Martin Luther King, Jr. Community Hospital

“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: 37663 Based on interview and record review, the hospital failed to ensure the RN reassessment was accurate for one of three sampled patients (Patient 1) related to the patient’s abdominal wound drainage. This failure posed an increased risk of substandard health outcomes for the patient. Findings: Review of the hospital’s P&P titled Acute Care Clinical Practice Standards for Medical Surgical and Telemetry Nursing revised 10/27/25, showed the following: * Physical assessment are to be done every four hours for telemetry patients and ... as the patients’ condition or need warrant. Findings are documented in the patient’s Electronic Health Record (EHR). * Any changes noted in reassessments are to be recorded by exception as these are identified, or as patient condition warrants. * Documentation in the EHR of physical assessment findings and or care interventions must be done at the same frequency that each care intervention is performed such as vital signs, patient positioning assessment or reassessment findings, etc. On 7/22/26 at 1300 hours, an interview and concurrent record review of Patient 1’s medical record was conducted with Director 1 and the Director of Quality. Patient 1 was admitted to the hospital on 12/16/25, for acute general abdominal pain requiring emergent surgery. Review of the Surgical Progress Note result date 1/1/2026 at 1300 hours, showed the MD documented that there was a lot of drainage noted from the abdominal wound. The intra abdominal drain was reconnected to the drainage bag using a connector. On the physical examination, the bile tinged drainage was noted from abdominal wound and incision. The wound was cleaned and an ostomy bag was placed over the wound. The left intraabdominal drain was reconnected to a Tru-Closed drainage bag using a connector. On 7/23/26 at 1050 hours, review of Patient 1’s medical record and concurrent interview was conducted with Director 5 with the presence of Director of Quality. Director 5 verified the date of the surgical note performed on 1/1/26 at 1300 hours, when the MD changed the dressing and the suction drainage system from JP bulb to Tru-Closed drainage system. Review of the Surgical Drains/Tubes showed on 12/31/25 and 1/1/26, the RNs documented under the Closed Bulb Abdomen for Patient 1’s abdominal wound output. However, as per the MD’s Progress note, the suction drainage system was changed to Tru-Closed drainage system on 1/1/26 at 1300 hours. On 7/23/26 at 1130 hours, interview and concurrent review of Patient 1’s medical record was conducted RN 2 in the presence of Director of Quality and Director 6. RN 1 was asked the frequency of assessment/reassessment for the patients in the telemetry unit. RN 2 stated the assessment/reassessment was performed every four hours. RN 2 was asked about the reassessment for Patient 1 on 1/1/26. RN 2 stated the change on Patient 1’s reassessment for the 1600 hours documentation was the SPO2 from 97% to 91%. On 7/23/26 at 1205 hours, Director 6 was asked about Patient 1’s assessment/reassessment documentation of the drainage system from 1/1/26 to 1/6/26. Director 6 stated if the drainage system was changed to a different system, the RN should go in the chart and document the change. Director 6 verified the suction drainage system assessment/reassessment did not show the correct drainage system from 1/1/26 to 1/6/26.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff developed an individualized plan of care for one of three sampled patients (Patient 1) to reflect the care and services rendered for the patient. This failure posed an increased risk for the patient. Findings: Review of the hospital’s P&P titled Acute Care Clinical Practice Standards for Medical. Surgical and Telemetry Nursing revised 10/27/25, showed the following: * Nursing Diagnoses: analyze and synthesize data from the assessment in determining nursing diagnoses or conditions relevant to care. Derive diagnoses or conditions relevant from the assessment data. Validate diagnoses with the patient and family and other healthcare providers. Document nursing diagnoses and relevant issues in EHR under IPOC. Initiate the IPOC within 24 hours of admission to M/S/T document progress towards goals every shift. * Outcomes Identification/Planning/Evaluation (IPOC): Individualized POC: Interdisciplinary POC initiation within 24 hours of admission to ICU. IPOC Components are Assessment, Diagnosis, Outcomes or Care goals, Timeframes required to meet those goals, Planning, Implementation, and Evaluation. Update every 24 hours of care. Document progress towards the goal every 12 hours or every shift. On 7/22/26 at 1300 hours, an interview and concurrent record review of Patient1’s medical record was conducted with Director 1 and the Director of Quality. Patient 1 was admitted to the hospital on 12/16/25, for acute general abdominal pain. Review of the Surgical Consult for Patient 1 dated 12/17/25, showed the surgery was consulted for perforated viscus and peritonitis. The surgical consult plan was treatment for sepsis, decompensated cirrhosis, acute generalized abdominal pain, AKI, Coagulopathy ... Review of the Operative Report for Patient 1 dated 12/17/25 at 1230 hours, showed after surgery, Patient 1 was diagnosed to have perforated duodenal ulcer, peritonitis, and cirrhosis of the liver. After the surgery, Patient 1 was hemodynamically unstable, intubated, and in critical but fair condition. Continued review of Patient 1’s medical record on 12/20/25 at 1500 hours, showed Patient 1 went back to OR for reexploration and washout of abdomen, closure of abdomen with drains right and left on the abdomen. There was a small collection of pus under the right lobe of the liver. After the surgery, Patient 1 was brought to ICU intubated and in critical condition. Continued review of Patient 1’s Operative Report on 1/3/26, showed Patient 1 was brought back to the OR for reexploration of the abdomen, washout, partial midline closure of the abdomen, placement of wound vac. There was bleeding from multiple exposed abdominal areas ... ascites with pockets of purulent ascites in the pelvis and the right lower quadrant. Review of the Critical Care Progress note on 1/4/26 at 1714 hours, showed overnight Patient 1 had worsening of hypotension and noted to have significant bloody output from the wound vac as well as the oropharynx (mouth). MTP was activated, transfused RBCs, FFP, Platelets, Cryoprecipitate with improvement. Patient 1 was noted to have worsening abdominal distention with tense abdomen overnight. Review of the plan of care did not show the individualized care plan to show the accurate care and services provided for the patient. On 7/23/26 at 1415 hours, Director 1 verified the findings.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the P&P for Grievance and Complaints investigation was implemented for one of the three sampled patients (Patient 1). Patient 1’s grievance was not completed as per the hospital’s P&P. This failure posed an increased risk for the patient’s quality of care concern to be addressed appropriately and on time. Findings: Review of the hospital’s P&P titled Grievance and Complaint’s revised date 4/2026, showed the following: * Grievance: written complaints regarding patient care. Whenever the patient or his/her representative requests that the complaint be handled formally or requests a response from the hospital. A written complaint (including email or fax) is always considered a grievance. * Time Frames: Grievances will be investigated and resolved as promptly as feasible based on the nature and complexity of the issue. The designated responder will establish a reasonable timeframe and will keep the patient or representative informed of the progress until completion. In any case the grievance is not resolved within 7 days the patient will be informed, within that 7 day time period, when expected resolution will occur, and will be kept regularly updated as to progress until resolution. Grievances should be resolved as quickly as possible under the circumstances, and in general within 30 days. On 7/22/26 at 1259 hours, interview and concurrent record review of Patient 1’s medical record was conducted with the Director of Quality, Directors 1 and 2, and the Lead Supervisor. Patent 1 was admitted to the hospital on 12/16/25, and had expired on 1/6/26. Review of the Patient Information for Patient 1 showed Family Member 2 was the patient’s next of kin. Review of the grievance letter via email to the hospital showed Family Member 2 submitted a grievance regarding concerns of quality of patient care and services provided for Patient 1. The Director of Quality was asked about the grievance process submitted for Patient 1. The Director of Quality stated the hospital sent a response letter within 7 days to Family Member 2 acknowledging the receipt of the grievance letter. The Director of Quality was asked for the letter to Family Member 2 for the completion of the grievance investigation in 30 days. The Director of Quality could not show a letter sent to Family Member 2 for the resolution of the grievance in relation to the quality of care and services provided for Patient 1’s admission to the hospital. On 7/23/26 at 1530 hours, the concern was shared with the CNO, Director of Quality, and Director 1.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 36703 Based on observation and interview, the hospital failed to ensure the confidentiality and security of patient medical records when an unattended workstation in the ED remained open in a high traffic area. This failure created the potential for unauthorized access to protected health information. Findings: Review of the hospital’s P&P titled Patient Rights dated 4/7/25, showed the patient will have the right to confidential treatment of all communications and records pertaining to the care and stay in the hospital. On 6/6/26 at 1107 hours, a tour of the ED hallway leading to the ambulance bay was conducted with the Director of ED, the Assistant Nurse Manager of ED 1 and the Director of Quality. A mobile workstation computer was open with sensitive patient information while being unattended by staff. The mobile workstation was located in the hallway with high traffic flow of staff and patients. The Director of ED, the Assistant Nurse Manager of ED, and the Director of Quality acknowledged the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure nursing staff documented the use of restraint as per the hospital’s P&P for two of six sampled patients (Patients 4 and 6) as evidenced by: 1. For Patient 4, there was no documented evidence to show the restraint assessment at the time the restraints were applied to the patient. In addition, there was no documented evidence to show the soft limb restraints being discontinued or the restraint assessment for the patient. 