indicated, “...Transferred Date and Time: 1/5/25 [January 5, 2025] at 0658 [6:58 a.m.]...” 1 d. A review of Patient 9’s medical record was conducted on January 15, 2025, at 3:20 p.m., with the ARM. The facility undated document titled, “ED Note-Physician,” was reviewed and indicated Patient 9 was admitted on January 4, 2025, at 9:10 p.m., on a 5150 hold for danger to self and others. It further indicated Patient 9 was alert and oriented times two [person knows who and where they are]. The facility’s document titled, “Transfer Summary,” was reviewed and indicted Patient 9 was being transferred to another facility for 5150 (psychiatric services). This form did not have Patient 9’s or a witness signature. The facility document titled, Transfer Contact Documentation form,” was reviewed and indicted, “...Transferred Date and Time: 1/6/25 [January 6, 2025] at 2135 [9:35 p.m.]...” On January 15, 2025, at 9:10 a.m., an interview was conducted with the Emergency Department Clinical Manager (EDCM). The EDCM stated suicidal patients are placed on a 5150 involuntary hold and transferred to another facility for inpatient treatment. The EDCM further stated consent to transfer must be obtained, either from the patient if alert and oriented, or from the patient’s guardian, family member, or person with Power of Attorney, involved in the patient care, for the transfer to occur. On January 15, 2025, at 2 p.m., an interview was conducted with the ARM. The ARM stated a Social Worker (SW) had given out information that patients on a 5150 hold, does not need to sign a consent for transfer form. The ARM stated Patients 1, 3, 7, and 9’s, transfer forms did not include a signature from the patient or patient representative, and had no other documentation to support why signatures were not secured. The ARM further stated staff need to be re-educated on how to properly complete the transfer form. On January 16, 2025, at 2:18 p.m., an interview with the ARM was conducted. The ARM stated consent and notification is important so patients understand where they are going, and why they are being transferred to another facility. The ARM further stated patient’s family/next of kin should be made aware of the patient transfer so they can follow up on the patient’s whereabouts. On January 16, 2025, at 3:30 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated it is very important to seek patient/representative consent and fill out the form during transfer. The ICNO stated it is a patient hand off tool for patient safety during transport. The ICNO stated the transfer form must be signed by the patient, or by a representative if the patient is unable to sign. The ICNO further stated, “The family or responsible party had to be notified of the patient transfer.” A review of the facility policy titled, “ASSESSMENT OF NEED OF (VOLUNTARY OR NON-VOLUNTARY) PSYCHIATRIC CARE”, dated June 15, 2023, was conducted. It indicated, “Purpose: To set guidelines for a mental health assessment of patients exhibiting psychiatric/behavioral symptoms or a status post attempted suicide event and provide a service referral policy which ensures a safe discharge with an appropriate placement...NOTE: Persons detained retain their legal rights regarding consent for medical treatment...” A review of the facility policy titled, “PATIENT RIGHTS AND RESPONSIBILITIES”, dated July 18, 2024, was conducted. It indicated, “PURPOSE: To encourage awareness of patient’s rights and responsibilities and provide guidelines to assist patients in making decisions regarding care and to actively participate in care planning...PATIENT RIGHTS: You and/or your representative have the right to...Receive information about your health...You 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 as you may need in order to give informed consent or to refuse a course of treatment...” A review of the facility policy titled, “EMTALA POLICY”, dated June 17, 2021, was conducted. It indicated, “PURPOSE: The purpose of this policy is to set forth policies and procedures for Hospital’s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)...Transfer of Unstable Individuals...When the Hospital transfers an individual...The Hospital must send...The written patient consent or physician certification to transfer...””