Emanate Health Foothill Presbyterian Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to meet the Condition of Participation of Patient’s Rights (The Patient’s Bill of Rights is a document that outlines what patients can expect when receiving health care) as evidenced by: 1.a. The facility failed to ensure that the condition of admission (COA, a document that included provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits]) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient’s rights to a hospital discharge appeal) was provided to one of thirty (30) sampled patients (Patient 28) when, there was no identification of who signed Patient 28’s COA and IMM forms, in accordance with the facility’s policy and procedure regarding COA and language interpreter services (facilitates communication between the healthcare provider and the patient who does not speak the same language). This deficient practice resulted in Patients 28 to not be informed of the rights as a patient, which may result in Patients 28’s inability to effectively make decisions regarding care or treatment. (Refer to A-0117) 1.b. The facility failed to ensure Patient 28’s COA and IMM forms were provided in a language that the patient (Patient 28) could understand, in accordance with the facility’s policy and procedure regarding language interpreter services. This deficient practice resulted in Patients 28 to not be informed of the rights as a patient, which may result in Patients 28’s inability to effectively make decisions regarding care or treatment. (Refer to A-0117) 1.c. The facility failed to ensure that language interpreter (a person who translates spoken language from one language to another) was used for one of 30 sampled patients (Patient 29) when the condition of admission (COA) document was provided in a language that the patient (Patient 29) could not understand, in accordance with the facility’s policy and procedure regarding language interpreter services. This deficient practice resulted in Patients 29 to not be informed of the rights as a patient, which may result in Patients 29’s inability to effectively make decisions regarding care or treatment. (Refer to A-0117) 2. The facility failed to ensure that for one of 30 sampled patients (Patient 28), the safety requirements were implemented when, Patient 28 did not have an identification (ID) arm band (for identification of all hospital patient that includes the patient’s full name, medical record number, date of birth, age, sex, and name of attending physician) while in the facility as a patient, in accordance with the facility’s policy and procedure regarding patient identification. This deficient practice resulted in Patient 28 to not be accurately identified and had the potential for the patient’s safety, while in the facility, to be jeopardized such as with medication errors, etc., due to lack of proper identification. (Refer to A-0142) 3. a. The facility failed to ensure that for one of 30 sampled patients (Patient 27), a safe care was provided when Patient 27’s Morphine (narcotic pain medication) intravenous (IV, inject through the vein) was prepared by Registered Nurse 1 (RN 1) using a contaminated needleless syringe after the tip of the needleless syringe touched the paper towel. This deficient practice had the potential for Patient 27 to suffer from hospital acquired infection and/or transmission of bacteria that can cause infection from the use of contaminated needleless syringe. (Refer to A-0144) 3.b. The facility failed to ensure that for one of 30 sampled patients (Patient 27), a call light (a system device used by the patient to call for help), was within the patient’s (Patient 27) reach. This deficient practice had the potential for Patient 27’s needs to not be met since Patient 27 is unable to call for help with the call light being out of reach and may result in delayed treatment that could have a negative effect on Patient 27’s provision of care. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments and/or death.”

“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: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure for two of thirty (30) sampled patients (Patients 27 and 29), nursing care was provided when: 1.a. Patient 27 was not reassessed (reevaluation of a patient’s health status), in accordance with the facility’s policy and procedure regarding medication policies, after administration of as needed (PRN) medication (Ativan, a sedative and can be used for treatment of anxiety) for agitation (feeling of irritability or severe restlessness). 1.b. Patient 27’s pain was not addressed, in accordance with the facility’s policy and procedure regarding pain management, after the patient (Patient 27) reported to still be in pain after receiving pain medication. These deficient practices had the potential to result in delayed treatment and had the potential to worsen Patient 27’s agitation and pain which can delay recovery from health condition. (Refer to A-0395) 2. The facility failed to ensure for one of 30 sampled patients (Patients 29), nursing care was provided, when Patient 29’s surgical wound dressing change was not performed in accordance with the physician’s order. This deficient practice had the potential to result in surgical complication such as wound infection, pain, and delayed wound healing. (Refer to A-0395) 3. The facility failed to ensure for two of five employee files reviewed (Registered Nurse [RN] 1 and RN 5), the evaluation process to ensure the RNs were competent (includes competencies for Performance Expectations, Risk Management, Department Response to Code Calls [Example is Code Blue- an emergency code that indicates an adult patient is in critical condition], Triage Assessment [categorize patients based on the severity of their injuries], Assessment and Care, Medication Administration, Sedation [a state of relaxation or sleepiness that is caused by certain drugs]) in their assigned RN positions were implemented in accordance with the facility’s policy and procedure regarding unit orientation and required competencies (the knowledge, skills, and behaviors that healthcare professionals need to perform their jobs). This deficient practice had the potential for the RNs’ inability to perform the essential functions of their respective positions due to lack of competencies, which may compromise patient safety when patient care interventions were not performed appropriately. (Refer to A-0397) 4. The facility’s nursing staff failed to re- assess and document vital signs (VS, measurements of the body’s basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body’s overall condition), prior discharge from the emergency department (ED, a part of a hospital for treating people who have just come to the hospital) for two of thirty (30) sampled patients (Patient 2 and Patient 3) in accordance with the facility’s policy and procedure regarding obtaining VS before discharge. This deficient practice had the potential for Patient 2 and Patient 3’s health condition to be unstable and unsafe to leave the facility. (A-0398) 5. The facility’s nursing staff failed to assess and document pain level for one patient of 30 sampled patients (Patient 2) after administration of Toradol (a nonsteroidal anti-inflammatory drug (NSAID) to relieve pain and reduce inflammation) medication as per the facility’s policy and procedure regarding patient’s pain assessment and re-assessment after administering an analgetic (a class of medications designed specifically to relieve pain). This deficient practice had the potential for negatively impact Patient 2’s physical and emotional well-being if pain management was not effective. (A-0398) 6. The facility failed to ensure nursing staff obtained and documented Vital Signs (VS) in accordance with the facility’s CIWA protocol (Clinical Institute Withdrawal Assessment) that is used to assess and manage alcohol withdrawal symptoms to ensure the safe treatment of patients at risk for alcohol withdrawal syndrome (AWS) when VS frequency for one patient of 30 sampled patients (Patient 5) was not monitored and recorded at a required frequency. This deficient practice had the potential for Patient 5’s worsening symptoms, such as increasing heart rate and blood pressure to go unnoticed resulting in negative outcomes for Patient 5, such as seizures (a sudden, uncontrolled burst of electrical activity in the brain) or delirium tremens (DTs- a severe and life-threatening form of alcohol withdrawal)), which is associated with high mortality if untreated. (A-0398) 7.a. The facility failed to ensure, for one of 30 sampled patients (Patient 28), who was considered a high risk for fall (an unintentional event that causes a person to land on the ground or a lower level), had a yellow armband, in accordance with the facility’s policy and procedure regarding fall management. This deficient practice had the potential to result in an unsafe care that may lead to Patient 28 suffering from a fall injury. (Refer to A-0398) 7.b. The facility failed to ensure, for one of 30 sampled patients (Patient 28), had a properly labeled peripheral IV (Intravenous- through the vein) dressing to indicate the date the IV cannula was inserted, in accordance with the facility’s policy and procedure regarding IV access care. This deficient practice had the potential to cause complications for Patient 28 such as infection, pain in the IV access site, etc. (Refer to A-0398) 8. The facility failed to ensure, for Patient 29, the fall risk intervention was implemented, in accordance with the facility’s policy and procedure regarding fall management when, Patient 29 did not have a fall (an unintentional event that causes a person to land on the ground or a lower level) risk sign at the patient’s door and a yellow arm band that indicated the patient (Patient 29) was at risk for fall. This deficient practice had the potential to result in an unsafe care that may lead to Patient 29 suffering from a fall injury. (Refer to A-0398) 9. The facility failed to provide one of 30 sampled patients (Patient 2) with necessary medical information/discharge instructions for follow-up upon Patient 3’s discharge from the facility, in accordance with the facility’s policy and procedure regarding discharge instructions. This deficient practice had the potential for Patient 2 not being aware of the outcome of hospital treatment or follow-up care needs which could compromise patients’ outcomes after discharge. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation for Discharge Planning was met as evidenced by: 1. The facility failed to include one of 30 sampled patients (Patient 4) and/or Patient 4’s designated family representative in discharge planning (the process of transitioning a patient from one level of care to another) when arranging for a discharge of Patient 4 to a long-term acute care facility (LTAC, a type of specialized hospital care for patients with serious medical conditions that require ongoing treatment but no longer need intensive care). In addition, the facility failed to discuss the results of discharge planning and did not include Patient 4’s and/or Patient 4’s representative’s preferences regarding post (after)-discharge care. This deficient practice had the potential for Patient 4 and Patient 4’s representatives to not fully understand the discharge care needs of Patient 4 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice also had the potential to violate Patient 4 and/or Patient 4’s family/representative’s right to participate in discharge planning. (Refer to A-0808) 2. The facility failed to actively engage one of 30 sampled patients (Patient 1) and/or patient’s family/representative(s) in the development of a discharge plan for Patient 1 as well as failed to discuss the discharge plan evaluation with Patient 1’s family representative, in accordance with the facility’s policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home). This deficient practice had the potential for Patient 1 and Patient 1’s representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1’s rights when the patient (Patient 1) and/or Patient 1’s representative were not included in Patient 1’s discharge planning. (Refer to A-0808). 3. The facility failed to provide one of 30 sampled patients (Patient 13) with a referral to the appropriate home health agency (HHA, provide a range of services to patients in their homes, including skilled nursing, therapeutic services, and other care), in accordance with the facility’s policy and procedure regarding the discharge process. This deficient practice had the potential to ineffectively transition Patient 13 to post-discharge and had the potential for Patient 13’s needs not being met after discharge. (Refer to A-0813) The cumulative effect of these deficient practices resulted in the facility’s inability to provide effective discharge planning process that focuses on the patient goals and treatments preferences, potentially placing patients at risk for ineffective post-discharge care, leading to negative patient outcomes.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46238 Based on interview and record review the facility’s Governing Body (GB, responsible for guiding the hospital’s long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the facility’s contracted Managed Care personnel ensure the discharge planning process (the process of preparing a patient to leave a healthcare facility, and ensuring a smooth and safe transition to the next phase of care such as going home, moving to a rehabilitation center, nursing home, or other healthcare setting) promoted safe, effective patient transition from hospital to their next level of care, for four (Patients 1, 2, 4, and 13) of 30 sampled patients. This deficient practice had the potential to result in negative consequences for patients post-discharge leading to higher patient re-admission rates and worsening of their conditions due to delays in care coordination or inadequate follow-up care set-up. In addition, this deficient practice had the potential to violate patients and their caregivers’ rights when they were not involved in the discharge planning process. Findings: 1. During an interview on 9/3/2024, at 9:19 a.m., with the Corporate Director of Care Coordination department (DCC), the DCC stated, discharge planning (the process of creating a personalized plan for a patient when they leave a hospital to ensure a smooth transition for the patient and to continue their care after leaving the hospital) process should be focused on the patient’s individualized goals and needs after leaving the hospital. The DCC further stated, care managers (CM, a professional who works with patients, their families, and the medical team to ensure that patients receive the appropriate care and services they need) must ensure that the patient and/or the patient’s representatives are involved in the development of the discharge plan and their preferences should be considered. During a review of Patient 1’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated, 1/20/2024, the H&P indicated 1/20/2024, Patient 1 was admitted with signs and symptoms (S&S) of a cerebrovascular accident (CVA, a medical condition that occurs when blood flow to the brain is suddenly interrupted). During a concurrent interview and record review on 9/4/2024 at 11:02 a.m. with Quality Review Nurse (QRN), Patient 1’s medical record (MR) dated 1/20/2024 through 1/25/2024, was reviewed. The MR indicated, on 1/22/2024, one of the facility’s CMs documented, Patient 1’s health plan (a program or organization that provides health benefits, either directly or through insurance) provides their own CM (for discharge planning). The QRN stated, no other CM notes were found in Patient 1’s chart from 1/20/2024 through 1/25/2024. During an interview on 9/4/2024 at 3:02 p.m. with Registered Nurse (RN) 4, RN 4 stated, on 1/24/2024, “I received an order for Patient 1’s discharge and transfer to SNF. I informed Patient 1 and Patient 1’s representative(s) about the discharge at bedside, but the Patient 1’s representative became upset saying they were not aware about the discharge plans and placement.” RN 4 further stated, the physician was notified, and Patient 1’s discharge was postponed. 2. During a review of Patient 2’s medical record (MR) titled, “History of Present Illness (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it),” dated 9/3/2024, the HPI indicated, Patient 2 was seen in the ED on 9/3/2024 for the evaluation of hand pain. During a concurrent interview and record review on 9/4/2024 at 10:24 a.m. with Quality Review Nurse (QRN), Patient 2’s ACI (After Care Instructions- containing information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals), dated 9/3/2024, was reviewed. The ACI indicated, Patient 2 did not sign the ACI and a handwritten “Verbal (verbal discharge instructions),” at 1:05 p.m. was written on the first page of the ACI indicating that Patient 2 did not receive printed after-visit information. The QRN stated, Patient 2 was not provided with printed discharge instructions as per the facility’s policy. 3. During a review of Patient 4’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 8/31/2024, the H&P indicated, Patient 4 was admitted for shortness of breath (difficulty breathing) and tachypnea (rapid breathing). During further review of Patient 4’s MR titled, “Care Manager Notes,” dated 9/2/2024, the MR indicated, “Order for LTAC (long-term acute care, a type of specialized hospital care for patients with serious medical conditions that require ongoing treatment but no longer need intensive care)-choice list provided. During a review of Patient 4’s MR titled, “Care Manager Notes,” dated 9/3/2024, the MR indicated, “Care Manager (CM 1) received a message that Patient 4 was accepted at two LTAC facilities.” During an interview on 9/4/2024 at 2:19 p.m. with Care Manager (CM 1), CM 1 stated, “Patient 4 is not capable of making decisions for themselves and has a decision maker that is involved with Patient 4’s care.” CM 1 said, Patient 4 got approved for two LTAC facilities, but Patient 4’s decision maker has not been contacted yet. The CM 1 stated, Patient 4’s decision maker should be involved in discharge planning and should have been notified of Patient 4’s need to go to LTAC, but the CM 1 stated, the physician should have notified the family, not the CM. During an interview, on 9/4/2024 at 2:24 p.m. with the CM 1, the CM 1 stated, typically, the patient and/or the patient’s representative(s) should be involved in discharge planning and their preferences should be considered, but the CM 1 has not had the chance to contact Patient 4’s decision maker due to a heavy workload. 