2. For Patient 6, there was no documented evidence to show the restraint type, the initiation time, and the restraint location when the restraints were applied to the patient. These failures had the potential to result in incomplete patient assessment, and substandard patient outcomes. Findings: Review of the hospital’s P&P titled Restraints dated 2/21/24, showed to document the intervention used, including the time of application and removal. 1. During a concurrent interview and record review on 6/10/26 at 1306 hours, with the RN Data Abstractor, Patient 4’s closed medical record was reviewed. Patient 4’s medical record showed the patient was admitted on 6/4/26, and discharged on 6/7/26. Review of the physician’s order for “Restraint Initiate Non-Violent” was ordered STAT on 6/6/26 at 1532 hours, for a soft limb restraint to the right arm due to interfering with medical treatments. The order also showed a comment for “both arms”. Review of Patient 4’s Restraint Needs Analysis performed on 6/6/26 1702 hours, showed the type of restraint for the patient was for soft limb restraints to the right and left arm. The document showed the restraint initiation time was dated 6/6/26 at 1510 hours. However, the first Restraint Documentation was dated 6/6/26 at 1700 hours. The “Need for Continuation” of the restraint showed a “Yes” response. There was no documented evidence of documentation to support the restraint assessment at the time the restraints were applied to Patient 4. At 6/6/26 at 1706 hours, the Restraint Documentation showed the “Need for Continuation” of the restraint showed a “Yes” response again. However, there was no documentation of the soft limb restraints being discontinued or the restraint assessment for Patient 4. 2. During a concurrent interview and record review on 6/10/26 at 1400 hours, with the RN Data Abstractor, Patient 6’s open medical record was reviewed. Patient 6’s medical record showed the patient was admitted to the hospital on 6/3/26. Review of the physician’s order for “Restraint Initiate Non-Violent” was ordered STAT on 6/4/26 at 0442 hours, for soft limb restraints to the left and right arms for interfering with medical treatments. The requested start time was for 6/4/26 at 0400 hours. However, review of Patient 6’s Restraint Documentation showed the first documentation of restraints was on 6/4/26 at 0600 hours. Review of the document failed to show the restraint type, and the initiation time. Additionally, the last Restraint Documentation of Patient 6’s restraints were on 6/4/26 at 0800 hours. The documentation showed the need for the continuation of the restraint was no longer necessary. However, the restraint type failed to identify the soft limb restraints to the left and right arms. On 6/10/26 at 1500 hours, the above findings were shared and acknowledged with the Chief Nursing Officer/VP of Quality, the Director of Quality, and the RN Data Abstractor.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure nursing staff clarified a non-violent restraint order for one of six sampled patients (Patient 4) when the order contained conflicting information regarding laterality. This failure had the potential to result in inappropriate restraint use, and substandard patient outcomes. Findings: During a concurrent interview and record review on 6/10/26 at 1306 hours, with the RN Data Abstractor, Patient 4’s closed medical record was reviewed. Patient 4’s medical record showed the patient was admitted on 6/4/26, and discharged on 6/7/26. Review of the physician’s order for “Restraint Initiate Non-Violent” was ordered STAT on 6/6/26 at 1532 hours, for a soft limb restraint to the right arm due to interfering with medical treatments. The order also showed a comment for “both arms”. However, further review of Patient 4’s medical record failed to show evidence the nursing staff clarified the conflicting order to determine whether the restraint was intended for the right arm only or for both arms. On 6/10/26 at 1500 hours, the above findings were shared and acknowledged with the Chief Nursing Officer/VP of Quality, the Director of Quality, and the RN Data Abstractor.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36703 Based on observation, interview, and record review, the hospital failed to ensure medications were administered appropriately for two of six sampled patients (Patients 1 and 3) as evidenced by: 1. Patient 3’s medication was left unattended at the patient’s bedside. 2. The nursing staff failed to administer medications as per the physician’s order and P&P for Patients 1 and 3. These failures created the risk of medication errors and poor health outcomes to the patients. Findings: 1. Review of the hospital’s P&P titled Administration of Medications dated 5/30/24, showed medications are never left at the bedside. On 6/9/26 at 1143 hours, an observation of Patient 3’s medication administration with RN 3 was conducted. A tube of diphenhydramine-zinc acetate topical (antihistamine) was observed on the bedside table in front of Patient 3. RN 3 acknowledged the medication was found on the bedside table and stated it was possibly left behind by another RN. 2. Review of the hospital’s P&P titled Medication Administration, Appendix A dated 5/30/24, showed daily medications are given at 0900 hours. Twice daily medications are given at 0900 and 2100 hours. Medications scheduled for every eight hours are given at 0600, 1400 and 2200 hours. Unless delayed for diagnostic testing, medication should be given no earlier than one hour before the scheduled time or no later than one hour after the scheduled time. a. On 6/9/26, Patient 1’s closed medical record review was initiated and showed Patient 1 was admitted to the hospital on 3/29/26 and discharged on 4/5/26. Review of the Medication Administration Record showed Patient 1 was ordered to receive meropenem (antibiotic) 1 gm IV every eight hours. However, the dose scheduled for 4/4/26 at 1400 hours, was administered at 1500 hours. b. On 6/9/26 at 1143 hours, RN 3 was observed administering medications to Patient 3 with the Director of Quality present. Patient 3 was sitting upright in bed eating a meal placed on her bedside table. RN 3 reviewed the medications Patient 3 was scheduled to receive. Patient 3 acknowledged which medications to take and not to take. RN 3 placed the medications in a cup and gave it to Patient 3, who swallowed the medications. On 6/10/26 at 1009 hours, Patient 3’s open medical record was initiated with the RN Data Abstractor and showed Patient 3 was admitted on 6/4/26. Review of the MAR showed Patient 3 received the following medications on 6/9/26 at 1152 hours: - Prednisone (steroid) 5 mg tablet by mouth daily. - Lactulose (laxative) 20 gm/30 ml oral solution two times a day. Further review of the MAR showed an “Early/Late Reason” as “Wean to Standard Admin Times.” However, the above listed medications were already set to the standard administration times. The RN Data Abstractor acknowledged the above medications were not administered at the schedule times.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff completed the admission assessment for two of four sampled patients (Patients 3 and 4) as per the hospital’s P&P. This failure had the potential to result in substandard care for the patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Admission, Assessment and Reassessment revised on 10/30/24, showed the following: * The RN completes the Nursing Admission Assessment which includes Basic Admission Information Adult, Adult Patient History, and Infectious Disease Risk Screening within 8 hours of the patient’s physical admission to an inpatient bed for all patients admitted to the hospital, including patients hospitalized for observation. * The RN Nursing admission assessment documentation includes the following components: a. Physical Exam b. Vital Signs c. Allergies d. Pain Screen e. Abuse/Neglect/Assault Screen f. Functional Screen g. Nutritional Screen h. Advance Directives/Power of Attorney i. Suicide Risk Assessment k. Fall/Skin Risk Assessment l. Cultural/Spiritual Screening m. Sensory/Communication Screen n. Discharge Planning Screen o. Additionally developmental, stage, age appropriate, and population specific assessment are completed as indicated. On 8/13/25 at 1134 hours, the ED was toured with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. During the tour, RN 1 was interviewed. RN 1 stated medical surgical float nurses cared for patients who were boarding in the ED after the admission order was received the level of care as the physician’s order. On 8/13/25 at 1533 hours, RN 2 was interviewed in the presence of the Director of ED and the Assistant ED Nurse Manager. RN 2 stated RN 2 was a medical/surgical telemetry nurse. RN 2 stated the nursing admission assessment was to be performed for all admitted patients and for patients on observation status and included completing the Adult Admission History form. Review of the Adult Admission History form showed the following items were to be completed: Pain history, Family history, Allergy, Immunization, Procedure history, Anesthesia/ sedation, Transfusion reaction and consent, Nutrition, Malnutrition screening tool, Functional/fall risk assessment, Social history, Risk assessment, Psychosocial/spiritual, Advanced Directive, CSSRS (Columbia-Suicide Severity Rating Scale), Current living status, Diabetes history, Heart failure admission assessment, PHQ-2, and AUDIT-C. 1. On 8/13/25 at 1407 hours, Patient 3’s medical record was reviewed with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. Patient 3’s medical record showed Patient 3 arrived at the ED on 8/12/25 at 1004 hours. Review of the physician’s order dated 8/12/25 at 2248 hours, showed to admit Patient 3 to medical surgical level of care as an observation status. Further medical record review showed the Adult Admission History was not opened to document. There was no documented evidence to show that the Adult Admission History was completed. 2. On 8/13/25 at 1430 hours, Patient 4’s open medical record was reviewed with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. Review of the physician’s order dated 8/12/25 at 2250 hours, showed to admit Patient 4 to telemetry level of care as an inpatient status. Further medical record review showed the Adult Admission History was not opened to document. There was no documented evidence to show that the Adult Admission History was completed. On 8/13/25 at 1600 hours, the Director of ED and the Director of Quality verified the above findings.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff performed the pain assessment for two of four sampled patients (Patients 1 and 3) as per the hospital’s P&P, creating the risk of substandard care to the patients. Findings: Review of the hospital’s P&P titled Pain Assessment and Reassessment revised on 12/12/24, showed the following: * Patients admitted to Emergency Department (ED) shall receive an initial screen at the emergency department visit and at the time of admission to identify the presence of pain. * Pain reassessments post pain medication administration will be completed as often as necessary and within one hour after treatment/intervention. * If the screen is positive, proceed with completing and documenting an in depth pain assessment to gather detailed pain information as follows: Pain Characteristics (a) Location- whether pain is in abdomen, leg, arm, ankle etc. (b) Laterality- determines if pain is on right, left side or is bilateral (c) Quality- identifies if the pain is aching, burning, cramping etc. (d) Time Variation- describes if pain is constant or intermittent (e) Onset- explains if pain is gradual or sudden (f) Duration- determines how long the pain has been (g) Alleviating factors- identifies interventions that help pain relief such as massage, repositioning, etc. (h) Aggravating factors- describes what makes pain worse such as movement, breathing, palpating/pressure etc. (i) Non-pharmacological Therapy - determines if cold, heat, music therapy etc. help in pain relief (j) The patient’s history of analgesic use or abuse 1. On 8/13/25 at 1310 hours, an interview and review of Patient 1’s closed medical record was conducted with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. Patient 1’s medical record showed Patient 1 arrived in the ED on 4/3/25 at 1107 hours, and was discharged from the ED on 4/3/25 at 1534 hours. Review of the Tier 2 Triage dated 4/3/25 at 1112 hours, showed Patient 1 complained of pain to the upper abdomen with the pain score of 10 out of 10 (0 being no pain and 10 being the worst pain). There was no documentation to show pain time variation, onset, aggravating and alleviating factors, non-pharmacological therapy, and the patient’s history of analgesic use or abuse. Review of the Orders-Medication dated 4/3/25 at 1327 hours, showed to administer morphine (narcotic pain medication) 4 mg IVP to Patient 1. Review of the MAR dated 4/3/25 at 1335 hours, showed Patient 1 received morphine. Review of the Pain documentation showed Patient 1 complained of pain. The pain score was nine out of 10 on 4/3/25 at 1405 hours, and two out of 10 on 4/3/25 at 1527 hours. During an interview with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality, the Director of ED and the Assistant ED Nurse Manager stated the pain level documented on 4/3/25 1405 hours, must have been a pain level performed on 4/3/25 at 1335 hours. The Director of ED and Assistant ED Nurse Manager verified there was no reassessment within one hour after the medication was given on 4/3/25 at 1335 hours. 2. On 8/13/25 at 1407 hours, an interview and concurrent review of Patient 3’s medical record was conducted with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. Review of the Pain Assessment dated 8/12/25 at 1007 hours, showed Patient 3 complained of abdominal pain. The pain score was nine out of 10. There was no documentation to show pain onset, aggravating and alleviating factors, non-pharmacological therapy, and the patient’s history of analgesic use or abuse. Review of the Pain Assessment dated 8/12/25 at 1229 hours, showed Patient 3 reported pain, but there was no documented pain level. On 8/3/25 at 1600 hours, the Director of ED and the Director of Quality verified the above findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 38660 Based on interview and record review, the hospital failed to notify the patient’s responsible party of the patient’s change in condition for one of nine sampled patients (Patient 9) as per hospital P&P. This failure posed the risk of the family member not involving in decision making process and getting the patient’s condition update. Findings: Review of the hospital’s P&P titled Cardiopulmonary Resuscitation Team Response dated 2/21/24, showed the purpose is to establish the response of a Resuscitation Team to efficiently implement resuscitative measures for patients, visitors, and staff. If present, the family of the patient will be informed of the patient’s condition by the primary physician. If family is not present, the social worker (or designee) will attempt to locate family members by phone. The physician will talk to the family as soon as the patient’s condition allows. On 11/18/24, review of Patient 9’s medical record was initiated. Patient 9’s medical record showed the patient came to the ED on 9/15/24, for abdominal pain with nausea and vomiting. Review of ED nurse note dated 9/15/24 at 1745 hours, showed the ED physician was notified Patient 9’s mental status was increasingly altered with abnormal posturing movements and dilated pupils. The ED physician came to patient’s bedside to reevaluate the patient. Review of ED nurse note dated 9/15/24 at 1836 hours, showed Patient 9 had cardiac arrest. Review of the Code Record showed Patient 9 coded on 9/15/24 at 1836 hours and survived at 1853 hours. Review of the Progress Note dated 9/16/24 at 0640 hours, showed Patient 9’s family members at bedside. On 11/19/24 at 1600 hours, an interview and concurrent review of Patient 9’s medical record was conducted with the Director of Quality, Licensing and Accreditation. The Director of Quality, Licensing and Accreditation confirmed no documented evidence showing Patient 9’s family member was notified after Patient 9 coded on 9/15/24.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure one of nine sampled patients (Patient 8) plan of care was updated to reflect the use of restraints during their hospitalization. This failure created the risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints dated 2/21/24, showed a written modification to the patient’s interdisciplinary plan of care is made when the restraint order is written. On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2. Patient 8’s medical record showed the patient came to the ED on 11/4/24. Review of the physician’s order dated 11/4/24 at 1908 hours, showed to initiate the restraints for Patient 8 to manage the violent behaviors. Review of Patient 8’s Restraint Documentation - ED dated 11/5/24, showed the behavioral restraints were initiated on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours. However, further review of Patient 8’s medical record did not show Patient 8’s plan of care was updated to reflect the use of restraints. On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the use of restraints for the management of violent or self-destructive (VSD) behaviors was renewed within four hours for one of nine sampled patients (Patient 8). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints dated 2/21/24, showed orders for a VSD restraint may only be renewed according to the following time limits for up to a total of 24 consecutive hours: - Four hours for adults. On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2. Patient 8’s medical record showed the patient came to the ED on 11/4/24. Review of Patient 8’s Restraint Documentation - ED dated 11/5/24, showed the hard limb restraints were applied to the patient’s all four extremities on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours, for a total duration of 376 minutes (6 hours and 16 minutes). Review of Patient 8’s medical record showed that the initial physician’s order for restraints to manage violent behavior was issued on 11/4/24 at 1908 hours. However, the physician’s order for renewal of the restraints was issued on 11/4/24 at 2349 hours (or more than four hours later). On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings. RN 2 verified the VSD restraint orders for adults could only be renewed for up to four hours at a time.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the staff reassessed and monitored one of nine sampled patients (Patient 8) while Patient 8 was restrained. This failure had the potential to result in unsafe care for the patient. Findings: Review of the hospital’s P&P titled Restraints dated 2/21/24, showed under the section, Reassessment of the VSD Behavior Patient, that observation and monitoring will be done on an ongoing basis. Reassessment documentation will be completed as often as necessary depending on the patient’s condition, and a minimum every one hour. Documentation of hourly assessment includes: - Any signs of injury, - Level of consciousness, - Circulation, - Sensory and motor function. On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2. Patient 8’s medical record showed the patient came to the ED on 11/4/24. Review of Patient 8’s Restraint Documentation - ED dated 11/5/24, showed the hard limb restraints were applied to the patient’s all four extremities on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours, for a total duration of 376 minutes (6 hours and 16 minutes). Review of Patient 8’s medical record showed documented hourly reassessments on 11/4/24 at 1850, 1949, 2049, 2149, and 2249 hours, and on 11/5/24 at 0049 hours. However, there was no documented hourly reassessment of Patient 8 between 11/4/24 at 2249 hours and 11/5/24 at 0049 hours. On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings.”