4. During a review of Patient 13’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 7/15/2024, the H&P indicated, Patient 13 was admitted to the facility for left total knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis). During a review of Patient 13’s medical record (MR) titled, “Care Manager (CM) Notes,” dated 7/16/2024, the MR indicated, a request for Home Health Services with Physical therapy (HH/PT), the authorization for HH/PT was received and will be scheduled within 24 hours. During a concurrent interview and record review on 9/5/2024, at 1:13 p.m., with Quality Review Nurse (QRN), Patient 13’s medical record (MR) titled, “Discharge Instructions,” 7/16/2024 was reviewed. The QRN stated, Patient 13’s MR record contained no recorded information regarding HH/PT, the name and the contact information for the agency, and any confirmed arrangements made by the facility prior to patient’s (Patient 13) discharge. During an interview on 9/6/2024, at 10:15 am., with Director of Care Coordination (DCC), the DCC stated, the facility’s discharge planning process required care managers/care coordinators documenting all pertinent information regarding the patient’s discharge information into the patient’s medical record. The DCC further stated, if any services had been arranged by the facility (such as Home Health Services), the information must be communicated to the patient and this information had to be documented in the patient’s medical record. During the same interview on 9/6/2024 at 10:15 a.m., the DCC stated, discharge planning process involves assessing patient needs for placement, reviewing insurance and options for short- and long-term care, and considering preferences. If the patient agrees to placement, “we communicate with the family or patient, notify them, and document the details.” In a follow-up interview on 9/6/2024 at 10:30 a.m., the DCC stated that the facility’s Governing Body had been aware of the ongoing issues with care managers from the managed health plans not documenting or communicating the discharge planning process. The DCC also said, “We (Care Coordination staff) met with the managed health plan’s representatives to discuss the lack of communication with patients, families, and our healthcare team. We offered to oversee their documentation and process, but they declined our involvement.” During the same interview on 9/6/2024, at 10:31 a.m., the DCC stated, “Managed care is responsible for patient management. I met with them earlier this year due to our concerns regarding their care managers not communicating with our facility. We are currently working to include documentation requirements in the contract we are negotiating with them.” During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Instructions,” dated 10/2023, the P&P indicated, “All patients discharged from the Emergency Department will receive verbal and written instructions using discharge documents or an after-care instruction (ACI) containing information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals. Medical doctor, Physician’s assistant or Registered nurse should have patient or significant other sign the ACI. A printed copy should be given to patient or significant other. An original copy should be retained as a permanent part of the patient’s record (instruction sheet) or retain signature page from discharge information.” During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Planning,” dated 3/2021, the P&P indicated, “The goal of discharge plan is to improve or maintain the patient’s health status or provide comfort and support to patients/families/caregivers in the post-acute care transition. The discharge planning process is a collaborative approach that will include the patient, families/caregivers/other patient-identified support persons, attending physicians and other members of the health care plan.” During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Planning,” dated 3/2021, the P&P indicated, “The care coordination team will document the discharge plan in the patient’s medical record on the post-acute needs being addressed. The discharge plan will include the following (but not limited to) procedural documentation components: Patient discharge assessment including date and time initiated. Plan, goals, implementation, and revision of goals. Patient/family/representative participation in response. Date, time, topic, and outcome of any Discharge Planning Conference held.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge Process,” dated, 9/2022, the P&P indicated, “Care coordination will evaluate the patient as early as possible in the hospitalization as possible when the discharge of a patient requires continued services post hospitalization, including extended care facilities or transfer to another facility and home health agency. Care coordination and or Social Worker provides the family with information and facilitates transition from the hospital in a manner which ensures a plan for continuing care.” During a review of facility’s “Amended and Restated Bylaws,” last amended on 02/18/2024, the Bylaws indicated the following. Article VIII, Quality of Professional Services. Section 1. Board of Directors Responsibility. The Board of Directors shall require ...(b) that there is one level of patient care in the Medical Center, so that all patients with the same health problems receive the same level of care, consistent with the professional standards of the community and the Medical Center ...(c) that the person or body (e.g., Medical Staff department or committee) responsible for oversight of each basic and supplemental service provided in the Medical Center, shall cause written policies and procedures to be developed and maintained for such service, and that such policies and procedures are approved by the Board.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 39503 Based on interview and record review the facility failed to ensure for two of 30 sampled patients (Patients 28 and 29) the following: 1. For Patient 28, the condition of admission (COA, a document that included provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits]) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient’s rights to a hospital discharge appeal) was provided to the patient (Patient 28) when, there was no identification of who signed Patient 28’s COA and IMM forms. In addition, the facility failed to ensure Patient 28’s COA and IMM was provided in a language that the patient (Patient 28) understood, in accordance with the facility’s policy and procedure regarding COA and language interpreter services (facilitates communication between the healthcare provider and the patient who does not speak the same language). 2. For Patient 29, the COA was provided in a language that the patient (Patient 29) understood when, there was no information of the Language Interpreter (facilitates communication between the healthcare provider and the patient who does not speak the same language) used in providing the COA information to Patient 29, in accordance with the facility’s policy and procedure regarding language interpreter services. These deficient practices resulted in Patients 28 and 29 to not be informed of their rights as a patient, which may result in Patients 28 and 29’s inability to effectively make decisions regarding their care or treatment. Findings: During a concurrent observation and interview on 9/3/2024 at 1:49 p.m. with the Director of Nursing Administration (DON), Patient 28 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 28 requested to have a Spanish interpreter. Subsequently, Registered Nurse 3 (RN 3) came into Patient 28’s room to interpret. Patient 28 stated she (Patient 28) was admitted to the facility after having a fall (an unintentional event that causes a person to land on the ground or a lower level) at her (Patient 28) house and had pain on her left hip. During a review of Patient 28’s “Inpatient FaceSheet (demographic information),” the facesheet indicated Patient 28 was admitted to the facility on 8/26/2024 and the “Language: Eng (English).” During a review of Patient 28’s “Admission Assessment,” dated 8/26/2024, the assessment indicated Patient 28’s language preference was Spanish. 1.a. During a concurrent interview and record review on 9/4/2024 at 1:23 p.m. with the Director of Registration (DR), Patient 28’s COA (Condition of Admission- a document that included provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits]), was reviewed. The COA indicated on the “Patient Initials,” it was filled with “verbal consent.” Furthermore, Patient 28’s COA indicated on the “Signature (responsible party)” line, was filled out with “verbal consent,” and dated 2/26/2024 at 2:01 p.m., and the “witness (signature)” line was blank. The DR stated, Admitting Staff 1 (AS 1), who gave Patient 28’s COA, had documented on 8/26/2024 at 2:15 p.m., that Patient 28’s family member was called and within minutes the family member called back and gave a verbal consent for the patient’s (Patient 28) COA. The DR stated, AS 1 documented as well that a verbal consent was obtained from Patient 28 prior to family member giving the verbal consent. During the same interview on 9/4/2024 at 1:23 p.m., the DR stated Patient 28’s record indicated the patient was alert and oriented. The DR stated the COA should have been signed by Patient 28 and not a verbal consent. During the same interview on 9/4/2024 at 1:23 p.m., the DR stated AS 1 should have asked Patient 28’s language preference and updated the language preference in the patient’s facesheet. The DR stated Patient 28’s COA should have been given in the language the patient (Patient 28) understood. Furthermore, the DR stated the COA did not have the name of who gave the verbal consent and did not have a witness signature of who obtained the verbal consent. The DR stated the COA was incomplete and therefore was not valid. During a review of the facility’s policy and procedure (P&P) titled, “Condition of Admission,” revised in 7/2024, the P&P indicated the following: - Every patient has a legal right to decide upon the medical treatment he/she is to be given. Therefore, every patient who is admitted to the hospital must sign a Condition of Admission form granting consent for hospital services prior to medical treatment. - Condition of Admission, Financial Letter and Hospital Policies Letter are available in English, Spanish and Chinese. 1.b. During a concurrent interview and record review on 9/4/2024 at 1:23 p.m. with the Director of Registration (DR), Patient 28’s IMM (Important Message from Medicare - a notice given to the patient with Medicare benefits indicating the patient’s rights to a hospital discharge appeal), was reviewed. The IMM indicated on the “Signature of Patient or Representative” line, was filled out with “verbal consent,” and dated 2/26/2024 at 1:55 p.m. The DR stated, Admitting Staff 1 (AS 1), who gave Patient 28’s IMM, had documented on 8/26/2024 at 2:15 p.m., that Patient 28’s family member was called and within minutes the family member called back and gave a verbal consent for the patient’s (Patient 28) IMM. The DR stated, AS 1 documented as well that a verbal consent was obtained from Patient 28 prior to family member giving the verbal consent. During the same interview on 9/4/2024 at 1:23 p.m., the DR stated Patient 28’s medical record indicated the patient (Patient 28) was alert and oriented. The DR stated the IMM should have been signed by Patient 28 and not a verbal consent. During the same interview on 9/4/2024 at 1:23 p.m., the DR stated AS 1 should have asked Patient 28’s language preference and updated the language preference in the patient’s facesheet. The DR stated Patient 28’s IMM should have been given in the language the patient understood. Furthermore, the DR stated the IMM did not have the name of who gave the verbal consent. The DR stated the IMM was incomplete and therefore was not valid. During a review of the facility’s policy and procedure (P&P) titled, “Condition of Admission,” revised in 7/2024, the P&P indicated the following: - Every patient has a legal right to decide upon the medical treatment he/she is to be given. Therefore, every patient who is admitted to the hospital must sign a Condition of Admission form granting consent for hospital services prior to medical treatment. - Condition of Admission, Financial Letter and Hospital Policies Letter are available in English, Spanish and Chinese. 2. During a concurrent observation and interview on 9/3/2024 at 2:04 p.m. with the Director of Nursing Administration (DON), Patient 29 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 29 requested to have a Thai interpreter. Subsequently, the Voyce (a virtual certified medical interpretation device) was brought into Patient 29’s room for an interpreter (facilitates communication between the healthcare provider and the patient who does not speak the same language). During a review of Patient 29’s “Inpatient FaceSheet (demographic information),” the facesheet indicated Patient 29 was admitted to the facility on 8/25/2024 and the “Language: Tai (Thai).” During a review of Patient 29’s “Admission Assessment,” dated 8/25/2024, the assessment indicated Patient 29’s preferred language was Taiwanese. During a concurrent interview and record review on 9/4/2024 at 1:52 p.m. with the DON, Patient 29’s COA indicated the copy was in English version and was signed by Patient 29 on 8/25/2024. The “Interpreter,” information on the COA was blank. The DON stated Patient 29 needed an interpreter and the information of the interpreter used for giving the COA should have been documented. During a review of the facility’s policy and procedure titled, “Language Interpreter Services and Special Needs for the Hearing and Sight Impaired,” dated 12/2021, the P&P indicated the following: - Following interpretation, document in the medical record the interpreters’ name and/or ID number (if applicable), clinician’s name, date of service, and a brief description of interpreter service ...provided. - Voyce (a medical interpretation service) ...Use the dedicated IPAD (computer device) to access the interpreter of the language you need ...The employee is to ...Document the interpreter’s ID (identification) number in the medical record.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 39503 During an observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 28), the safety requirements were implemented when, Patient 28 did not have an Identification (ID) arm band (for identification of all hospital patient) that included the patient’s full name, medical record number, date of birth, age, sex, and name of attending physician), while in the facility as a patient, in accordance with the facility’s policy and procedure regarding patient identification. This deficient practice resulted in Patient 28 to not be accurately identified and had the potential for the patient’s safety, while in the facility, be jeopardized such as with medication errors, etc. due to lack of proper identification. Findings: During a concurrent observation and interview, on 9/3/2024 at 1:49 p.m., with the Director of Nursing Administration (DON), Patient 28 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 28 requested to have a Spanish interpreter. Subsequently, Registered Nurse 3 (RN 3) came into Patient 28’s room to interpret. During the same observation and interview, on 9/3/2024 at 1:49 p.m., Patient 28 was observed not wearing an ID (identification) arm band. Patient 28 stated it fell and it was taped at the end of the bed. RN 3 verified that Patient 28’s ID arm band was taped on the foot of the bed. Patient 28 stated it fell three days ago and that she (Patient 28) asked for a new one, but no one came to give her a new ID arm band. RN 3 stated ID arm band should be on the patient’s wrist for safety. During an interview on 9/3/2024 at 2:23 p.m., with RN 2, RN 2 stated she (RN 2) was aware Patient 28’s ID arm band fell. RN 2 stated she (RN 2) asked the Charge Nurse to print a new one, but she (RN 2) did not get a chance to put it on to Patient 28. RN 2 stated the patient should have an ID arm band with them to ensure safe care specially in administering medications, for correct identification. During a review of Patient 28’s “Hospitalist - H&P (History and Physical, a formal and complete assessment of the patient and the problem),” dated 8/26/2024, the H&P indicated Patient 28 was admitted to the facility after suffering from a recent fall (an unintentional event that causes a person to land on the ground or a lower level). During a review of the facility’s policy and procedure (P&P) titled, “Patient Identification for Clinical Care and Treatment,” revised in 7/2021, the P&P indicated the following: - It is the policy of (name of the facility) to ensure that all patients are properly identified prior to any care, treatment or services provided. - If the Emergency Department (responsible for providing medical and surgical care to patients arriving to the hospital in need of immediate care) patient is converted to inpatient status, the patient will have a hospital identification band applied upon admission to an inpatient care unit, with the Emergency Department identification band removed. - Before any procedures is carried out, the identification band shall be on the patient and will be checked by the responsible care provider for the following (2) identifier to ensure that the right patient is involved: Patient name. Patient date of birth.”