“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: 29558 Based on interview and record review, the hospital failed to ensure the ICU nursing staff adhered to the hospital’s P&Ps for one of nine sampled patients (Patient 3) when the ICU nursing staff did not assess Patient 3’s RASS score every one hour. This failure posed the potential to result in poor health outcomes to the patient. Findings: Review of Attachment A: Nursing Assessment/Reassessment Grid for Med/Surg ICU of the hospital’s P&P titled Critical Care Practice Standards for ICU dated 9/20/22, showed to assess the Richmond Agitation Sedation Score, Scale RASS prior to initiation of the sedation, with each titration, and every one hour once the goal reached. On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3’s medical record was conducted with RN 1 and the ACNO. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 11/12/24, and transferred to ICU on 11/14/24 at 1723 hours. Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol (a medication used to sedate a patient) at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min. Review of the Medication Administration Record showed Patient 3 received propofol at 45 mcg/kg/min on 11/17/24 at 1810 and 2249 hours; and 11/18/24 at 0450 hours. Review of the RASS score showed Patient 3’s RASS score was minus two on 11/17/24 at 2000 hours. There was no documented evidence to show the ICU nursing staff assessed Patient 3’s RASS score every one hour on 11/17/24, from 2000 hours to 2300 hours (or at 2100, 2200, and 2300 hours) and on 11/18/24, from 0100 hours to 0400 hours (or at 0100, 0200, 0300, and 0400 hours) as per the hospital’s P&P. RN 1 confirmed the findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 39199 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the physician’s orders to titrate the medications for three of nine sampled patients (Patients 1, 2, and 3) as evidenced by: 1. For Patient 1, the nursing staff did not titrate esmolol (a medication used to slow down a fast heartbeat and treat high blood pressure) to maintain the patient’s heart rate less than 70 beats per minute as per the physician’s order. 2. For Patient 2, the nursing staff did not titrate propofol as per the physician’s order. 3. For Patient 3, the nursing staff did not titrate propofol as per the physician’s order These failures posed the risk of not attaining therapeutic goals, ineffective treatment, or adverse health outcomes for the patients. Findings: Review of the hospital’s P&P titled Medication Administration dated 5/30/24, showed medications must be administered consistent with the physician’s orders and consistent with the hospital’s policies, medical staff bylaws, rules and regulations, and other applicable laws. Review of the hospital’s P&P titled Medication Titration dated 2/23/23, showed the following: - Medications are titrated to specific endpoint/effect as per physician order. - All medication drip rates ordered to be titrated will be adjusted according to suggested guidelines unless otherwise specified by the prescriber as appropriate. - The nurse is responsible for documenting parameters and titration adjustments in the medical record as per policy. 1. On 11/18/24 at 1051 hours, medical record review for Patient 1 was initiated with the Director of Quality, Licensing and Accreditation. Patient 1’s medical record showed the patient was admitted to the hospital on 10/20/24. Review of the physician’s order dated 10/20/24 at 1335 hours, showed to initiate esmolol 250 ml at 50 mcg/kg/min. The order specified titrating the medication incrementally by 50 mcg/kg/min every 5 minutes to maintain a heartrate less than 70 beats per minute, with a maximum dose of 200 mcg/kg/min. Review of Patient 1’s medications flowsheet showed the esmolol IV drip was initiated on 10/20/24 at 1353 hours. Review of Patient 1’s Vital Signs showed on 10/20/24, Patient 1’s heart rate was as follows: - At 1402 hours, Patient 1’s heart rate was 80 beats per minute, - At 1416 hours, Patient 1’s heart rate was 87 beats per minute, and - At 1422 hours, Patient 1’s heart rate was 89 beats per minute. However, review of Patient 1’s medical record did not show evidence the esmolol IV drip was titrated to maintain the patient’s heart rate below 70 beats per minute. On 11/18/24, the Director of Quality, Licensing and Accreditation verified the findings and acknowledged the nursing staff did not follow the physician’s orders to titrate the medication to maintain the patient’s heart rate below 70 beats per minute. 29558 2. On 11/18/24 at 1015 hours, a tour of ICU was conducted with the ACNO and Director of Quality, Licensing and Accreditation. Patient 2 was observed lying on the bed in Room A. Propofol was observed infusing to the patient. On 11/18/24 at 1046 hours, an interview and concurrent review of Patient 2’s medical record was conducted with RN 1 and the ACNO. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 11/17/24 at 0318 hours and came to the ICU on 11/17/24 at 0557 hours from the ED. Review of the Order Sheet dated 11/17/24 at 0058 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min; replace propofol and tubing every 12 hours. Review of the RASS Vital Sign and IV Drips showed the nursing staff did not titrate the propofol for Patient 2 as per the physician’s order. For examples, * On 11/17/24: - At 0035 hours, Patient 2’s RASS score was zero and the rate of the propofol was infused at 10 mcg/kg/min. - At 0040 hours, Patient 2’s RASS score was zero and the rate of the propofol was increased to 15 mcg/kg/min. - At 0045 hours, Patient 2’s RASS score was minus one and the rate of the propofol was increased to 20 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2’s RASS score was within the goal, from zero to minus two. * On 11/17/24: - At 0245 hours, Patient 2’s RASS score was zero and the rate of the propofol was 35 mcg/kg/min. - At 0250 hours, Patient 2’s RASS score was minus one and the rate of the propofol was increased to 40 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2’s RASS score was within the goal, from zero to minus two. - At 0320 hours, Patient 2’s RASS score was minus three and the rate of the propofol was increased to 45 mcg/kg/min. The rate of the propofol was increased instead of decreased when Patient 3’s RASS score was minus three. * On 11/17/24: - At 0406 hours, Patient 2’s RASS score was minus one and the rate of the propofol was 45 mcg/kg/min. - At 0530 hours, Patient 2’s RASS score was minus one and the rate of the propofol was increased to 50 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2’s RASS score was within the goal, from zero to minus two. - At 0545 hours, the section of RASS score was left blank and the rate of the propofol was increased to 55 mcg/kg/min. The rate of the propofol was increased when there was no documented evidence to show the nursing staff assessed Patient 2’s RASS score. - At 0600 hours, Patient 2’s RASS score was minus two and the rate of the propofol was increased to 60 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2’s RASS score was within the goal, from zero to minus two. RN 1 verified the above findings. 3. On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3’s medical record was conducted with RN 1 and the ACNO. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 11/12/24. Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min; replace propofol and tubing every 12 hours. Review of the RASS Vital Sign and IV Drips showed the nursing staff did not titrate the propofol for Patient 3 as per the physician’s order. For example, * On 11/15/24: - At 1615 hours, Patient 3’s RASS score was zero and the propofol was infused at 75 mcg/kg/min. - At 1620 hours, Patient 3’s RASS score was minus one and the rate of the propofol was increased to 80 mcg/kg/min. - At 1625 hours, Patient 3’s RASS score was minus one and the rate of the propofol was increased to 85 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2’s RASS score was within the goal, from zero to minus two. * On 11/16/24 at 2315, 2330, and 2345 hours, the rate of the propofol was decreased to 70, 65, and 60 mcg/kg/min respectively. However, the sections of RASS score were left blank on at 2315, 2330, and 2345 hours. RN 1 verified the findings.”

“ACCEPTING VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent with Federal and State law. This Standard is not met as evidenced by: 29558 Based on observation, interview, and record review, the hospital failed to ensure the physician’s verbal orders were written for two of nine sampled patients (Patients 2 and 3) as per the hospital’s P&P. This failure posed the potential to result in poor health outcomes to the patients. Findings: Review of the hospital’s P&P titled Medication Administration dated 5/30/24, showed the medications must be administered to be consistent with the physician’s orders and hospital’s policies, medical staff by laws, rules and regulations, and other applicable laws. Review of the hospital’s P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed verbal/telephone orders are patient care, treatment, and service order issued verbally by a physician either directly face to face or via telephone to a licensed professional authorized to receive and record such orders. Verbal or telephone orders must be entered in the patient’s EHR at the time the order is received, except in life threatening emergencies, if order entry is thought to delay effective emergency response. Verbal or telephone order entries shall be authenticated/attested within 48 hours by the ordering licensed provider. 1. On 11/18/24 at 1015 hours, a tour of ICU was conducted with the ACNO and Director of Quality, Licensing and Accreditation. Patient 2 was observed lying on the bed in Room A. Precedex (a medication used to start or maintain sedation) was observed infusing at 1.4 mcg/kg/hr to Patient 2. On 11/18/24 at 1046 hours, an interview and concurrent review of Patient 2’s medical record was conducted with RN 1 and the ACNO. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 11/17/24 at 0318 hours and went to the ICU on 11/17/24 at 0557 hours, from the ED. Review of the Order Sheet dated 11/18/24 at 0926 hours, showed to initiate dexmedetomidine (same as Precedex) at 0.2 mcg/kg/hr and titrate incrementally 0.2 mcg/kg/hr with the frequency of 30 minutes to maintain the RASS score from zero to minus two, with the maximum dose of 1.4 mcg/kg/hr. Review of the Medication Administration Record showed the dexmedetomidine was started at 1.4 mcg/kg/hr for Patient 2 on 11/18/24 at 0932 hours. The Result Comment section showed “ok per MD to max dose...” When asked, RN 1 stated it was the verbal order to administer the dexmedetomidine to the patient with the maximum dose of 1.4 mcg/kg/hr. When asked, RN 1 was unable to find a verbal order was written to initiate the dexmedetomidine with the maximum dose as of 1.4 mcg/kg/hr for the patient. 2. On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3’s medical record was conducted with RN 1 and the ACNO. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 11/12/24. Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min. Review of the Medication Administration Record showed on 11/15/24, the propofol was infused to the patient at 5 mcg/kg/min at 1549 hours. At 1550 hour, the propofol was increased to 50 mcg/kg/min and the Result Comment section showed “initiated during bronchoscopy procedure. MD aware.” When asked, RN 1 stated the physician was aware the propofol was administered at 50 mcg/kg/min to the patient on 11/15/24 at 1550 hours. When asked, RN 1 was unable to find a verbal order was written to administer 50 mcg/kg/min to the patient during the bronchoscopy procedure. On 11/18/24 at 1430 hours, during a follow-up interview with RN 1, RN 1 confirmed the above verbal orders were not written for Patients 2 and 3 as per the hospital’s P&P.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for the Administration of Blood and Blood Products for one of nine sampled patients (Patient 7) to assess and document the vital signs before, during, and after the blood transfusion. This posed the risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during the blood transfusion process. Findings: Review of the hospital’s P&P titled Administration of Blood and Blood Products dated 5/30/24, showed the following: * Prior to blood/blood product pick up from the blood bank, obtain baseline vital signs (blood pressure, heart rate, temperature, and respiratory rate) to assure expected normalcy before proceeding with blood/blood products transfusion. * During the transfusion, the RN will assess and document vital signs (blood pressure, heart rate, temperature, and respiratory rate) and oxygen saturation as follows: - At 15 minutes from the beginning of the transfusion, - Then every one hour up until transfusion completion, and - At the end of the transfusion. On 11/19/24 at 0915 hours, medical record review for Patient 7 was initiated with the Senior Director of Critical Care Services, ICU Director, and RN 1. Patient 7’s medical record showed the patient was admitted to the hospital on 11/12/24. a. Review of the physician’s order dated 11/12/24 at 2304 hours, showed to transfuse two units of red blood cells to Patient 7. Review of Patient 7’s Blood Transfusion Summary showed the second unit of red blood cells was transfused on 11/13/24 from 0500 hours to 0800 hours. However, there was no documented evidence Patient 7’s vital signs were assessed at the end of the blood transfusion on 11/12/24 at 0800 hours. b. Review of the physician’s order dated 11/13/24 at 1349 hours, showed to transfuse one unit of plasma to Patient 7. Review of Patient 7’s Blood Transfusion Summary showed the one unit of plasma was transfused on 11/13/24 from 1449 hours to 1544 hours. However, there was no documented temperature 15 minutes after the start of the transfusion and no documented evidence Patient 7’s vital signs were assessed at the end of the blood transfusion on 11/13/24 at 1544 hours. c. Review of the physician’s order dated 11/14/24 at 1352 hours, showed to transfuse two units of red blood cells to Patient 7. Review of Patient 7’s Blood Transfusion Summary showed that the first unit of red blood cells was transfused on 11/14/24 from 1417 hours to 1440 hours, and the second unit was transfused on 11/14/24 from 1441 hours to 1533 hours. However, there were no documented baseline vital signs at the start of the first unit transfusion, no documented respiratory rate at 1440 hours (the end of the first unit transfusion), and no documented temperature at 1535 hours (the end of the second unit transfusion). On 11/19/24, the Senior Director of Critical Care Services, ICU Director, and RN 1 verified the findings.”

“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: 40483 Based on interview and record review, the hospital failed to ensure the nursing staff assessed the vital signs every two hours for three of four sampled patients (Patients 1, 2 and 3) as per the hospital’s P&P. This failure created the risk for substandard health outcomes to these patients. Findings: Review of the hospital’s P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the purpose is to establish the guidelines for performing the ED assessments and reassessments for the initial and ongoing care and/or observation of the patients in treatment areas or those who are waiting for the placement in the treatment area. The primary nurse responsibilities for the assessments and reassessments include to complete the more in depth assessments when the patients are in the treatment areas; obtain the initial complete vital signs including blood pressure, heart rate, temperature, respiratory rate, and pain score; and assure the subsequent vital signs and assessments are completed at least every two hours for ESI levels 2 and 3 patients and/or more frequently based on the patients’ conditions and/or changes. 1. On 10/4/24, review of Patient 3’s medical record was initiated. Patient 3’s medical record showed the patient came to the ED on 10/2/24. Review of Patient 3’s General Triage Assessment and Chief Complaint/Mechanism of Injury showed the patient presented to the hospital and was assessed with a tracking Acuity (ESI) level of 2. Review of Patient 3’s documented vital signs showed the following: * On 10/02/24 at 1610 hours, Patient 3’s vital signs were: T-36.8 degrees C, HR- 69 bpm, RR-18 br/min, BP-120/87 mmHg. * On 10/02/24 at 1810 hours, no vitals were taken or documented for Patient 3 as per the hospital’s P&P. * On 10/02/24 at 2010 hours, no vitals were taken or documented for Patient 3 as per the hospital’s P&P. * On 10/02/24 at 2112 hours Patient 3’s vital signs were: T-37 degrees C, HR-68 bpm, RR-18 br/min, BP- 150/89 mmHg. * On 10/02/24 at 2200 hours Patient 3’s vital signs were: T-37 degrees C, HR- 88 bpm, RR-17 br/min, BP- 164/95 mmHg. * On 10/03/24 at 0000 hours Patient 3’s vital signs were: T- 37 degrees C, HR- 89 bpm, RR-16 br/min, BP 165/78 mmHg. * On 10/03/24 at 0200 hours Patient 3’s vital signs were: T-36.6 degrees C, HR- 79 bpm, RR-18 br/min, BP-136/108 mmHg. On 10/04/24 at 1255 hours, an interview and concurrent medical record was conducted with the Director of Quality. The Director of Quality verified Patient 3 was admitted to the ED on 10/02/24 with an ESI level of 2. The Director of Quality reviewed Patient 3’s vital signs. The Director of Quality verified no vital signs were documented for Patient 3 on 10/2/24 at 1810 or 2010 hours. The Director of Quality reviewed the hospital’s ED P&P and verified the expectation was to follow the hospital’s P&P. The Director of Quality stated the purpose of assessing a patient’s vital sign was to assess the patient’s status, cardiovascular stability and mentation of the