“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: 39503 Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 27), a safe care was provided when: 1. Patient 27’s Morphine (narcotic pain medication) intravenous (IV, inject through the vein) was prepared by Registered Nurse 1 (RN 1) using a contaminated needleless syringe after the tip of the needleless syringe touched the paper towel. This deficient practice had the potential for Patient 27 to suffer from hospital acquired infection and/or transmission of bacteria that can cause infection from the use of contaminated needleless syringe. 2. Patient 27’s call light (a system device used by the patient to call for help) was not within the patient’s (Patient 27) reach. This deficient practice had the potential for Patient 27’s needs to not be met since Patient 27 is unable to call for help with the call light being out of reach and may result in delayed treatment that could have a negative effect on Patient 27’s provision of care. Findings: 1. During an observation and interview on 9/3/2024 at 1:33 p.m. with the Director of Nursing Administration (DON), Registered Nurse 1 (RN 1) was observed preparing a medication inside the Medical Surgical Unit (responsible for the care of patients undergoing surgery or patients with acute [develops suddenly] medical conditions) Medication Room. RN 1 stated he (RN 1) was preparing Morphine 2 milligram (mg, a unit of measurement) IV to administer to Patient 27. RN 1 stated Morphine IV comes in 4 mg per vial, and he (RN 1) would need to waste the 2 mg. RN 2 stated she (RN 2) was there to witness the waste (any leftover, unused, expired medication that is being discarded). During the same observation and interview, 9/3/2024 at 1:33 p.m., RN 1 was observed drawing the entire Morphine 4 mg from the vial using a needless syringe, then RN 1 squirted out 2 mg of Morphine IV into the paper towel that was on the medication counter. The tip of the needleless syringe was touching the paper towel when RN 1 was injecting out the medication into the paper towel and RN 2 was witnessing. RN 1 stated it is the facility’s policy and procedure (P&P) when wasting narcotic medication, to squirt it out first into the paper towel then throw the paper towel with the wasted medication into the pharmaceutical waste bin. Furthermore, RN 1 injected the needless syringe back into the Morphine vial and stated Morphine 2 mg IV was ready to be administered to Patient 27. RN 1 stated he (RN 1) would use the same needleless syringe (contaminated from the paper towel) to give Morphine 2 mg IV to Patient 27. RN 1 acknowledge that the tip of the needleless syringe touched the paper towel when he was squirting out the Morphine into the paper towel. RN 1 and RN 2 did not have concern in using the contaminated needleless syringe to administer Morphine 2 mg IV to Patient 27. During an interview on 9/3/2024 at 1:35 p.m., with the DON, the DON stated the tip of the needleless syringe was contaminated when it touched the paper towel. The DON stated Morphine prepared with the contaminated needleless syringe should not be administered to Patient 27. The DON directed RN 1 to waste the entire Morphine. DON told RN 1 to prepare a new dose without contaminating the needleless syringe. During a review of Patient 27’s “Order Detail,” dated 9/2/2024, the order indicated for Patient 27 to receive Morphine 2 mg IV push every 4 hours as needed for pain. During a record review on 9/4/2024 at 10:56 a.m., with the Pharmacy Operation Manager (POM), the facility’s policy and procedure (P&P) titled, “Waste Management,” revised in 8/2024, indicated, “Controlled Substances ...Liquids and injectable items should be squirted into an absorbent material (gauze, swab, paper towel, etc.) before being placed into the pharmaceutical container.” The POM verified it was the facility’s P&P for wasting narcotic medication. The POM stated it was expected to keep the environment for medication preparation area clean. The POM stated when wasting narcotic medication, it was expected to keep the sterility (free from germs) of the syringe and medication, when it was to be administered to the patient, to prevent cause of an infection to the patient. During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Peripheral: Access and Care,” dated 9/2022, the P&P indicated, “Before every access, disinfect catheter hubs, needleless connectors, and injection ports with a 30 second “hub scrub” using Chlorhexidine (CHG, antiseptic solution) and allow drying.” 2. During an observation on 9/3/2024 at 1:30 p.m. with the Director of Nursing Administration (DON), the Medical Surgical Unit (MSU, responsible for the care of patients undergoing surgery or patients with acute [develops suddenly] medical conditions) was observed. Upon entering the unit, the patient (Patient 27) in room 401 was heard yelling “help.” Subsequently, the DON entered in Room 401 and told the patient that the nurse would come and help. The DON then walked into the nursing station and told a staff to send the nurse immediately in Room 401. During a concurrent observation and interview, on 9/3/2024 at 1:39 p.m., with the DON, Patient 27 was observed in Room 401, was alert and awake, moaning and stating “help me.” Patient 27 had a bilateral hand mitten (restraint, a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), with a peripheral intravenous catheter (PIV, a small flexible catheter placed into peripheral vein for IV therapy) on the right and left forearm, and an indwelling foley catheter (FC, a thin flexible tube that drains urine from the bladder into a bag outside of the body). Patient 27 was wearing a yellow arm band. The DON stated the yellow arm band indicated Patient 27 was a high risk for fall (an unintentional event that causes a person to land on the ground or a lower level). During a concurrent observation and interview on 9/3/2024 at 1:43 p.m., with the DON and Registered Nurse 5 (RN 5), RN 5 stated she (RN 5) was the charge nurse on the unit. RN 5 stated Patient 27 was placed on bilateral hand mitten restraint because the patient was trying to take out her (Patient 27) PIV and FC. RN 5 stated Patient 27 could still use the call light (a system device used by the patient to call for help) and stated she (Patient 27) called for help using the call light earlier in the shift. During the same observation and interview on 9/3/2024 at 1:43 p.m., Patient 27’s call light was not observed within the patient’s reach. The DON tried to look for Patient 27’s call light by tracing the call light cord. The DON found Patient 27’s call light under the two pillows at the back of Patient 27 then the DON placed the call light within the patient’s reach. The DON acknowledged that the call light was under the pillows and Patient 27 was not able to reach. The DON stated the patient’s call light should be within the patient’s reach. During a review of Patient 27’s “HPI (History of Present Illness) - ED (Emergency Department) General,” dated 9/1/2024, the HPI indicated Patient 27 was admitted to the facility with a chief complaint of shortness of breath (difficulty breathing). During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction and Precautions,” dated 12/2021, the P&P indicated, “For patients identified as moderate risk, implement moderate fall risk prevention interventions ...Apply yellow Fall Risk armband ...Call light, urinal, water, and necessary belongings are within reach ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39503 Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 27 and 29), nursing care was provided when: 1.a. Patient 27 was not reassessed (reevaluation of a patient’s health status), in accordance with the facility’s policy and procedure regarding medication policies, after administration of as needed (PRN) medication (Ativan, a sedative and can be used for treatment of anxiety) for agitation (feeling of irritability or severe restlessness). 1.b. Patient 27’s pain was not addressed, in accordance with the facility’s policy and procedure regarding pain management, after the patient (Patient 27) reported to still be in pain after receiving pain medication. These deficient practices had the potential to result in delayed treatment and had the potential to worsen Patient 27’s agitation and pain which can delay recovery from health condition. 2. Patient 29’s surgical wound dressing change was not performed in accordance with the physician’s order. This deficient practice had the potential to result in surgical complication such as wound infection, pain, and delayed wound healing. Findings: 1. During a review of Patient 27’s “HPI (History of Present Illness) - ED (Emergency Department) General,” dated 9/1/2024, the HPI indicated Patient 27 was admitted to the facility with a chief complaint of shortness of breath (difficulty breathing). 1a. During a concurrent interview and record review on 9/4/2024 at 10:46 a.m., with the Director of Nursing Administration (DON), Patient 27’s “Order Detail,” indicated on 9/2/2024 at 9:33 a.m., for Patient 27 to receive Ativan 1 milligram (mg, a unit of measurement) Intravenous (IV, injection of fluid through the vein) push every 4 hours as needed (PRN) for agitation (feeling of irritability or severe restlessness). The DON verified Ativan 1 mg IVP was administered to Patient 27 on the following dates and times: - On 9/2/2024 at 9:42 a.m. and at 8:26 p.m.; and, - On 9/3/2024 at 3:41 a.m. During the same interview and record review on 9/4/2024 at 10:46 a.m., the DON stated Patient 27’s record did not have documentation of Patient 27’s condition after Ativan 1 mg was given for the patient’s (Patient 27) agitation. During a concurrent interview and record review on 9/4/2024 at 10:46 a.m., with the DON, Patient 27’s “Order Detail,” indicated on 9/3/2024 at 12:55 p.m., for Patient 27 to receive Ativan 1.5 mg IVP every 4 hours PRN for agitation. The DON verified Ativan 1.5 mg IVP was administered to Patient 27 on the following dates and times: - On 9/3/2024 at 6:21 p.m. and at 10:11 p.m.; and, - On 9/4/2024 at 3:30 a.m. During the same interview and record review on 9/4/2024 at 10:46 a.m., the DON stated Patient 27’s record did not have documentation of Patient 27’s condition after Ativan 1.5 mg was given for the patient’s agitation. The DON stated it was an expectation for the Registered Nurse (RN) to reassess the patient after giving PRN medication to know if the medication was effective or not and if additional intervention or change in the treatment plan was needed. During a review of the facility’s policy and procedure (P&P) titled, “Medication Policies,” revised in 6/2024, the P&P indicated, “The patient’s response to medication will be monitored. Monitor the patient after the first dose of a medication. Monitor the effects on the patient based on the following ...Clinical responses ...the appropriateness of an expected response ...” 1.b. During a review of Patient 27’s “Order Detail,” the order indicated, on 9/2/2024 at 9:33 a.m., for Patient 27 to receive Morphine 2 milligram (mg, a unit of measurement) intravenous (IV, injection of fluid through the vein) push every 4 hours as needed (PRN) for pain. During a concurrent interview and record review on 9/4/2024 at 10:50 a.m., with the Director of Nursing Administration (DON), the DON stated Patient 27’s record indicated the patient (Patient 27) was given Morphine 2 mg IVP on 9/2/2024 at 9:28 p.m. The DON stated Patient 27’s corresponding pain assessment was 6 out of 10 (pain score of 4-6 was moderate pain) with a comment, “Pt (Patient 27) calling out and grimacing.” The DON stated Patient 27’s pain was reassessed on 9/2/2024 at 10:06 pm, the pain score was 6 out of 10 (moderate pain) with a comment, “No change in pts status. Calling out and grimacing.” During the same interview on 9/4/2024 at 10:50 a.m., the DON stated there was no documentation that Patient 27’s pain was addressed after pain reassessment indicating the patient was still in pain. The DON stated the nurse should have notified the physician for new orders and/or pain intervention for Patient 27’s pain. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” revised in 7/2023, the P&P indicated, “Pain reassessment to assess if the pain medication is working or if there are any adverse effect must be completed ...If unable to maintain an acceptable pain level as defined above, the chain of command may be enacted upon joint consideration between the patient and the caregiver ...” 2. During a review of Patient 29’s “General Surgery H&P (History and Physical, a formal and complete assessment of the patient and the problem),” dated 8/25/2024, the H&P indicated, Patient 29 was admitted for a laparoscopic (a minimally invasive surgical procedure that uses camera and small incision to examine or treat conditions in the abdomen or pelvis) versus (vs) open appendectomy (a surgical procedure that removes the appendix [a small, finger-shaped organ that is attached to the large intestine] through a large incision in the lower right abdomen). During a review of Patient 29’s “Order Detail,” dated 8/29/2024, the order indicated, “Clean with NS (normal saline, cleaning solution), gauze, apply foam dressing to lap site (laparoscopic surgical incision) daily and PRN (as needed). During a review of Patient 29’s “Wound Assessment,” dated 8/27/2024 through 9/4/2024, the assessment indicated Patient 29’s wound dressing was changed on 8/29/2024 and 8/31/2024. During an interview on 9/4/2024 at 1:52 p.m. with the Director of Nursing Administration (DON), the DON stated Patient 29’s wound dressing change was ordered daily. Patient 29’s record had no documentation that the wound dressing was changed daily, it was only changed on 8/29/2024 and 8/31/2024. The DON stated the physician’s order should be followed to help prevent wound infection and promote wound healing. During a review of the facility’s policy and procedure (P&P) titled, “Postoperative Care,” dated 4/2023, the P&P indicated, “Continuing Postoperative Care ...Dressings are changed per physician order.””

“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: 39503 Based on interview and record review, the facility failed to ensure for two of five employee files reviewed (Registered Nurse [RN] 1 and RN 5), the evaluation process to ensure the RNs were competent (includes competencies for Performance Expectations, Risk Management, Department Response to Code Calls [Example is Code Blue- an emergency code that indicates an adult patient is in critical condition], Triage Assessment [categorize patients based on the severity of their injuries]) in their assigned RN positions were implemented, in accordance with the facility’s policy and procedure regarding unit orientation and required competencies (the knowledge, skills, and behaviors that healthcare professionals need to perform their jobs) . This deficient practice had the potential for the RNs’ inability to perform the essential functions of their respective positions due to lack of competencies, which may compromise patient safety when patient care interventions were not performed appropriately. Findings: 1. During a concurrent interview and record review on 9/5/2024 at 1:23 p.m., with the Human Resources Information System Supervisor (HRIS), the HRIS stated Registered Nurse (RN) 1 was hired on 10/20/2023 as Medical Surgical RN. During a review of RN 1’s “Medical Surgical Unit (responsible for the care of patients undergoing surgery or patients with acute [develops suddenly] medical conditions) RN Competency (the knowledge, skills, and behaviors that healthcare professionals need to perform their jobs),” dated 8/2021, the form indicated the following: - Self-Assessment: The nurse is to complete the self-assessment column PRIOR to unit-based orientation in order for the preceptor to individualize the learning needs of the orientee. The following numerical codes are to be used: 1 = Need to learn the skill, new or fairly unfamiliar with concept/task ... - Competent: The preceptor/mentor is to date and initial this column when the orientee has validated competency in stated measurable criteria. The method used to measure their performance should be included using the following codes: O = observed; W = written test; N/A = Not Applicable; V = Verbalized; S = Skills demonstrated; D = Demonstrated; M= Self-study. Further review of RN 1’s competency form indicated the following signature: - RN 1 signed on 10/7/2023 - Preceptor 1 signed on 10/7/2023 - Preceptor 2 signed on 10/7/2023 - Director of Nursing Administration signed on 1/16/2024 During a concurrent interview and record review, on 9/5/2024 at 1:36 p.m., with the Director of Education (DE), the DE verified RN 1’s RN Competency had multiple scores of 1 in different categories such as: Performance Expectations, Risk Management, Infection Control, Assessment and Care, and Medication Administration. The DE stated RN 1 self-evaluated and the score of 1 means RN 1 was not competent. During the same interview and record review, on 9/5/2024 at 1:36 p.m., the DE stated on the “Competent” column, Preceptors 1 and 2 had signed and dated each item but did not indicate how RN 1’s performance was measured. Duirng the same interview on 9/5/2024 at 1:36 p.m., the DE stated RN 1 was new grad (graduate) and there was supposed to have been frequent meetings with RN 1 as part of the new grad program for follow-up on training plans to address RN 1’s training needs. The DE stated there was no documentation of the follow-up meetings made with RN 1 and there should be one. Furthermore, the DE stated there was no documentation that RN 1 was reevaluated for the skills with self-evaluation score of 1 (need to learn). The DE stated the RN competency record was not followed and filled out correctly to show RN 1 was competent to perform the job of an RN. During a review of the facility’s policy and procedure (P&P) titled, “Orientation,” dated 5/2023, the P&P indicated, “Unit Specific Orientation ...The preceptor and designated staff assigned to help the orientee will monitor and document successful completion of required competencies. The appropriate department leader, preceptor, and orientee will meet during the orientation to ensure identified objectives are being met ...” 2. During a concurrent interview and record review on 9/5/2024 at 1:38 p.m., with the Human Resources Information System Supervisor (HRIS), the HRIS stated RN 5 was hired on 1/18/2022 as Emergency Services RN. During a review of RN 5’s “Emergency Department RN Competency (the knowledge, skills, and behaviors that healthcare professionals need to perform their jobs),” dated 7/2020, the form indicated the following: - Self-Assessment: The nurse is to complete the self-assessment column PRIOR to unit-based orientation in order for the preceptor to individualize the learning needs of the orientee. The following numerical codes are to be used: 1 = Need to learn the skill, new or fairly unfamiliar with concept/task ... - Competent: The preceptor/mentor is to date and initial this column when the orientee has validated competency in stated measurable criteria. The method used to measure their performance should be included using the following codes: O = observed; W = written test; N/A = Not Applicable; V = Verbalized; S = Skills demonstrated; D = Demonstrated; M= Self-study. Further review of RN 1’s competency form indicated the following signature: - RN 5 signed on 4/13/2022 - Preceptor 3 signed on 4/13/2022 - Preceptor 4 signed on 4/13/2022 - Preceptor 5 signed on 4/22/2022 - The Director signed on 4/13/2022 During a concurrent interview and record review, on 9/5/2024 at 1:40 p.m., with the Director of Education (DE), the DE verified RN 5’s RN Competency had multiple scores of 1 in different categories such as: Performance Expectations, Risk Management, Department Response to Code Calls (Example is Code Blue- an emergency code that indicates an adult patient is in critical condition) , Triage Assessment (categorize patients based on the severity of their injuries), Assessment and Care, Medication Administration, Sedation (a state of relaxation or sleepiness that is caused by certain drugs) and Miscellaneous. The DE stated RN 5 self-evaluated and the score of 1 means RN 5 was not competent. During the same interview and record review, on 9/5/2024 at 1:40 p.m., the DE stated on the “Competent” column, Preceptors 3,4, and 5 had signed and dated each item but did not indicate how RN 5’s performance was measured. The DE stated the RN competency record was not followed and filled out correctly to show RN 5 was competent to perform the job of an RN. During a review of the facility’s policy and procedure (P&P) titled, “Orientation,” dated 5/2023, the P&P indicated, “Unit Specific Orientation ...The preceptor and designated staff assigned to help the orientee will monitor and document successful completion of required competencies. The appropriate department leader, preceptor, and orientee will meet during the orientation to ensure identified objectives are being met ...””