patients. The Director of Quality also verified once vital signs were again assessed and documented, Patient 3 had the documented elevated blood pressure. The Director of Quality stated by not taking the vital signs for five hours, Patient 3’s elevated blood pressures could have occurred during those five hours and could have been a sign of additional health problems and cardiovascular events leading to a poor outcome. On 10/04/24 at 1525 hours, an interview was conducted with Senior Director of Critical Care and ED. The Senior Director of Critical Care Services and ED verified she was also the Director of the ED. The Senior Director of Critical Care Director and ED reviewed the hospital’s P&P for ED, Triage, Assessment and Reassessment Standards. The Senior Director of Critical Care Services and ED stated the policy was for the ED nursing staff. The Director of Critical Care Services and ED stated the expectation was for the nursing staff to follow this hospital’s P&P in both areas, triage and treatment areas. The Senior Director of Critical Care Services and ED verified Patient 3 was admitted on 10/02/24 at 1608 hours. The Senior Director of Critical Care Services and ED verified Patient 3 was triaged with the acuity level of 2. The Senior Director of Critical Care Services and ED stated per the hospital’s policy, patients with an ESI level of 3 or 2 were to have their vital signs assessed every two hours. The Senior Director of Critical Care Services and ED reviewed Patient 3’s medical record and verified Patient 3’s vital signs were taken on 10/02/24 at 1610 and then 2112 hours. The Senior Director of Critical Care Services and ED stated per the hospital’s policy, the expectation was to take vital signs every two hours for Patient 3. Based on the initial assessment, Patient 3 should have assessed for vital sign assessment at approximately 1800 and 2000. The Senior Director of Critical Care Services and ED stated it was a missed opportunity for the nursing staff to follow the hospital’s P&P. The Senior Director of Critical Care Services and ED and Director of Quality were both informed and acknowledged the findings. 39796 2. On 10/4/24, Patient 1’s closed medical record was reviewed. Patient 1’s closed medical record showed the patient was admitted to the hospital on 9/11/24, with a chief complaint of psychiatric problem. Patient 1 was triaged to have an acuity level of 3. Review of the Interactive View/I &O flowsheet dated 9/12/24 showed under the section of Vital Signs, the RN had assessed the patient’s vital signs every two hours as follows: - At 0800 hours, the patient’s temperature was 36.4 degrees C. The patient’s pulse rate was 74 bpm. The patient’s respiratory rate was 16 br/min. And the patient’s BP was 110/74 mmHg. - At 1000 hours, the patient’s temperature was 36.9 degrees C. The patient’s pulse rate was 94 bpm. The patient’s respiratory rate was 18 br/min. And the patient’s BP was 140/84 mmHg. However, review of vital signs flowsheet failed to show documented evidence the patient’s vital signs were taken at 1200 hours or after two hours as per the hospital’s P&P. On 10/4/24 at 1124 hours, an interview and concurrent medical record review was conducted with the Senior Director of Clinical Care and ED. The Senior Director of Clinical Care and ED was asked how often the vital signs were taken. The Senior Director of Clinical Care and ED stated every two hours. The Senior Director of Clinical Care and ED was also asked when the last set of vital signs was taken. The Senior Director of Clinical Care and ED stated the last set of vital signs was taken at 1000 hours. The Senior Director of Clinical Care and ED was further asked if the patient’s vital signs were taken at 1200 hours. The Senior Director of Clinical Care and ED stated there was, but it was not documented on the chart. The Senior Director of Clinical Care and ED further stated the staff took the vital signs, but it was not logged. The Senior Director of Clinical Care and ED was informed and acknowledged the findings. 3. Review of Patient 2’s medical record was initiated on 10/4/24. The patient went to the hospital on 9/30/24 at 2249 hours. The patient had a chief complaint of overdose. Review of the Tier 2 Triage dated 9/30/24 at 2256 hours, showed the patient was triaged with the acuity level of 2. Review of the Interactive View/I &O flowsheet dated 10/3/24, showed under the section for Vital Signs, the RN had assessed the patient’s vital signs every two hours as follows: - At 1400 hours, the patient’s BP was 138/96 mmHg. The patient’s pulse rate was 74 bpm. The patient’s respiratory rate was 18 br/min. And the patient’s temperature was 36.6 degrees C. - At 1600 hours, the patient’s BP was 139/100 mmHg. The patient’s pulse rate was 70 bpm. The patient’s respiratory rate was 18 br/min. And the patient’s temperature was 37.0 degrees C. - At 1800 hours, the patient’s BP was 151/106 mmHg. The patient’s pulse rate was 88 bpm. The patient’s respiratory rate was 18 br/min. And the patient’s temperature was 36.5 degrees C. Further review of the Interactive View/I &O flowsheet showed the sections of BP, pulse rate, and respiratory rate was left blank on 10/3/24 at 2000 hours. On 10/4/24 at 1030 hours, an interview was conducted with MHA 1. MHA 1 was asked about the frequency of vital signs monitoring. MHA 1 stated every two hours. On 10/4/24 at 1100 hours, an interview was conducted with RN 3. RN 3 was asked about the frequency of the vital signs monitoring. RN 3 stated every two hours. On 10/4/24 at 1354 hours, an interview and concurrent medical record review was conducted with the Senior Director of Clinical Care and ED. The Senior Director of Clinical Care and ED was asked about the frequency of the vital signs for a patient with the ESI level 2. The Senior Director of Clinical Care and ED stated every two hours. The Senior Director of Clinical Care and ED was also asked if they needed to recheck the patient vital signs if the BP was elevated. The Senior Director of Clinical Care and ED stated it did not look like there was. The Senior Director of Clinical Care and ED was informed and acknowledged the findings. On 10/4/24 at 1526 hours, a follow-up interview and concurrent document review was conducted with the Senior Director of Clinical Care and ED, Director of Quality, and Chief Operating Officer. They were asked if the hospital’s P&P related to ED Triage, Assessment and Reassessment Standards was applicable for the patient. The Senior Director of Clinical Care and ED stated yes. They were informed and acknowledged the findings.”

“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: 22553 Based on observation, interview, and record review, the hospital failed to ensure to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for one of 20 sampled patients (Patient 13) and failed to ensure the OB physician and MHA 1 had completed the EMTALA training annually. Cross reference to A2406. 2. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for 11 of 20 sampled patients (Patients 1, 2, 5, 8, 9, 10, 12, 16, 17, 18, and 20). Cross reference to A2407. 3. The hospital failed to ensure the ED staff appropriately transferred four of 20 sampled patients (Patients 5, 8, 11, and 20) when the Patient Transfer Summary forms were not completed for Patients 5, 8, 11, and 20 as per the hospital’s P&P. Cross reference to A2409.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 36703 Based on observation, interview, and record review, the hospital failed to ensure the signages for EMTALA rights with respect to the examination and treatment for emergency medical conditions (EMC) and women in labor were posted conspicuously in the ED areas where the signages would likely be noticed by the individuals visiting the ED area as evidenced by: 1. The EMTALA signage in the Main ED, Triage Tent, and Ambulance Bay were not clearly visible from a distance as per the hospital’s P&P. 2. The EMTALA signage was not posed in the ED procedure room. These failures had the potential to result in the individuals to not be aware of their rights to the examination and treatment in the event of an emergency medical conditions. Findings: Review of the hospital’s P&P titled EMTALA dated 10/15/21, showed signage refers to the requirement that the hospital post conspicuous signs in the ED and L&D Department and other places in which patients may present. The signs must specify the rights of unstable individuals with emergency conditions and women in labor who come to the ED and L&D Department. The letters within the sign must be clearly readable at a distance of 20 feet from the vantage point of persons in the ED and L&D department. 1. On 7/3/2024 at 0950 hours, a tour of the Main ED, Triage Tent, and Ambulance Bay was conducted with the ED Director. The posted EMTALA signage was noted conspicuously. However, the font of the letter was too small and could not be read from a distance of 20 feet. On 7/3/2024 at 1050 hours, the above findings were shared with the ED Director and CNO. 22553 2. On 7/3/24 at 1128 hours, a tour of the ED was conducted with the Sr. Director of Critical Care. In the hospital lobby, it was observed a space which was divided by the plastic partition panels. According to the Sr. Director of Critical Care, this area was an ED procedure room where the minor procedures would be performed. The Sr. Director of Critical Care confirmed there was no EMTALA signage posted in this area.