“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: 46238 Based on observation, interview and record review the facility failed to: 1. Ensure nursing staff re-assessed and documented vital signs (VS, measurements of the body’s basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body’s overall condition), prior to discharge from the emergency department (ED, a part of a hospital for treating people who have just come to the hospital) for two of 30 sampled patients (Patient 2 and Patient 3), in accordance with the facility’s policy and procedure regarding obtaining VS before discharge. This deficient practice had the potential for Patient 2 and Patient 3’s health condition to be unstable and unsafe to leave the facility. 2. Ensure nursing staff assessed and documented pain level for one of 30 sampled patients (Patient 2) after administration of Toradol (a nonsteroidal anti-inflammatory drug (NSAID) to relieve pain and reduce inflammation) medication as per the facility’s policy and procedure regarding patient’s pain assessment and re-assessment after administering an analgesic (a class of medications designed specifically to relieve pain). This deficient practice had the potential for Patient 2’s pain to worsen and negatively impact Patient 2’s physical and emotional well-being if pain management was not effective. 3. Ensure nursing staff obtained and documented Vital Signs (VS) in accordance with the facility’s CIWA protocol (Clinical Institute Withdrawal Assessment) that is used to assess and manage alcohol withdrawal symptoms to ensure the safe treatment of patients at risk for alcohol withdrawal syndrome (AWS) when VS frequency for one of 30 sampled patients (Patient 5) was not monitored and recorded at a required frequency. This deficient practice had the potential for Patient 5’s worsening symptoms, such as increasing heart rate and blood pressure to go unnoticed resulting in negative outcomes for Patient 5, such as seizures (a sudden, uncontrolled burst of electrical activity in the brain) or delirium tremens (DTs- a severe and life-threatening form of alcohol withdrawal), which is associated with high mortality (death) if untreated. 4.a. Ensure, for one of 30 sampled patients (Patient 28), who was considered a high risk for fall (an unintentional event that causes a person to land on the ground or a lower level), had a yellow armband, in accordance with the facility’s policy and procedure regarding fall management. This deficient practice had the potential to result in an unsafe care that may lead to Patient 28 suffering from a fall injury. 4.b. Ensure, for one of 30 sampled patients (Patient 28), had a properly labeled peripheral IV (Intravenous- through the vein) dressing to indicate the date the IV cannula was inserted, in accordance with the facility’s policy and procedure regarding IV access care. This deficient practice had the potential to cause complications for Patient 28 such as infection, pain in the IV access site, etc. 5. Ensure, for Patient 29, the fall risk intervention was implemented in accordance with the facility’s policy and procedure regarding fall management when, Patient 29 did not have a fall (an unintentional event that causes a person to land on the ground or a lower level) risk sign at the patient’s door and a yellow arm band that indicated the patient (Patient 29) was at risk for fall. This deficient practice had the potential to result in an unsafe care that may lead to Patient 29 suffering from a fall injury. 6. Provide one of 30 sampled patients (Patient 2) with necessary medical information/discharge instructions for follow-up, upon Patient 3’s discharge from the facility, in accordance with the facility’s policy and procedure regarding discharge instructions. This deficient practice had the potential for Patient 2 not being aware of the outcome of hospital treatment or follow-up care needs which could compromise patients’ outcomes after discharge. Findings: 1.a. During a review of Patient 2’s medical record (MR) titled, “History of Present Illness,” (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it), dated 9/3/2024, the HPI indicated, Patient 2 was seen in the ED on 9/3/2024 for the evaluation of hand pain. During a review of Patient 2’s MR titled, “History of Present Illness,” dated 9/3/2024, the MR indicated, Patient 2 arrived at the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) on 9/3/2024, at 10:51 a.m. The MR further indicated, Patient 2’s first set of vital signs (VS, measurements of the body’s basic functions, such as temperature [T], pulse [P], respiration rate [RR], and blood pressure [BP] that provide critical information about the body’s overall condition) was obtained and documented at 10:51 a.m. During a review of Patient 2’s “Vital Signs” record, dated 9/3/2024 at 10:51 a.m., the record indicated, Patient 2’s temperature was 98.5 F (Fahrenheit, a unit of temperature measurement), Pulse was 88 bpm (beats per minute), breathing rate was 16 breaths per minute (bpm), and BP was 163/102 mm Hg (millimeters of mercury- a unit of measurement) (a BP reading of 163/102 indicates that both systolic [163, pressure in the arteries when the heart contracts and pumps blood out into the body] and diastolic [102, pressure in the arteries when the heart is at rest] pressures are elevated, with the diastolic pressure being particularly high. This level of hypertension increases the risk of cardiovascular issues such as heart disease, stroke, and kidney damage). During an interview on 9/3/2024 at 1:42 p.m. with charge nurse (CN 1), in the emergency department (ED, a part of a hospital for treating people who have just come to the hospital, need to be treated quickly), the CN 1 stated, typically, vital signs in ED area were obtained every two hours, and there was no need to check VS before patients’ discharge from the facility. During a review of Patient 2’s medical record (MR) titled, “After-Care Instructions (ACI, contains patient visit information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals),” dated 9/3/2024, the ACI Indicated, Patient 2 was discharged on 9/3/2024 at 1:05 p.m. During a concurrent interview and record review on 9/4/2024 at 10:24 a.m. with Quality Review Nurse (QRN), Patient 2’s “Vital Signs” record, dated 9/3/2024, was reviewed. The record indicated, on 9/3/2024, Patient 2’s vital signs were only obtained and recorded at 10:51 a.m. The QRN stated, Patient 2’s vital signs were not obtained and documented prior to Patient 2’s departure from Emergency Department at 1:05 p.m., in accordance with the facility’s policy and procedure regarding “Vital Signs.” During a review of the facility’s Policy and Procedure (P&P) titled, “Vital Signs (VS), Emergency Department,” dated 10/2023, the P&P indicated, “All person’s presenting to the Emergency Department will have their vital signs assessed during triage and as appropriate during the ED stay. All patients’ vital signs will be re-assessed within half hour (30 minutes) of their discharge/transfer from Emergency Department. 1.b. During a review of Patient 3’s medical record (MR) titled, “History of Present Illness (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it),” dated 9/3/2024, the HPI indicated, Patient 3 was seen in the ED (Emergency Department) on 9/3/2024 for the evaluation of right heel pain. During further review of Patient 3’s MR titled, “HPI,” dated 9/3/2024, the MR indicated, Patient 3 arrived at the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) on 9/3/2024, at 10:44 a.m. During a review of Patient 3’s “Vital Signs (VS, measurements of the body’s basic functions, such as temperature [T], pulse (P), respiration rate [RR], and blood pressure [BP] that provides critical information about the body’s overall condition) record,” dated 9/3/2024 at 10:44 a.m., the record indicated, Patient 3’s temperature was 98.2 F (Fahrenheit, a unit of temperature measurement), Pulse was 81 bpm (beats per minute), breathing rate was 17 breaths per minute, and BP was 121/70 mmHg (millimeters of mercury, a unit of measurement) (120/70 means the systolic pressure [120] is at the high end of the normal range, while the diastolic pressure [70] is well within the normal range). During an interview on 9/3/2024 at 1:42 p.m., with charge nurse (CN 1), in the emergency department, the CN 1 stated, typically, vital signs in the ED area obtained every two hours, and there is no need to check VS before patients’ discharge from the facility. During a review of Patient 3’s medical record (MR) titled, “After-Care Instructions” (ACI, contains patient visit information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals), dated 9/3/2024, the MR Indicated, Patient 3 was discharged on 9/3/2024 at 12:34 p.m. During a concurrent interview and record review on 9/4/2024, at 1:26 p.m. with Quality Review Nurse (QRN), Patient 3’s “Vital Signs” record, dated 9/3/2024, was reviewed. The record indicated, on 9/3/2024, Patient 3’s vital signs were only obtained and recorded one time, at 10:44 a.m. The QRN stated, Patient 3’s vital signs were not obtained and documented prior to Patient 3’s departure from the Emergency Department at 12:34 p.m., in accordance with the facility’s policy and procedure regarding “Vital Signs.” During a review of the facility’s Policy and Procedure (P&P) titled, “Vital Signs (VS), Emergency Department,” dated 10/2023, the P&P indicated, “All person’s presenting to the Emergency Department will have their vital signs assessed during triage and as appropriate during the ED stay. All patients’ vital signs will be reassessed within half hour (30 minutes) of their discharge/transfer from Emergency Department. 2. During a review of Patient 2’s medical record (MR) titled, “History of Present Illness (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it),” dated 9/3/2024, the HPI indicated, Patient 2 was seen in the ED on 9/3/2024 for the evaluation of hand pain. During a review of Patient 2’s MR titled, “HPI,” dated 9/3/2024, the MR indicated, Patient 2 arrived at the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) on 9/3/2024, at 10:51 a.m. During a review of Patient 2’s medical record (MR) titled, “Pain Assessment,” dated 9/3/2024, the MR indicated, on 9/3/2024, at 10:51 a.m. Patient 2’s pain level was recorded 4 out 10 (Pain scale is categorized as 0: No pain, 1-3: Mild pain, 4-6: Moderate pain, 7-9: Severe pain,10: Worst possible). During review of Patient 2’s Medication Administration Record (MAR), dated 9/3/2024, the MAR indicated, on 9/3/2024 at 12:09 p.m., Patient 2 was administered 30 milligrams (mg, measuring unit) of Toradol (a nonsteroidal anti-inflammatory drug (NSAID) that’s used to relieve moderate-to-severe pain) IM (intramuscularly, a method of injecting a medication into a muscle). During an interview on 9/3/2024 at 1:41 p.m., with charge nurse (CN 1) and Chief Nursing Officer (CNO), in the emergency department, the CN 1 stated, typically, nurses re-assess (re-evaluation of patient’s functioning, health and any changes since the initial or most recent assessment and or intervention to determine new or ongoing needs) all patients who receive pain medications within 20 minutes after administration. The CN 1 further stated re-assessment was done to establish if pain medication administered was effective and to ensure patients do not experience any side effects (unwanted undesirable effects that are related to a drug). The CNO stated, per the facility’s policy and procedure (P&P), pain re-assessment should be done within 60 minutes of intervention. During a concurrent interview and record review on 9/4/2024, at 10:27 a.m., with Quality Review Nurse (QRN), Patient 2’s MR titled, “Pain Assessment”, dated 9/3/2024, was reviewed. The MR indicated, on 9/3/2024, Patient 2’s pain level was only recorded one time, at 10:51 a.m., when Patient 2 arrived at the facility. The QRN stated, Patient 2’s medical record contained no additional documentation of Patient 2’s pain level being re-assessed after Patient 2 received 30 mg of Toradol IM. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Management Plan,” dated 7/2023, the P&P indicated, “it is the philosophy of the organization that every patient has the right to be as pain free as possible, and that patients should have access to the best level of pain relief that may be safely provided. Definition of pain level for 0-10 scale is as follows: Mild pain 1-3; Moderate pain 4-6; Severe Pain 7-10. All patients will be assessed for their perceptions of satisfactory pain control. Pain assessment to assess if the pain medication is working or if there are any adverse effects must be completed within 60 minutes of intervention and documented.” 3. During a review of Patient 5’s medical record (MR) titled, “History of Present Illness,” (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it), dated 9/2/2024, the MR indicated, Patient 5 was admitted to the facility for evaluation of chest pain and palpitations (having a rapid, strong, or irregular heartbeat). During a review of Patient 5’s MR titled, “HPI,” dated 9/2/2024, the MR indicated, Patient 5 had past medical history (PMH, a patient’s complete record of health-related events and conditions experienced prior to the current visit or assessment and includes previous diagnoses, treatments, surgeries, hospitalizations, and chronic conditions that may impact their current health status) of alcohol abuse and liver cirrhosis (chronic liver disease characterized by the irreversible scarring [fibrosis] of the liver). During a review of Patient 5’s MR titled, “Physician’s Orders,” dated 9/3/2024, the MR indicated, on 9/3/2024 at 6:01 a.m., the physician ordered CIWA-Ar protocol (The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar, used to assess the severity of alcohol withdrawal for patients admitted with a diagnosis of alcohol withdrawal). The MR indicated, the CIWA-Ar protocol order indicated to perform and document CIWA-Ar assessment with Vital Signs (VS, measurements of the body’s basic functions, such as temperature [T], pulse [P], respiration rate [RR], and blood pressure [BP] that provide critical information about the body’s overall condition) and Pulse Oximetry reading (measures the oxygen saturation level [SpO?] in the blood, indicating how much oxygen is being carried by the red blood cells to body organs and tissues) at the following frequency (based on CIWA-Ar score): CIWA-Ar score of 0-7, every 4 hours CIWA-Ar score of 8-15, every 2 hours CIWA -Ar score of 16-42 Every 1 hour CIWA-Ar score of 25 or > (more) Every 30 min During a review of Patient 5’s “Vital Signs” record dated 9/3/2024, the record indicated, on 9/3/2024, first complete set of VS was recorded at 8:24 a.m. as follows: BP 128/64 mm Hg (millimeters of mercury, a unit of measurement), Pulse 100 beats per minute (bpm), SpO2 98%. The record further indicated, second complete set of Patient 5’s VS was recorded at 3:00 p.m. as follows: BP132/64 mm Hg, Pulse 120 bpm (considered high for adults and is referred to as tachycardia, which is an abnormally fast heart rate. The normal resting heart rate for adults typically ranges between 60 and 100 bpm), then at 4:38 p.m. BP 140/77 mm Hg, Pulse 124 bpm, SpO2 94% (indicates that the oxygen saturation level in the blood is at 94%, which is slightly below the normal range [95%-100% is normal range]), and then at 8:00 p.m. BP 144/78 mm Hg, Pulse 120 bpm, SpO2 97%. During concurrent interview and record review on 9/4/2024 at 2:09 p.m., with Quality Review Nurse (QRN), Patient 5’s MR titled, “Vital Signs,” dated 9/3/2024 from 8:24 a.m. to 8:00 p.m. and CIWA-Ar assessment record, dated 9/3/2024 from 6:14 a.m. to 11:59 p.m., was reviewed. The “Vital Signs” record indicated, Patient 5’s VS were obtained and recorded 5 times at 8:24 a.m., 3:00 p.m., 4:38 p.m., 8 p.m., and 11:59 p.m. The CIWA-Ar assessment record indicated: At 6:14 a.m., Patient 5’s CIWA-Ar assessment had a total score of 8 (requires assessment of VS every 2 hours, as per protocol). At 2:00 p.m., Patient 5’s CIWA-Ar assessment total score was 8 At 3:00 p.m., Patient 5’s CIWA-Ar assessment total score was 13 (requires assessment of VS every 2 hours, as per protocol) At 4:00 p.m., Patient 5’s CIWA-Ar assessment total score was 13 From 8 p.m. to 11:43 p.m., Patient 5’s CIWA-Ar total score was 10, unchanged (requires assessment of VS every 2 hours, as per protocol). The QRN nurse stated, VS were not obtained and recorded as per the physician’s order and in accordance with the facility’s CIWA-Ar protocol (to obtain and record VS and SpO2 level with each CIWA-Ar assessment). During a review of the facility’s Policy and Procedure (P&P) titled, “Alcohol Withdrawal Syndrome,” dated 6/2024, the P&P indicated, “The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) will be used to assess the severity of alcohol withdrawal for patients admitted with a diagnosis of alcohol withdrawal and/or patients who have a physicians’ order for alcohol withdrawal. It is a ten (10) item survey that is administered at bedside and is performed by assessing and rating each of the ten criteria of the CIWA-Ar scale. Each score for all 10 criteria is added after each assessment and indicate the total CIWA-Ar score for the patient. CIWA-Ar assessment is to be performed at a frequency as indicated: CIWA-Ar score of 0-7, every 4 hours CIWA-Ar score of 8-15, every 2 hours CIWA -Ar score of 16-42 Every 1 hour CIWA-Ar score of 25 or > (more) Every 30 min Record vital signs and oxygen saturation level with each CIWA-Ar assessment. 4.a. During a concurrent observation and interview, on 9/3/2024 at 1:49 p.m. with the Director of Nursing Administration (DON), Patient 28 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 28 requested to have a Spanish interpreter. Subsequently, Registered Nurse 3 (RN 3) came into Patient 28’s room to interpret. Patient 28 stated she(Patient 28) was admitted to the facility after having a fall (an unintentional event that causes a person to land on the ground or a lower level) at her house and had pain on her left hip. During the same observation and interview, on 9/3/2024 at 1:49 p.m., Patient 28 was observed not wearing any armband. The DON stated if Patient 28 was a high risk for fall, the patient should be wearing a yellow armband. During a review of Patient 28’s “Hospitalist - H&P (History and Physical, a formal and complete assessment of the patient and the problem),” dated 8/26/2024, the H&P indicated Patient 28 was admitted to the facility after suffering from a recent fall. During a concurrent interview and record review, on 9/4/2024 at 11:24 a.m., with the DON, Patient 28’s “Morse Fall Scale (a rapid and simple method of assessing a patient’s likelihood of falling),” from 8/26/2024 through 9/4/2024, the scale indicated Patient 28’s risk score was from 60 to 85 (score of above 45 is high risk for fall). The DON stated Patient 28 was a high risk for fall. The DON stated Patient 28 should have a yellow armband to ensure the staff were aware of her (Patient 28) high risk and preventive measure would be implemented to help prevent Patient 28 from suffering a fall. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction and Precautions,” dated 12/2021, the P&P indicated, “For patients identified as moderate risk, implement moderate fall risk preventions...Apply yellow Fall Risk armband...In addition to above strategies, for patients identified as high risk, implementing high risk prevention interventions ...” 4.b. During a concurrent observation and interview, on 9/3/2024 at 1:49 p.m., with the Director of Nursing Administration (DON), Patient 28 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 28 requested to have a Spanish interpreter. Subsequently, Registered Nurse 3 (RN 3) came into Patient 28’s room to interpret. During the same observation and interview, on 9/3/2024 at 1:49 p.m., Patient 28 was observed to have a PIV (Peripheral Intravenous line, inserted through the vein) on the right arm. RN 3 verified Patient 28’s PIV dressing did not have a label, RN 3 stated PIV dressings should have a label indicating the date the PIV was inserted. Patient 28 stated the PIV was inserted when she (Patient 28) was admitted to the unit (On 8/26/24). During a review of Patient 28’s “Hospitalist - H&P (History and Physical, a formal and complete assessment of the patient and the problem),” dated 8/26/2024, the H&P indicated Patient 28 was admitted to the facility after suffering from a recent fall (an unintentional event that causes a person to land on the ground or a lower level). During a review of Patient 28’s “IV/Invasive Line, Place/Manage,” flowsheet from 8/27/2024 at 8 p.m., through 9/3/2024 at 8 a.m., the flowsheet indicated Patient 28’s PIV on the right wrist was inserted on 8/27/2024 (Patient 28’s PIV on the right wrist was in place for a total of 7 days). During an interview on 9/4/2024 at 11:24 a.m., with the DON, the DON verified Patient 28’s record review of PIV insertion date was accurate. The DON stated the patient’s PIV should be changed every 96 hours (4 days) as indicated in the P&P (policy and procedure). During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy Peripheral: Access and Care,” dated 9/2022, the P&P indicated, “All peripheral IV sites are to be changed every 96 hours, unless veins are difficult to access and maintain.” 5. During a concurrent observation and interview on 9/3/2024 at 2:04 p.m., with the Director of Nursing Administration (DON) and Registered Nurse 2 (RN 2), Patient 29 was observed in bed, alert, awake, and oriented (a person’s level of awareness of self, place, time, and situation). Patient 29 had a nasogastric tube (a flexible tube that’s inserted through the nose, down the throat and esophagus, and into the stomach) to low intermittent suction (a method of applying suction to stomach in intervals) draining dark brown thin fluid. Patient 29 stated he (Patient 29) had abdominal surgery. During the same observation and interview on 9/3/2024 at 2:04 p.m., Patient 29 was observed to only have the ID armband. Subsequently, RN checked Patient 29’s door and verified there was no “fall risk” signage posted. The DON stated, if Patient 29 was at risk for fall, the patient should have yellow armband and “fall risk” signage posted at the door. During a review of Patient 29’s “General Surgery H&P (History and Physical, a formal and complete assessment of the patient and the problem),” dated 8/25/2024, the H&P indicated, Patient 29 was admitted for a laparoscopic (a minimally invasive surgical procedure that uses camera and small incision to examine or treat conditions in the abdomen or pelvis) versus (vs) open appendectomy (a surgical procedure that removes the appendix [a small, finger-shaped organ that is attached to the large intestine] through a large incision in the lower right abdomen). During a concurrent interview and record review, on 9/4/2024 at 1:52 p.m., with the DON, Patient 29’s “Morse Fall Scale (a rapid and simple method of assessing a patient’s likelihood of falling),” from 8/31/2024 at 8 p.m., through 9/4/2024 at 8 a.m., the scale indicated Patient 29’s risk score was from 35 (25 - 45 is moderate risk for fall). The DON stated Patient 29 was a moderate risk for fall and should have a yellow armband and “fall risk” signage at the door as indicated in the P&P. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction and Precautions,” dated 12/2021, the P&P indicated, “For patients identified as moderate risk, implement moderate fall risk preventions...Apply yellow Fall Risk armband. Apply yellow Fall Risk magnet to door frame.” 6. During a concurrent observation and interview on 9/3/2024 at 1:42 p.m., with charge nurse (CN 1), in the emergency department (ED, a part of a hospital for treating people who have just come to the hospital, need to be treated quickly) Patient 2’s medical records were observed placed along with other patients’ records, for medical records department (MRD, a vital part of a hospital or healthcare facility that stores and manages patient medical records ) to pick up charts for scanning. Patient 2’s cover sheet contained a handwritten word “Verbal” written on the sheet. The CN 1 stated, Patient 2 was discharged from the ED with verbal instructions. The CN 1 stated, at times, ED providers discharge patients to home, without printing After-Care Instructions (ACI, containing information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals) and only providing them with verbal instructions for follow-up care. During an interview on 9/3/2024, at 1:42 p.m., with the CN 1, the CN 1 stated, the facility’s ED discharge process requires the provider to place a discharge order, and then speak with the patient regarding their results. The CN 1 further stated, the nurse should print the AVI and go over the instructions with the patient and provide educations if necessary. The CN 1 stated, the patient has to sign the ACI upon discharge and the signed paged is retained by the facility. During a review of Patient 2’s medical record (MR) titled, “History of Present Illness (HPI, a detailed account of a patient’s current health issue, including the symptoms and conditions that led to it),” dated 9/3/2024, the HPI indicated, Patient 2 was seen in the ED on 9/3/2024 for the evaluation of hand pain. During a review of Patient 2’s HPI, dated 9/3/2024, the HPI indicated, Patient 3 was discharged in a stable condition with instructions to follow-up with their primary care physician for further evaluation and management within a week. During a concurrent interview and record review on 9/4/2024, at 10:24 a.m., with Quality Review Nurse (QRN), Patient 2’s ACI, dated 9/3/2024, was reviewed. The AVI indicated, Patient 2 did not sign the ACI and a handwritten “Verbal” at 1:05 p.m. was written on the first page of the ACI indicating that Patient 2 did not receive printed after-visit information. The QRN stated, Patient 2 was not provided with printed discharge instructions as per the facility’s policy. During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Instructions,” dated 10/2023, the P&P indicated, “All patients discharged from the Emergency Department will receive verbal and written instructions using discharge documents or an after-care instruction (ACI) containing information about procedures and tests performed, follow-up care, medication reconciliation, specific instructions, and referrals. Medical doctor, Physician’s assistant or Registered nurse should have patient or significant other sign the AVI. A printed copy should be given to patient or significant other. An original copy should be retained as a permanent part of the patient’s record (instruction sheet) or retain signature page from discharge information.””

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to: 1. Include one of 30 sampled patients (Patient 4) and/or Patient 4’s designated family representative in discharge planning (the process of transitioning a patient from one level of care to another) when arranging for a discharge of Patient 4 to a long-term acute care facility (LTAC, a type of specialized hospital care for patients with serious medical conditions that require ongoing treatment but no longer need intensive care). In addition, the facility failed to discuss the results of discharge planning and did not include Patient 4’s and/or Patient 4’s representative’s preferences regarding post (after)-discharge care. This deficient practice had the potential for Patient 4 and Patient 4’s representatives to not fully understand the discharge care needs of Patient 4 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice also had the potential to violate Patient 4 and/or Patient 4’s family/representative’s right to participate in discharge planning. 2. Actively engage one of thirty (30) sampled patients (Patient 1) and/or patient’s family/ representative(s) in the development of a discharge plan for Patient 1 as well as failed to discuss the discharge plan evaluation with Patient 1’s family representative, in accordance with the facility’s policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home). This deficient practice had the potential for Patient 1 and Patient 1’s representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1’s rights when the patient (Patient 1) and/or Patient 1’s representative were not included in Patient 1’s discharge planning. Findings: 1. During a review of Patient 4’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 8/31/2024, the H&P indicated, Patient 4 had past medical history (PMH, records information about the patient’s medical, personal and family history that might be relevant to the presenting illness) of end-stage renal disease (ESRD, a medical condition where the kidneys permanently stop functioning, requiring dialysis or a kidney transplant to remain alive), hypertension (HTN, a chronic medical condition that refers to high blood pressure), ventilator dependent (when a patient is unable to breathe independently and requires a ventilator [breathing machine] for extended periods of time). The H&P further indicated, Patient 4 was admitted for shortness of breath (difficulty breathing) and tachypnea (rapid breathing). During further review of Patient 4’s H&P, dated 8/31/2024, the H&P indicated, Patient 4 was not able to communicate effectively. During a review of Patient 4’s medical record (MR) titled, “Care Manager (CM, a professional who works with patients, their families, and the medical team to ensure that patients receive the appropriate care and services they need) Notes,” dated 9/2/2024, the MR indicated, Patient 4 was admitted from (Name of Organization) subacute facility (a place that provides long-term care for patients who need more intensive care than a skilled nursing facility but less than acute care). During further review of Patient 4’s MR titled, “Care Manager Notes,” dated 9/2/2024, the MR indicated, “Order for LTAC (long-term acute care, a type of specialized hospital care for patients with serious medical conditions that require ongoing treatment but no longer need intensive care)-choice list provided. During a review of Patient 4’s MR titled, “Care Manager Notes,” dated 9/3/2024, the MR indicated, “Care Manager (CM 1) received a message that Patient 4 was accepted at two LTAC facilities.” During an interview on 9/4/2024, at 2:19 p.m., with Care Manager (CM 1), the CM 1 stated, “Patient 4 is not capable of making decisions for themselves and has a decision maker that is involved with Patient 4’s care.” The CM 1 stated, Patient 4 got approved for two LTAC facilities, but Patient 4’s decision maker has not been contacted yet. The CM 1 stated, Patient 4’s decision maker should be involved in discharge planning and should have been notified of Patient 4’s need to go to LTAC, but the CM 1 stated, the physician should have notified the family, not the CM. During an interview, on 9/4/2024, at 2:24 p.m., with the CM 1, the CM 1 stated, typically, the patient and/or the patient’s representative(s) should be involved in discharge planning and their preference should be considered, but the CM 1 has not had the chance to contact Patient 4’s decision maker due to a heavy workload. During an interview on 9/6/2024, at 10:15 a.m., with DCC, the DCC stated, discharge planning process begins on admission and discharge planning evaluation for anticipated patient needs should be done within 24 hours. The DCC stated, if a patient requires placement, the care manager should review the patient’s insurance, the length of placement required, patient needs, and preferences and then discuss it with the patient or the patient’s representative(s). The DCC further said, care managers should document all communication between the patient and/or family member (s) in the patient’s medical record. The DCC stated, patients and/or a patients’ representative(s) were expected to be involved in their discharge planning. The DCC also stated, all patients should be presented with a list of available facilities for admission and should be communicated regarding their placement options, depending on their health insurance. The DCC stated, the process of discharge planning for the facility’s care manager’s and health plan’s care managers was the same, and the expectation was for the care managers to follow the facility’s discharge planning process for procedural documentation. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Process,” dated 9/2022, the P&P indicated, “Patient and/or designated caregiver must be informed that they have the freedom to choose among participating Medicare (federal health insurance for anyone age 65 and older) provider of post-hospital services. When possible, the facility shall respect patient and family preferences when they are expressed. The care coordinator and/or discharge planner must document in the medical record that the list was presented to the patient or to the individual action on patient’s behalf. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Planning,” dated 3/2021, the P&P indicated, “The discharge planning process is a collaborative approach that will include the patient, families/caregivers, and members of the health care team. Documentation includes but is not limited to: Patient/family/representative participation and response to discharge planning.” 2. During a review of Patient 1’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 1/20/2024, the H&P indicated, Patient 1 had past medical history (PMH, records information about the patient’s medical, personal and family history that might be relevant to the presenting illness) of arthritis (painful inflammation and stiffness of the joints), breast cancer (a disease that occurs when breast cells grow out of control and form tumors) and hypertension (a condition where the pressure in the blood vessels is consistently too high). The H&P further indicated, on 1/20/2024, Patient 1 was admitted with signs and symptoms (S&S) of a cerebrovascular accident (CVA, a medical condition that occurs when blood flow to the brain is suddenly interrupted). During a review of Patient 1’s medical record (MR) titled, Hospitalist-Progress Note,” dated 1/22/2024, the MR indicated, Patient 1 needed an evaluation for placement at a skilled nursing facility (SNF, a nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services) and other related health services after discharge. During an interview on 9/3/2024, at 9:19 a.m., with Corporate Director of Care Coordination department (DCC), the DCC stated, discharge planning (the process of transitioning a patient from one level of care to another) process should be focused on the patient’s individualized goals and needs after leaving the hospital. The DCC further stated, care managers (CM, a professional who works with patients, their families, and the medical team to ensure that patients receive the appropriate care and services they need) must ensure that the patient and/or the patient’s representatives were involved in the development of the discharge plan and their (Patient and family/representatives) preferences should be considered. During a concurrent interview and record review on 9/4/2024, at 11:02 a.m., with Quality Review Nurse (QRN), Patient 1’s medical record (MR) dated 1/20/2024 through 1/25/2024, was reviewed. The MR indicated, on 1/22/2024, one of the facility’s CMs documented, Patient 1’s health plan (a program or organization that provides health benefits, either directly or through insurance) provides their own CM [for discharge planning]. The QRN stated, no other CM notes were found in Patient 1’s chart from 1/20/2024 through 1/25/2024. During further review of Patient 1’s MR titled, “Nurse Note,” dated 1/24/2024, the MR indicated, Registered Nurse (RN 4) documented, on 1/24/2024, Patient 1 was informed of arranged transfer to SNF, but Patient 1’s representative (R1) became upset, stating was not aware of discharge. During an interview, on 9/4/2024 at 3:02 p.m., with RN 4, RN 4 stated, on 1/24/2024, RN 4 received an order for Patient 1’s discharge and transfer to SNF. RN 4 stated, Patient 1 and Patient 1’s representative(s) were informed of discharge by the RN 4 at bedside, but the Patient 1’s representative became upset saying they were not aware about the discharge plans. The RN 4 further stated, the physician was notified, and Patient 1’s discharge was postponed. During an interview on 9/6/2024, at 10:15 a.m., with DCC, the DCC stated, discharge planning process begins on admission and discharge planning evaluation for anticipated patient needs should be done within 24 hours. The DCC stated, if a patient requires placement, the care manager should review the patient’s insurance, the length of placement required, patient needs, and preferences and then discuss it with the patient or the patient’s representative(s). During the same interview on 9/6/2024 at 10:15 a.m., the DCC stated, care managers should document all communication between the patient and/or family member (s) in the patient’s medical record. The DCC stated, patients and/or a patients’ representative(s) were expected to be involved in their discharge planning. The DCC said, all patients should be presented with a list of available facilities for admission and should be communicated regarding their placement options, depending on their health insurance. The DCC stated, the process of discharge planning for the facility’s care manager’s and health plan’s care managers was the same, and the expectation was for the care managers to follow the facility’s discharge planning process for procedural documentation. During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Planning,” dated 3/2021, the P&P indicated, “The goal of discharge plan is to improve or maintain the patient’s health status or provide comfort and support to patients/families/caregivers in the post-acute care transition. The discharge planning process is a collaborative approach that will include the patient, families/caregivers/other patient-identified support persons, attending physicians and other members of the health care plan.” During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge Planning,” dated 3/2021, the P&P indicated, “The care coordination team will document the discharge plan in the patient’s medical record on the post-acute needs being addressed. The discharge plan will include the following (but not limited to) procedural documentation components: Patient discharge assessment including date and time initiated. Plan, goals, implementation, and revision of goals. Patient/family/representative participation in response. Date, time, topic, and outcome of any Discharge Planning Conference held.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge Process,” dated 9/2022, the P&P indicated, “Care coordination will evaluate the patient as early as possible in the hospitalization as possible when the discharge of a patient requires continued services post hospitalization, including extended care facilities or transfer to another facility and home health agency. Care coordination and or Social Worker provides the family with information and facilitates transition from the hospital in a manner which ensures a plan for continuing care.” During a review of the facility’s policy and procedure (P&P) titled, “Discharge/Transfer of a Patient to Acute Care Facility, Skilled Nursing Facility (SNF), Extended Care Facility (ECF) or Inpatient Rehab Facility (IRF),” dated 6/2024, the P&P indicated, “Care Coordination Staff shall make arrangement for patient transfer with the appropriate facility and discuss transfer with the patient and the family. The plan should be documented on patient care notes, care coordination worksheet, and discharge plan record.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to provide one of 30 sampled patients (Patient 13) with a referral to the appropriate home health agency (HHA, provide a range of services to patients in their homes, including skilled nursing, therapeutic services, and other care), in accordance with the facility’s policy and procedure regarding the discharge process. This deficient practice had the potential to ineffectively transition Patient 13 to post-discharge and had the potential for Patient 13’s needs not being met after discharge. Findings: During a review of Patient 13’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 7/15/2024, the H&P indicated, Patient 13 was admitted to the facility for left total knee arthroplasty (a surgical procedure to resurface a knee damaged by arthritis). During a review of Patient 13’s medical record (MR) titled, “Care Manager (CM) Notes,” dated 7/16/2024, the MR indicated, a request for Home Health Services with Physical therapy (HH/PT), the authorization for HH/PT was received and will be scheduled within 24 hours. The MR contained no documentation what HH/PT was going to be arranged for Patient 13 and had no contact information for the agency. During a concurrent interview and record review on 9/5/2024, at 1:13 p.m., with Quality Review Nurse (QRN), the Patient 13’s MR, dated 7/16/2024, was reviewed. The QRN stated, Patient 13’s MR contained no documentation confirming HH/PT was arranged and scheduled for Patient 13 prior to discharge. During a review of Patient 13’s MR titled, “Discharge Summary,” dated 7/16/2024, the MR indicated, Patient 13 was stable for discharge home with HH/PT once HHPT was arranged. During a concurrent interview and record review on 9/5/2024, at 1:13 p.m., with Quality Review Nurse (QRN), Patient 13’s medical record (MR) titled, “Discharge Instructions,” 7/16/2024 was reviewed. The QRN stated, Patient 13’s MR record contained no recorded information regarding HH/PT, did not have the name and contact information of the agency, and any arrangements made by the facility prior to patient’s (Patient 13) discharge. During an interview on 9/6/2024, at 10:15 am., with Director of Care Coordination (DCC), the DCC stated, the facility’s discharge planning process required care managers/care coordinators documenting all pertinent information regarding the patient’s discharge information into the patient’s medical record. The DCC further stated, if any services had been arranged by the facility (such as Home Health Services), the information must be communicated to the patient and or patient/family representative and this information had to be documented in the patient’s medical record. During a review of the facility’s P&P titled, “Discharge Process,” dated 9/2022, the P&P indicated, “Care coordination will evaluate the patient as early as possible in the hospitalization as possible when the discharge of a patient requires continued services post hospitalization, including extended care facilities or transfer to another facility and home health agency. Care coordination and or Social Worker provides the family with information and facilitates transition from the hospital in a manner which ensures a plan for continuing care.””

“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: 38310 Based on interview and record review, the facility failed to ensure one of twenty sampled patients’ (Patient 1) emergency medical condition (EMC - an illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm) was stabilized prior to transferring patient (Patient 1) to another facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates), in accordance with the facility’s policy and procedure regarding Emergency Medical Treatment and Labor Act (EMTALA, a Federal law that requires anyone coming to an Emergency Department to be stabilized and treated, regardless of their insurance status or ability to pay). This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open). On 12/13/2023, at 8:37 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ’ s noncompliance with one or more requirement has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) situation in the presence of the Chief Nursing Officer (CNO) and the Director of Performance Improvement (DPI). The facility failed to ensure Patient 1’s emergency medical condition (active labor [a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal]) was stabilized prior to transporting Patient 1 from GACH 1 (General Acute Care Hospital 1), to the other medical facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates). Patient 1, who was G5 (Gravida- number of pregnancies), P3 (Parity or Para- number of livebirths and stillbirths [death or loss of baby before or during delivery]), Ab 2 (abortion), with a history of three previous c-sections (surgical delivery of a baby), no prenatal care (medical care received during pregnancy), and was determined to be 34 weeks gestation (amount of time of pregnancy), based on prenatal ultrasound (imaging method to create pictures of the inside of the body), was transported via 9-1-1 ambulance to GACH 2, while in active labor. This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open). On 12/14/2023, at 3:35 p.m., the IJ was removed in the presence of the Chief Nursing Officer (CNO) and the Director of Nursing (DON), after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The acceptable IJ Removal Plan included the following: 1. Review and revisions to policy ED-0100, Obstetrical Patient (a branch of medicine specialized in the care of pregnant women and childbirth) Presenting in the ED (Emergency Department- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care), which included the process for assessing the need to transfer and to do emergency cesarean sections (c-sections) at the facility (GACH 1), if unable to transfer OB (Obstetric) patients. 2. Developed a checklist of items to assist in preparing OB (Obstetric) patient for vaginal delivery or c-section. 3. Process of preparing for c-sections at the facility. 4. Process of preparing OB patients for transfer and contacting ambulance services. 5. The duties of the ED physician and ED RN which included the responsibility for care of the newborn, until the NICU (Neonatal Intensive Care Unit- unit that specializes in providing intensive [critical] medical care to newborns) team arrives, after vaginal or c-section deliveries. 6. Surgical services - for operating room (OR) RNs to follow current practices for open lower abdominal procedures. Findings: During a concurrent interview and record review on 12/11/2023 at 3:39 p.m. with the Quality Review Nurse (QR), Patient 1’s face sheet, dated 12/5/2023, was reviewed. The QR stated Patient 1 was admitted to the hospital (GACH 1), at 4:06 a.m., with Ruptured of Membranes (ROM - when the membranes surrounding the fetus [unborn baby] spontaneously rupture prior to 37 weeks of pregnancy resulting in leakage of amniotic fluid [fluid that surrounds the fetus during pregnancy]). Concurrently, during record review of Patient 1’s Triage (to categorize patient based on the severity of their condition and the order in which they require care and monitoring) notes, dated 12/4/2023, QR stated the following: 1. Patient 1 arrived at facility’s (GACH 1) emergency department (ED- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care) as a walk-in via family vehicle. 2. Patient 1 complained of having contractions (tightening and relaxing of the uterine muscles during labor to push the unborn baby out of the uterus [female reproductive organ where the baby grows]) that increased after having been discharged from another facility (general acute care hospital - GACH 2) earlier, on 12/4/2023, prior to arrival at GACH 1. 3. Patient 1 stated she (Patient 1) was discharged from GACH 2 earlier because she (Patient 1) was told she (Patient 1) was not in labor (a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal) while she was at GACH 2. 4. Patient 1 stated she (Patient 1) had no prenatal care (medical care received during pregnancy). 5. Patient 1 stated she (Patient 1) was told from GACH 2, that fetus (unborn baby) was 34 weeks. 6. Patient 1 complained of pain 8/10 on arrival at GACH 1. 7. Patient 1 reported she (Patient 1) had a history of three previous cesarean sections (c-section - surgical operation for delivering a child by cutting through the wall of the mother’s abdomen). Concurrently, during record review of Patient 1 ’ s ED physician note, dated 12/5/2023, QR stated the following: 1. History of present illness indicated patient was pregnant for fifth time with three previous cesarean sections and one spontaneous miscarriage, and patient (Patient 1) complained of cramping pain every five minutes. 2. After initial examination, there was a concern for preterm labor (labor that starts before 37 weeks of pregnancy). 3. Obstetrician (OB - physician or surgeon qualified to provide medical care during pregnancy, labor and birth, after the birth) was consulted and recommended that patient (Patient 1) be transferred to GACH 2 for further care and evaluation in their labor and delivery unit (L&D unit- a unit that specializes in childbirth). 4. At 3:15 a.m., patient’s (Patient 1) bag of waters broke, and patient (Patient 1) was re-examined and found to be dilated at 5 cm (centimeters, a unit of measurement). 5. At 3:38 a.m., an attempt was made to call GACH 2 for a neonatal intensive care unit (NICU - a specialty unit where babies get around-the-clock care from a team of experts) nurse to come to this facility (GACH 1). 6. Spoke with facility’s house supervisor and chief nursing officer and informed that facility does not have any neonatal services and instructed to call 9-1-1 to transfer patient (Patient 1) to GACH 2. 7. At 3:40 a.m., OB was notified of patient’s (Patient 1) progression with labor and stated he (OB) would come to the facility (GACH 1) to do a c-section for the patient (Patient 1). 8. At 3:45 a.m., patient’s (Patient 1) fetus’ heart rate was 136 beats-per-minute (normal fetal heart rate is 120-160). 9. At 3:47 a.m., 9-1-1 ambulance arrived. 10. At 3:50 a.m., OB arrived at facility and accompanied patient to receiving hospital (GACH 2). 11. Impression - patient was in stable condition for transfer to GACH 2. During a concurrent interview and record review on 12/11/2023 at 4:00 p.m. with the Chief Nursing Officer (CNO) and the Director of Nursing (DON), Patient 1’s ED visit record, dated 12/5/2023, was reviewed. The CNO said facility (GACH 1) had contracts with private ambulance companies, and facility (GACH 1) contacted two ambulance companies to transfer Patient 1 to GACH 2 for higher level of care. CNO stated facility (GACH 1) had been having difficulty with getting private ambulance services to come right-away. CNO stated the first ambulance company was called, shortly after Patient 1 arrived at the facility (GACH 1) and could not come until 3:30 a.m. CNO said the second ambulance company was called and could not come until 7:30 a.m. CNO stated after Patient 1’s condition changed and was in active labor, after her (Patient 1) water broke, facility (GACH 1) called 9-1-1 to transport Patient 1 to GACH 2. During an interview on 12/12/2023, at 8:29 a.m., with ED physician (MD 1), MD 1 stated the following: 1. ED triage nurse told her (MD 1) that Patient 1 came from another facility (GACH 2), had no prenatal care, was complaining of abdominal pain. 2. Patient 1 was examined. 3. MD 1 consulted with Obstetrician (MD 2) and MD 2 advised MD 1 to get Patient 1 back to GACH 2 for higher level of care. 4. Ambulance services were called to transport Patient 1 back to GACH 2. 5. Patient 1’s labor progressed with the bag of waters breaking. 6. MD 1 consulted with MD 2, the second time. 7. MD 2 recommended that MD 1 call in a “crew” from GACH 2 to come to this facility (GACH 1), because there were no pediatric services (a specialty of medicine concerned with medical care of children from birth to young adulthood) and no NICU services at this facility (GACH 1). 8. CNO told MD 1 that this facility (GACH 1) cannot do c-section because there was no NICU services at this facility (GACH 1). 9. CNO instructed house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2. 10. Patient 1 was stable prior to transfer to GACH 2. 11. MD 2 arrived at facility and accompanied Patient 1 to GACH 2, in the ambulance. During an interview on 12/12/2023 at 9:00 a.m. with on-call Obstetrician (MD 2), MD 2 stated the following: 1. He (MD 2) received a call in the middle-of-the-night from MD 1 (ED physician) about Patient 1, who was in “hard labor” at 34 weeks pregnancy, was dilated at 6 cm, had a history of c-sections. 2. He (MD 2) advised MD 1 to transfer patient (Patient 1) to GACH 2 because facility (GACH 1) had no OB services, no pediatric services, and no NICU services. 3. He (MD 2) was instructed that private ambulance services were called and were going to take several hours to transfer Patient 1 from GACH 1 to GACH 2. 4. He (MD 2) instructed MD 1 to call in a “crew” from GACH 2 to come to this facility (GACH 1). 5. He (MD 2) was told by facility’s (GACH 1) nursing supervisor that this facility (GACH 1) cannot do a c-section. 6. He (MD 2) was frustrated with facility (GACH 1). 7. He (MD 2) went to GACH 1 to possibly deliver Patient 1’s baby at the facility (GACH 1). 8. When he (MD 2) arrived at facility (GACH 1), he (MD 2) found out facility (GACH 1) already called 9-1-1, and the 9-1-1 ambulance was at the facility (GACH 1) to pick up Patient 1 and transport patient to GACH 2, for higher level of care. 9. Prior to Patient 1 leaving facility (GACH 1), he (MD 2) interviewed the patient (Patient 1). 10. After Patient 1 left GACH 1, he (MD 2) called GACH 2 to prepare for an emergency c-section to deliver Patient 1’s baby, with a NICU team ready at the receiving facility (GACH 2). During an interview on 12/12/2023 at 10:32 a.m. with the Chief Nursing Officer (CNO), the CNO stated the following: 1. She (CNO) received a call from the facility’s house supervisor at 3:30 a.m., on 12/5/2023, that Patient 1 was in the ED and needed to get transferred to GACH 2 and the ambulance services were delayed and could not transfer Patient 1 to GACH 2, after Patient 1 arrived in ED, around midnight. 2. She (CNO) told house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2 (which is the receiving facility for higher level of care). 3. Patient 1 was in preterm labor, was seen by Emergency Department Physician (MD 1), who consulted with Obstetrician (MD 2) on-call. 4. MD 2 wanted Patient 1 transferred to GACH 2. 5. Patient 1 was 5 cm dilated, had a history of previous c-sections, and no prenatal care. 6. She (CNO) was not aware of MD 2’s recommendation to bring in a “crew” from GACH 2 to deliver Patient 1’s infant for c-section. 7. She (CNO) was informed that Patient 1was transferred to GACH 2, after facility (GACH 1) called 9-1-1. 8. Patient 1 did not have an emergency medical condition and was stable for transfer to GACH 2, per MD 1. 9. Facility had been having difficulties getting a private ambulance service to transfer patients right away. During an interview on 12/12/2023 at 11:22 a.m. with the house supervisor (Hse. Sup), Hse. Sup stated the following: 1. She (Hse. Sup) was working on 12/4/2023 as the night shift house supervisor for GACH 1. 2. Patient 1 was in the ED and needed to be transferred to GACH 2. 3. She (Hse. Sup) was informed of Patient 1’s condition from ED charge nurse, who told her (Hse. Sup) Patient 1 needed to be transferred to GACH 2. 4. Two private ambulance companies were called and could not transfer Patient 1 until 3:30 a.m. and 7:30 a.m., respectively, on 12/5/2023. 5. ED was monitoring Patient 1, until private ambulance arrives. 6. She (Hse. Sup) was informed that Patient 1 had a change-of-condition (COC), and that Obstetrician (MD 2) was notified. 7. MD 2 wanted to do a c-section for Patient 1 at GACH 1. 8. She (Hse. Sup) spoke with ED Physician (MD 1) and MD 2, regarding Patient 1’s COC - water bag broke and was in active labor. 9. She (Hse. Sup) was not aware that MD 2 wanted to do a c-section at the facility (GACH 1) for Patient 1. 10. She (Hse. Sup) stated she knew facility does not do c-sections anymore, per CNO. 11. She (Hse. Sup) stated she did not know MD 2 requested for a GACH 2 team to come to GACH 1, to do an emergency c-section for Patient 1. 12. She (Hse. Sup) called 9-1-1, after speaking with CNO and informing her of Patient 1’s change of condition, with ruptured membranes, premature labor, and history of previous c-sections. 13. She (Hse. Sup) saw MD 1 and MD 2 later, in the ED at GACH 1. During an interview on 12/12/2023 at 1:57 p.m., with the ED Director (EDD), the EDD stated the following regarding Patient 1’s ED visit from 12/4/2023 to 12/5/2023: 1. GACH 1 does not have Obstetric (OB - the branch of medicine and surgery concerned with childbirth and the care of women giving birth) services anymore. 2. OB patients that come to the ED get an initial examination by a provider who checks the labor, contractions, ruptured membranes, amniotic fluids, fetal heart tones, ultrasound, history of patient, number of pregnancies, history of deliveries. 3. The contraindications for labor included history of previous c-sections and placenta previa. 4. Women who come to the ED with above mentioned contraindications for labor must be transferred to another facility for higher level of care. 5. OB patients with a history of c-sections can be offered a trial of labor after c-sections, only at a medical center with medical services that offer 24- hour neonatal intensive care units (NICU) services, surgical services, anesthesia services, OB services, blood bank due to the potential risks to the mother and fetus. 6. During maternal patient transports to another facility, facility sends an ED nurse to accompany the patient to the receiving facility. 7. Patient 1 was a high-risk OB patient with no prenatal care and history of previous c-sections. 8. This facility (GACH 1) has no surgical services and no on-site anesthesia services. 9. After Patient 1’s membranes were ruptured on 12/5/2023, at 3:15 a.m., Patient 1 was already in active labor and facility planned to transfer her to another facility (GACH 2) right away, to attend to her urgent needs. 10. Calling 9-1-1 was the only option to get Patient 1 to another facility (GACH 2) for a higher level of care. 11. Getting a team from GACH 2 to deliver Patient 1’s fetus, at this facility (GACH 1) was not realistic. 12. After Patient 1’s membranes were ruptured there was an emergent condition, with high risk to both mother and fetus. 13. If Patient 1 were to deliver in the transport ambulance, with her (Patient 1) history of no prenatal care and history of previous c-sections, Patient 1 would have the risk of post-partum hemorrhage (excessive bleeding after childbirth) and/or uterine rupture (a rare but life-threatening event which requires immediate treatment, when the uterine wall tears open, especially in women who try a vaginal delivery, after having had a c-section). 14. Patient 1 probably should have been re-triaged sooner, rather than later, and transferred to GACH 2, prior to her membranes rupturing at 3:15 a.m., while waiting for private ambulance companies to transport her. A review of facility’s OB Patient Presenting in the ED policy, dated 12/2023, indicated the following: 1. The following cases will be triaged as urgent, and transfer arrangements made to send patient to the OB unit at GACH 2, and OB/GYN consultant will be contacted for evaluation for conditions, including: decreased fetal movement, bleeding, leakage of amniotic fluid, high blood pressure, premature labor, active labor, lower abdominal pain with pelvic pressure/abdominal cramping. 2. ED physician will request OB consultant for any illness/problem involving a pregnant or possible pregnant woman. 3. Fetal heart tones (FHT - pulse rate of fetus) will be obtained by the ED nurse or provider and will be documented. A review of facility’s Emergency Medical and Active Labor Act (EMTALA) policy, dated 12/2023, indicated: 1. Emergency Medical Condition (EMC - a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in either placing the health of the individual, including a pregnant woman, the health of the woman or her unborn fetus) in serious jeopardy. 2. With respect to a pregnant woman who is having contractions, there is inadequate time to affect a safe transfer to another hospital before delivery or that the transfer may pose a threat to the health or safety of the woman or her unborn fetus. 3. Labor means the process of childbirth, beginning with the latent or early phase, and continuing through the delivery of the placenta. 4. To stabilize means, with respect to an EMC, that the individual is provided with medical treatment that is necessary to assure that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from the hospital. 5. With respect to a pregnant woman who is having contractions and who cannot be transferred before delivery without threat to the health or safety of the woman or the unborn fetus, that the woman has delivered the child and placenta. 6. Stable for discharge means the physician has determined, withing reasonable clinical confidence, that the patient has reached the point where continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient, if the patient is given a plan for appropriate follow-up care with discharge instructions. 7. Stable for transfer between medical facilities means the physician determines within reasonable clinical confidence, that the patient will sustain no material deterioration in medical condition, because of the transfer, and that the receiving facility has the capability to manage the EMC and any reasonably foreseeable complication. 8. Transfer means the movement, including discharge, of a patient outside the hospital ’ s facilities, at the direction of any person employed or associated, directly or indirectly, with the hospital. 9. Within the capability of the hospital means those services which the hospital is required to have a condition of its license, as well as hospital ancillary services routinely available to the emergency department (ED). 10. A medical screening examination (MSE) will be provided by a qualified medical person to any individual who comes to the hospital and seeks an examination of medical treatment to determine if the individual has an EMC, whether eligible for insurance benefits and regardless of ability to pay. 11. If it is determined that the individual has an EMC, medical examination and treatment will be provided, as required to stabilize the EMC, within the capability of the hospital, or to arrange for transfer of the individual to another medical facility, in accordance with the procedures set forth. 12. The provision of MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual ’ s method of payment or insurance status. 13. The hospital will provide emergency services and care without regard to an individual’s preexisting medical condition, insurance status or ability to pay for medical services. 14. Policy applies to all individuals in any ambulance subject to the policies and procedures of the local EMS authority that is on the hospital property, even if instructed not to come to the hospital. 15. Within the capability of the ED, the MSE shall determine within reasonable medical probability, whether an EMC exists. The MSE shall be performed by a physician or by a qualified medical person and must be documented. 16. After an initial MSE, the physician determines that the individual requires the services of an on-call physician, the on-call physician shall be contacted. 17. The hospital may transfer an individual with no EMC to another facility for non-medical reason. Before transferring the individual, the hospital shall the individual for a preferred contact person to be notified of the transfer and contact the individual and alert the individual about the proposed transfer. 18. When it is determined that the individual has an EMC, the hospital shall, within the capability of the staff and facilities available, stabilize the individual to the point where the individual is either stable for discharge or stable for transfer. 19. The facility shall provide for an appropriate transfer of the unstabilized individual to another medical facility. 20. The facility shall provide an appropriate transfer of the unstabilized individual to another medical facility, only pursuant to patient request, or when a physician in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer. 21. The transfer from this facility to a receiving medical facility of an individual with an unstabilized EMC shall be carried out, within the facility’s capabilities, provide medical treatment, which minimizes the risks to the individual’s health, and the in the case of a woman who is having contractions, the health of the woman and the unborn fetus.”

“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: 38310 Based on interview and record review, the facility failed to ensure one of twenty sampled patients’ (Patient 1) emergency medical condition (EMC - an illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm) was stabilized prior to transferring patient (Patient 1) to another facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates). This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open). Findings: During a concurrent interview and record review on 12/11/2023 at 3:39 p.m. with the Quality Review Nurse (QR), Patient 1’s face sheet, dated 12/5/2023, was reviewed. The QR stated Patient 1 was admitted to the hospital (GACH 1), at 4:06 a.m., with Ruptured of Membranes (ROM - when the membranes surrounding the fetus [unborn baby] spontaneously rupture prior to 37 weeks of pregnancy resulting in leakage of amniotic fluid [fluid that surrounds the fetus during pregnancy]). Concurrently, during record review of Patient 1’s Triage (to categorize patient based on the severity of their condition and the order in which they require care and monitoring) notes, dated 12/4/2023, QR stated the following: 1. Patient 1 arrived at facility’s (GACH 1) emergency department (ED- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care) as a walk-in via family vehicle. 2. Patient 1 complained of having contractions (tightening and relaxing of the uterine muscles during labor to push the unborn baby out of the uterus [female reproductive organ where the baby grows]) that increased after having been discharged from another facility (general acute care hospital - GACH 2) earlier, on 12/4/2023, prior to arrival at GACH 1. 3. Patient 1 stated she (Patient 1) was discharged from GACH 2 earlier because she (Patient 1) was told she (Patient 1) was not in labor (a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal) while she was at GACH 2. 4. Patient 1 stated she (Patient 1) had no prenatal care (medical care received during pregnancy). 5. Patient 1 stated she (Patient 1) was told from GACH 2, that fetus (unborn baby) was 34 weeks. 6. Patient 1 complained of pain 8/10 on arrival at GACH 1. 7. Patient 1 reported she (Patient 1) had a history of three previous cesarean sections (c-section - surgical operation for delivering a child by cutting through the wall of the mother’s abdomen). Concurrently, during record review of Patient 1 ’ s ED physician note, dated 12/5/2023, QR stated the following: 1. History of present illness indicated patient was pregnant for fifth time with three previous cesarean sections and one spontaneous miscarriage, and patient (Patient 1) complained of cramping pain every five minutes. 2. After initial examination, there was a concern for preterm labor (labor that starts before 37 weeks of pregnancy). 3. Obstetrician (OB - physician or surgeon qualified to provide medical care during pregnancy, labor and birth, after the birth) was consulted and recommended that patient (Patient 1) be transferred to GACH 2 for further care and evaluation in their labor and delivery unit (L&D unit- a unit that specializes in childbirth). 4. At 3:15 a.m., patient’s (Patient 1) bag of waters broke, and patient (Patient 1) was re-examined and found to be dilated at 5 cm (centimeters, a unit of measurement). 5. At 3:38 a.m., an attempt was made to call GACH 2 for a neonatal intensive care unit (NICU - a specialty unit where babies get around-the-clock care from a team of experts) nurse to come to this facility (GACH 1). 6. Spoke with facility’s house supervisor and chief nursing officer and informed that facility does not have any neonatal services and instructed to call 9-1-1 to transfer patient (Patient 1) to GACH 2. 7. At 3:40 a.m., OB was notified of patient’s (Patient 1) progression with labor and stated he (OB) would come to the facility (GACH 1) to do a c-section for the patient (Patient 1). 8. At 3:45 a.m., patient’s (Patient 1) fetus’ heart rate was 136 beats-per-minute (normal fetal heart rate is 120-160). 9. At 3:47 a.m., 9-1-1 ambulance arrived. 10. At 3:50 a.m., OB arrived at facility and accompanied patient to receiving hospital (GACH 2). 11. Impression - patient was in stable condition for transfer to GACH 2. During a concurrent interview and record review on 12/11/2023 at 4:00 p.m. with the Chief Nursing Officer (CNO) and the Director of Nursing (DON), Patient 1’s ED visit record, dated 12/5/2023, was reviewed. The CNO said facility (GACH 1) had contracts with private ambulance companies, and facility (GACH 1) contacted two ambulance companies to transfer Patient 1 to GACH 2 for higher level of care. CNO stated facility (GACH 1) had been having difficulty with getting private ambulance services to come right-away. CNO stated the first ambulance company was called, shortly after Patient 1 arrived at the facility (GACH 1) and could not come until 3:30 a.m. CNO said the second ambulance company was called and could not come until 7:30 a.m. CNO stated after Patient 1’s condition changed and was in active labor, after her (Patient 1) water broke, facility (GACH 1) called 9-1-1 to transport Patient 1 to GACH 2. During an interview on 12/12/2023, at 8:29 a.m., with ED physician (MD 1), MD 1 stated the following: 1. ED triage nurse told her (MD 1) that Patient 1 came from another facility (GACH 2), had no prenatal care, was complaining of abdominal pain. 2. Patient 1 was examined. 3. MD 1 consulted with Obstetrician (MD 2) and MD 2 advised MD 1 to get Patient 1 back to GACH 2 for higher level of care. 4. Ambulance services were called to transport Patient 1 back to GACH 2. 5. Patient 1’s labor progressed with the bag of waters breaking. 6. MD 1 consulted with MD 2, the second time. 7. MD 2 recommended that MD 1 call in a “crew” from GACH 2 to come to this facility (GACH 1), because there were no pediatric services (a specialty of medicine concerned with medical care of children from birth to young adulthood) and no NICU services at this facility (GACH 1). 8. CNO told MD 1 that this facility (GACH 1) cannot do c-section because there was no NICU services at this facility (GACH 1). 9. CNO instructed house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2. 10. Patient 1 was stable prior to transfer to GACH 2. 11. MD 2 arrived at facility and accompanied Patient 1 to GACH 2, in the ambulance. During an interview on 12/12/2023 at 9:00 a.m. with on-call Obstetrician (MD 2), MD 2 stated the following: 1. He (MD 2) received a call in the middle-of-the-night from MD 1 (ED physician) about Patient 1, who was in “hard labor” at 34 weeks pregnancy, was dilated at 6 cm, had a history of c-sections. 2. He (MD 2) advised MD 1 to transfer patient (Patient 1) to GACH 2 because facility (GACH 1) had no OB services, no pediatric services, and no NICU services. 3. He (MD 2) was instructed that private ambulance services were called and were going to take several hours to transfer Patient 1 from GACH 1 to GACH 2. 4. He (MD 2) instructed MD 1 to call in a “crew” from GACH 2 to come to this facility (GACH 1). 5. He (MD 2) was told by facility’s (GACH 1) nursing supervisor that this facility (GACH 1) cannot do a c-section. 6. He (MD 2) was frustrated with facility (GACH 1). 7. He (MD 2) went to GACH 1 to possibly deliver Patient 1’s baby at the facility (GACH 1). 8. When he (MD 2) arrived at facility (GACH 1), he (MD 2) found out facility (GACH 1) already called 9-1-1, and the 9-1-1 ambulance was at the facility (GACH 1) to pick up Patient 1 and transport patient to GACH 2, for higher level of care. 9. Prior to Patient 1 leaving facility (GACH 1), he (MD 2) interviewed the patient (Patient 1). 10. After Patient 1 left GACH 1, he (MD 2) called GACH 2 to prepare for an emergency c-section to deliver Patient 1’s baby, with a NICU team ready at the receiving facility (GACH 2). During an interview on 12/12/2023 at 10:32 a.m. with the Chief Nursing Officer (CNO), the CNO stated the following: 1. She (CNO) received a call from the facility’s house supervisor at 3:30 a.m., on 12/5/2023, that Patient 1 was in the ED and needed to get transferred to GACH 2 and the ambulance services were delayed and could not transfer Patient 1 to GACH 2, after Patient 1 arrived in ED, around midnight. 2. She (CNO) told house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2 (which is the receiving facility for higher level of care). 3. Patient 1 was in preterm labor, was seen by Emergency Department Physician (MD 1), who consulted with Obstetrician (MD 2) on-call. 4. MD 2 wanted Patient 1 transferred to GACH 2. 5. Patient 1 was 5 cm dilated, had a history of previous c-sections, and no prenatal care. 6. She (CNO) was not aware of MD 2’s recommendation to bring in a “crew” from GACH 2 to deliver Patient 1’s infant for c-section. 7. She (CNO) was informed that Patient 1was transferred to GACH 2, after facility (GACH 1) called 9-1-1. 8. Patient 1 did not have an emergency medical condition and was stable for transfer to GACH 2, per MD 1. 9. Facility had been having difficulties getting a private ambulance service to transfer patients right away. During an interview on 12/12/2023 at 11:22 a.m. with the house supervisor (Hse. Sup), Hse. Sup stated the following: 1. She (Hse. Sup) was working on 12/4/2023 as the night shift house supervisor for GACH 1. 2. Patient 1 was in the ED and needed to be transferred to GACH 2. 3. She (Hse. Sup) was informed of Patient 1’s condition from ED charge nurse, who told her (Hse. Sup) Patient 1 needed to be transferred to GACH 2. 4. Two private ambulance companies were called and could not transfer Patient 1 until 3:30 a.m. and 7:30 a.m., respectively, on 12/5/2023. 5. ED was monitoring Patient 1, until private ambulance arrives. 6. She (Hse. Sup) was informed that Patient 1 had a change-of-condition (COC), and that Obstetrician (MD 2) was notified. 7. MD 2 wanted to do a c-section for Patient 1 at GACH 1. 8. She (Hse. Sup) spoke with ED Physician (MD 1) and MD 2, regarding Patient 1’s COC - water bag broke and was in active labor. 9. She (Hse. Sup) was not aware that MD 2 wanted to do a c-section at the facility (GACH 1) for Patient 1. 10. She (Hse. Sup) stated she knew facility does not do c-sections anymore, per CNO. 11. She (Hse. Sup) stated she did not know MD 2 requested for a GACH 2 team to come to GACH 1, to do an emergency c-section for Patient 1. 12. She (Hse. Sup) called 9-1-1, after speaking with CNO and informing her of Patient 1’s change of condition, with ruptured membranes, premature labor, and history of previous c-sections. 13. She (Hse. Sup) saw MD 1 and MD 2 later, in the ED at GACH 1. During an interview on 12/12/2023 at 1:57 p.m., with the ED Director (EDD), the EDD stated the following regarding Patient 1’s ED visit from 12/4/2023 to 12/5/2023: 1. GACH 1 does not have Obstetric (OB - the branch of medicine and surgery concerned with childbirth and the care of women giving birth) services anymore. 2. OB patients that come to the ED get an initial examination by a provider who checks the labor, contractions, ruptured membranes, amniotic fluids, fetal heart tones, ultrasound, history of patient, number of pregnancies, history of deliveries. 3. The contraindications for labor included history of previous c-sections and placenta previa. 4. Women who come to the ED with above mentioned contraindications for labor must be transferred to another facility for higher level of care. 5. OB patients with a history of c-sections can be offered a trial of labor after c-sections, only at a medical center with medical services that offer 24- hour neonatal intensive care units (NICU) services, surgical services, anesthesia services, OB services, blood bank due to the potential risks to the mother and fetus. 6. During maternal patient transports to another facility, facility sends an ED nurse to accompany the patient to the receiving facility. 7. Patient 1 was a high-risk OB patient with no prenatal care and history of previous c-sections. 8. This facility (GACH 1) has no surgical services and no on-site anesthesia services. 9. After Patient 1’s membranes were ruptured on 12/5/2023, at 3:15 a.m., Patient 1 was already in active labor and facility planned to transfer her to another facility (GACH 2) right away, to attend to her urgent needs. 10. Calling 9-1-1 was the only option to get Patient 1 to another facility (GACH 2) for a higher level of care. 11. Getting a team from GACH 2 to deliver Patient 1’s fetus, at this facility (GACH 1) was not realistic. 12. After Patient 1’s membranes were ruptured there was an emergent condition, with high risk to both mother and fetus. 13. If Patient 1 were to deliver in the transport ambulance, with her (Patient 1) history of no prenatal care and history of previous c-sections, Patient 1 would have the risk of post-partum hemorrhage (excessive bleeding after childbirth) and/or uterine rupture (a rare but life-threatening event which requires immediate treatment, when the uterine wall tears open, especially in women who try a vaginal delivery, after having had a c-section). 14. Patient 1 probably should have been re-triaged sooner, rather than later, and transferred to GACH 2, prior to her membranes rupturing at 3:15 a.m., while waiting for private ambulance companies to transport her. A review of facility’s OB Patient Presenting in the ED policy, dated 12/2023, indicated the following: 1. The following cases will be triaged as urgent, and transfer arrangements made to send patient to the OB unit at GACH 2, and OB/GYN consultant will be contacted for evaluation for conditions, including: decreased fetal movement, bleeding, leakage of amniotic fluid, high blood pressure, premature labor, active labor, lower abdominal pain with pelvic pressure/abdominal cramping. 2. ED physician will request OB consultant for any illness/problem involving a pregnant or possible pregnant woman. 3. Fetal heart tones (FHT - pulse rate of fetus) will be obtained by the ED nurse or provider and will be documented. A review of facility’s Emergency Medical and Active Labor Act (EMTALA) policy, dated 12/2023, indicated: 1. Emergency Medical Condition (EMC - a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in either placing the health of the individual, including a pregnant woman, the health of the woman or her unborn fetus) in serious jeopardy. 2. With respect to a pregnant woman who is having contractions, there is inadequate time to affect a safe transfer to another hospital before delivery or that the transfer may pose a threat to the health or safety of the woman or her unborn fetus. 3. Labor means the process of childbirth, beginning with the latent or early phase, and continuing through the delivery of the placenta. 4. To stabilize means, with respect to an EMC, that the individual is provided with medical treatment that is necessary to assure that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from the hospital. 5. With respect to a pregnant woman who is having contractions and who cannot be transferred before delivery without threat to the health or safety of the woman or the unborn fetus, that the woman has delivered the child and placenta. 6. Stable for discharge means the physician has determined, withing reasonable clinical confidence, that the patient has reached the point where continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient, if the patient is given a plan for appropriate follow-up care with discharge instructions. 7. Stable for transfer between medical facilities means the physician determines within reasonable clinical confidence, that the patient will sustain no material deterioration in medical condition, because of the transfer, and that the receiving facility has the capability to manage the EMC and any reasonably foreseeable complication. 8. Transfer means the movement, including discharge, of a patient outside the hospital ’ s facilities, at the direction of any person employed or associated, directly or indirectly, with the hospital. 9. Within the capability of the hospital means those services which the hospital is required to have a condition of its license, as well as hospital ancillary services routinely available to the emergency department (ED). 10. A medical screening examination (MSE) will be provided by a qualified medical person to any individual who comes to the hospital and seeks an examination of medical treatment to determine if the individual has an EMC, whether eligible for insurance benefits and regardless of ability to pay. 11. If it is determined that the individual has an EMC, medical examination and treatment will be provided, as required to stabilize the EMC, within the capability of the hospital, or to arrange for transfer of the individual to another medical facility, in accordance with the procedures set forth. 12. The provision of MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual ’ s method of payment or insurance status. 13. The hospital will provide emergency services and care without regard to an individual’s preexisting medical condition, insurance status or ability to pay for medical services. 14. Policy applies to all individuals in any ambulance subject to the policies and procedures of the local EMS authority that is on the hospital property, even if instructed not to come to the hospital. 15. Within the capability of the ED, the MSE shall determine within reasonable medical probability, whether an EMC exists. The MSE shall be performed by a physician or by a qualified medical person and must be documented. 16. After an initial MSE, the physician determines that the individual requires the services of an on-call physician, the on-call physician shall be contacted. 17. The hospital may transfer an individual with no EMC to another facility for non-medical reason. Before transferring the individual, the hospital shall the individual for a preferred contact person to be notified of the transfer and contact the individual and alert the individual about the proposed transfer. 18. When it is determined that the individual has an EMC, the hospital shall, within the capability of the staff and facilities available, stabilize the individual to the point where the individual is either stable for discharge or stable for transfer. 19. The facility shall provide for an appropriate transfer of the unstabilized individual to another medical facility. 20. The facility shall provide an appropriate transfer of the unstabilized individual to another medical facility, only pursuant to patient request, or when a physician in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer. 21. The transfer from this facility to a receiving medical facility of an individual with an unstabilized EMC shall be carried out, within the facility’s capabilities, provide medical treatment, which minimizes the risks to the individual’s health, and the in the case of a woman who is having contractions, the health of the woman and the unborn fetus.”