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to maintain a central ED log for two of 20 sampled patients (Patients 13 and 14) to show an ED disposition to the OB Triage. This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED and L&D Department for the treatments of their emergency medical conditions. Findings: Review of the hospital’s P&P titled EMTALA dated 10/15/21, showed the Central Log will indicate whether individuals refused treatment; were denied treatment; were treated, admitted, stabilized; and/or transferred or discharged. On 7/3/24, review of the ED log was conducted with the Sr. Director of Critical Care and the Director of Quality. a. Review of the ED log showed Patient 13 arrived to the ED on 4/19/24 at 1256 hours with abdominal pain after a MVA trauma during pregnancy. The disposition section of the ED log was left blank. The discharge time documented on the ED log was on 4/19/24 at 1649 hours. Review of Patient 13’s Encounter Location History Viewer showed the patient was in the LDRP on 4/19/24 at 1335 hours for an OB Triage. b. Review of the ED log showed Patient 14 arrived to the ED on 4/29/24 at 1345 hours with MVA, back pain, and abdominal pain. The patient was pregnant. The disposition section of the ED log showed “Discharged to Home or Self Care”. The discharge time documented on the ED log was on 4/29/24 at 1419 hours. Review of Patient 14’s Encounter Location History Viewer showed the patient was in the LDRP on 4/29/24 at 1419 hours for an OB Triage. On 7/3/24 at 1342 hours, an interview and concurrent review of the ED logs and EHR was conducted with the Sr. Director of Critical Care and Director of Quality. The Sr. Director of Critical Care stated there was a possible error in the EHR when transferring over the correct disposition for ED patients who went to the LDRP for following-up of an OB related complaint. The above findings were shared and verified by the Sr. Director of Critical Care and Director of Quality.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for one of 20 sampled patients (Patient 13) and failed to ensure the OB physician and MHA 1 had completed the EMTALA training annually as evidenced by: 1. For Patient 13, the L&D Attending Physician and L&D nursing staff did not evaluate the patient who was pregnant, in the ED as per the hospital’s P&P. 2. There was no documented evidence showing the OB physician and MHA 1 had completed the EMTALA training annually. These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. Review of the hospital’s P&P titled Assessment of the Obstetric Patient in the Emergency dated 8/23/21, showed pregnant patients with non-pregnancy related emergency cases with obstetrical implications will be treated by the ED physician for emergent medical problems and the OB provider on-call will be notified. The L&D Attending Physician will be called to evaluate the patient in the ED. The L&D nursing staff will also be called to monitor the fetus in the ED. On 7/5/2024 at 1130 hours, an interview and concurrent review of Patient 13’s medical record was conducted with the Director of Perinatal Services and Sr. Director of Critical Care. Patient 13’s medical record showed Patient 13 presented to the ED on 4/19/2024 at 1256 hours. Review of the Tier 2 Triage dated 4/19/24 at 1305 hours, showed Patient 13 presented with lower abdominal plan and s/p MVA today. Patient 13 was 36 weeks pregnant and reported having lower abdominal pain after the incident. Review of the ED Note - Physician dated 4/19/2024 at 1318 hours, showed Patient 13 received an MSE to rule out an EMC for the non-pregnancy related concern of abdominal pain. The medical decision making was that Patient 13 was experiencing abdominal pain in pregnancy after blunt trauma. Patient 13 was recommended to be admitted to OB/GYN for further workup and treatment and tocometry. Review of the Encounter Location History Viewer showed Patient 13 arrived in the LDRP on 4/19/24 at 1335 hours. Review of the History and Physical examination dated 4/19/2024 at 1750 hours, showed OB DO 1 consulted with Patient 13 in the LDRP. The Director of Perinatal Services confirmed OB DO 1 and L&D nursing staff did not evaluate Patient 13 in the ED. The Director of Perinatal Services stated OB DO 1 should have seen the patient before 1750 hours. The Director of Perinatal Services stated if the patient had an abdominal injury, then the L&D physician would come down to see the patient. 2. Review of the hospital’s P&P titled EMTALA dated 10/15/21, showed the hospital establishes the P&P to ensure the compliance with EMTALA requirement. The Dedicated Emergency Department (DED) includes the main ED and L&D Department. The EMC means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. a. On 7/5/24 at 1328 hours, OB DO 1’s credential file was reviewed with the Medical Staff Administrator. When asked for the document for the EMTALA training or in-service for OB DO 1, the Medical Staff Administrator stated there was none. The Medical Staff Administrator stated MD 2 said it was not necessary for the OB physician to have the EMTALA training. The hospital’s medical staff did not include the EMTALA training in their credentialing requirement. On 7/5/24 at 1328 hours, the CNO stated the hospital required the hospital staff to have the EMTALA training annually. The CNO stated the physician should have the same requirement. b. On 7/8/2024 at 1437 hours, an interview and concurrent review of training files of MHA 1 was conducted with the Director of Education and Professional Development. Review of MHA 1’s training file showed MHA 1’s last EMTALA training was completed on 12/21/21. The Director of Education and Professional Development acknowledged the findings and stated MHA 1 was contacted to complete the EMTALA training which was an annual training requirement.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for 11 of 20 sampled patients (Patients 1, 2, 5, 8, 9, 10, 12, 16, 17, 18, and 20) as evidenced by: 1. The ED staff did not ensure the pain management for Patients 5, 8, 9, 10, 12, 17, and 18 as per the hospital’s P&P. 2. The ED staff did not assess the vital signs every two hours for Patients 2, 5, 8, 16, 18, and 20 as per the hospital’s P&P. 3. The ED staff did not assess the orthostatic vital signs for Patients 1 and 2 as per the physician’s orders. 4. The ED staff did not ensure the discharge instructions for Patient 1 was completed as per the hospital’s P&P. 5. The ED staff did not perform the focused assessment related to the chief complaint for Patient 17 as per the hospital’s P&P. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. Review of the hospital’s P&P titled Pain Assessment and Reassessment Management dated 2/16/22, showed the following: * Screening patients for the presence of pain will be done according to the requirements in the care setting they are in as the 5th vital sign. * The hospital has adopted and consistently used the following Pain Assessment Scales to identify the patient’s level/intensity of plan, based on the patient’s condition, age, and ability to self-report. - The FACES Pain Scale is used in children ages 4-12 who are able to point to various degrees of pain expression faces for a total score of up to 10. On the scale from zero to 10, zero indicates the patient has no pain and ten indicates the patient has the worst possible pain. - The Numerical Rating Scale (NRS) is also known the Verbal Numerical Scale (VNS) is used for self-reporting of pain on a scale of zero to 10. Zero indicates the patient has no pain and ten indicates the patient has the worst possible pain. * ED patients shall receive treatment for acute pain related to their chief complaint or presenting condition when intensity exceeds their acceptable level of pain, or pain goal. * Pain screening and admission pain assessment for patient admitted to any care setting. The staff nurse is to complete and document the following upon a patient admission to any care setting within the hospital. - Perform an initial pain screen at the time of admission to identify the presence of pain. - If the pain screen is positive, the “Yes” option will open up into a complete and more in depth “Admission Pain Assessment” to gather sufficient information to identify the pain as follows: pain demographics and pain characteristics, including the pain location, laterality, quality, time variation. onset, duration, alleviating factors. * In the ED, the post treatment assessment includes to reassess pain within one hour following treatment/intervention or at the time of discharge or transfer, whichever comes first. All reassessments are documented in the EHR. Review of the hospital’s P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the following: - For the patients in the waiting room, the patient is reassessed all abnormal vital signs according to the ESI level. For patients with ESI level 3, the lobby manager and/or co-charge RN will ensure that a reassessment of systems related to the patient’s primary complaint is completed along with vital signs (BP, HR, RR, temperature, SpO2, and pain score) at least every two hours or more frequently based on patient condition or changes. - The primary RN responsibilities include to assure subsequent vital signs and reassessments are completed at least every two hours for ESI level 3 patients or more frequently based on the patient conditions and/or changes. Review of the hospital’s P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed STAT order are defined as patient care, treatment, and service orders issued verbally, by telephone or entered in EHR for life threatening, and/or emergency situations. The implementation of STAT orders will be initiated immediately. a. On 7/8/24 at 1100 hours, Patient 5’s medical record review was conducted with the Sr. Director of Critical Care. Patient 5’s medical record showed Patient 5 came to ED on 3/21/24 at 1432 hours and transferred to other hospital on 3/22/24 at 1145 hours. Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed Patient 5 had left side lower jaw swelling for a month. The Pain Assessment ED section showed “Pain Present: Yes actual or suspected pain.” There was no documented evidence to show the nursing staff assessed the patient’s pain characteristics as per the hospital’s P&P. Review of the physician’s order dated 3/21/24 at 1509 hours, showed to administer morphine (a pain medication) 4mg, IVP, once to the patient. Review of the MAR showed the morphine 4mg was administered to Patient 5 on 3/21/24 at 1609 hours (or one hour after the medication was ordered). There was no documented evidence to show Patient 5 was reassessed after the morphine was administered to the patient. There was no documented evidence to show the reason for the medication ordered as “once” was given one hour later. There was no documented evidence to show the pain reassessment was completed prior to the patient’s discharge on 3/22/24 at 1145 hours. On 7/8/24 at 1110 hours, the Sr. Director of Critical Care confirmed the findings. b. On 7/8/24 at 0932 hours, Patient 8’s medical record review was conducted with the Sr. Director of Critical Care. Patient 8’s medical record showed Patient 8 came to the ED on 5/10/24 and transferred to the HLOC on 5/11/24 at 0821 hours. Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient’s ESI level was “3.” Review of the Pain flowsheet showed the following: * On 5/10/24 at 2345 hours, the patient’s pain score was four. * On 5/11/24 at 0147 hours, the patient’s pain score was zero. * On 5/11/24 at 0533 hours, the patient’s was four. * On 5/11/24 at 0637 hours, the patient’s pain score was zero. Review of the physician’s order dated 5/11/24 at 0002 hours, showed to administer ibuprofen (a pain medication) 336 mg once, STAT to the patient. Review of the MAR showed the ibuprofen was administered to the patient on 5/11/24 at 0117 hours (one hour and 15 minutes later). Review of the physician’s order dated 5/11/24 at 0522 hours, showed to administer fentanyl (a pain medication) 25 mcg, IVP, once, STAT to the patient. Review of the MAR showed the fentanyl was administered to the patient on 5/11/24 at 0632 hours (one hours and 10 minutes later); and the RN documented the late reason to be given the medication to the patient was “wanted to wait patient asked for it.” During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed Patient 8’s medical record did not show the pain assessment was done every two hours for the patient as per the hospital’s P&P. There was no pain assessment documented on 5/11/24 from 0147 to 0533 hours (or approximately 3 hours). The Sr. Director of Critical Care confirmed the findings. c. On 7/8/24 at 0933 hours, Patient 10’s medical record review was conducted with the Sr. Director of Critical Care. Patient 10’s medical record showed the patient came to the ED on 5/27/24. Review of the Tier 2 Triage - Text dated 5/27/24 at 0532 hours, showed Patient 10 complained of back and bilateral leg pain. The patient’s ESI level was 3. The patient’s pain level was 10. The pain location was the back and low leg. The patient’s pain quality was aching, sharp, and throbbing. Review of the Pain flowsheets showed the following: * On 5/27/24 at 0532 hours, the patient’s pain score was 10 (severe pain). * On 5/27/24 at 0800 hours, the patient’s pain score was “8” (severe pain). * On 5/27/24 at 0908 hours, the patient’s pain score was “ 8.” The patient’s acceptable pain score was zero. * On 5/27/24 at 1025 hours, the patient’s pain score was “8.” Review of the physician’s order dated 5/27/24 at 0549 hours, showed to administer hydromorphone (a pain medication) 3 mg, IVP, once, STAT to the patient. Review of the MAR showed the hydromorphone was given to the patient on 5/27/24 at 0903 hours. During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed Dilaudid (same as hydromorphone) was given to the patient approximately three hours later, after the patient was assessed having severe pain on 5/27/24 at 0532 and 0800 hours. The Sr. Director of Critical Care confirmed there was no document evidence to show the justification why the hydromorphone was not administered immediately. d. Patient 9’s medical record review was initiated on 7/5/24. Patient 9’s medical record showed the patient came to the ED on 7/1/24. Review of the Tier 2 Triage - Text dated 7/1/24 at 1705 hours, showed Patient 9’s chief complaint was facial pain after falling. The patient had a numeric pain scale of “7 = Severe.” Review of Patient 9’s MAR showed the patient was administered acetaminophen (a pain medication) 650 mg by mouth on 7/1/24 at 1758 hours. Review of the Pain flowsheet showed Patient 9’s numeric pain scale was “8 = Severe” on 7/1/24 at 1911 hours. The pain location was the head with an aching quality and sudden onset. Review of Patient 9’s Discharge Information dated 7/1/24 at 1920 hours, showed Patient 9 was discharged from the ED. However, further record review failed to show any further interventions were performed or the ED provider was notified of Patient 9’s severe pain. On 7/8/2024 at 1205 hours, the above findings were shared and acknowledged with the Sr. Director of Critical Care and Quality Coordinator for ED. The Quality Coordinator for ED stated the physician should have been notified of Patient 9’s severe pain. e. Patient 12’s medical record review was initiated on 7/5/2024. Patient 12’s medical record showed the patient came to the ED on 2/15/24. Review of the Tier 2 Triage - Text dated 2/15/24 at 0247 hours, showed Patient 12 complained of abdominal pain, coughing, and vomiting. The patient’s numeric pain scale was “6 = Moderate.” The pain location was the left upper abdomen which was constant and sharp. Review of the physician’s order dated 2/15/24 at 0256 hours, showed to administer to Patient 12 ketorolac (a pain medication) 30 mg, IVP, STAT. However, review of the MAR showed Patient 12 did not receive the ketorolac 30 mg IVP until 0350 hours. Additionally, there was no reassessment of Patient 12’s pain level after the administration of the pain medication. Review of the Discharge Information showed Patient 12 was discharged from the ED on 2/15/2024 at 0452 hours. On 7/8/2024 at 1225 hours, the above findings were shared and acknowledged with the Sr. Director of Critical Care and Quality Coordinator for ED. The Sr. Director of Critical Care stated the RN should have reassessed Patient 12’s pain within one hour of administering the pain medication. f. Patient 17’s medical record review was initiated on 7/5/24. Patient 17’s medical record showed the patient came to the ED on 6/24/24. Review of the Tier 2 Triage - Text dated 6/24/24 at 1033 hours, showed Patient 17 complained of rectal pain with headache. Patient 17’s numeric pain scale was “10 = Severe.” However, further review of the document failed to show a comprehensive assessment including the pain characteristics for Patient 17. Review of the MAR showed on 6/24/24, Patient 17 received morphine 4 mg IM at 1132 hours and 2 mg IVP at 1423 hours. There was no documentation to show Patient 17 was reassesed for pain within one hour of administration of pain medications as per the hospital’s P&P. On 7/8/24 at 1228 hours, the above findings were shared and acknowledged by the Director of Quality and Sr. Director of Critical Care. The Director of Quality stated the expectation was to reassess a patient’s pain within one hours after a pharmacological intervention. g. Patient 18’s medical record review was initiated on 7/5/24. Patient 18’s medical record showed the patient came to the ED on 6/24/24. Review of the Tier 2 Triage - Text dated 6/24/24 at 1112 hours, showed Patient 18’s chief complaint was shortness of breath with mid-sternal chest pain and cough. The patient’s numeric pain scale was “10 = Severe.” Review of the Pain flowsheet showed on 6/24/24 at 1157 hours, Patient 18 had a numeric pain score of “10” in the left chest which had an aching quality. Review of the MAR showed Patient 18 was administered pain medications without a timely reassessment within one hour of medication administration. For example: - Patient 18 was administered morphine 4 mg IVP on 6/24/24 at 2229 hours. However, review of the pain assessment failed to show Patient 18’s pain was reassessed until 0040 hours with the numeric pain scale of “7= Severe.” - Patient 18 was administered Norco (a pain medication) 325/5 mg tablet on 6/25/24 at 0035 hours, and tramadol (a pain medication) 50 mg tablet on 6/25/24 at 0259 hours. However, there was no documentation to show Patient 18’s pain was reassessed within one hour of administering the pain medication as per the hospital’s P&P. - Patient 18 was administered Norco 325/5 mg tablet by mouth on 6/25/24 at 0753 hours. However, there was no documented evidence to show Patient 18’s pain was reassessed within one hour of administering the pain medication as per the hospital’s P&P. The next pain assessment was conducted on 6/25/24 at 1200 hours, which Patient 18 stated the patient’s numeric pain scale was “9 = Severe.”. On 7/8/24 at 1246 hours, the above findings were shared and verified by the Sr. Director of Critical Care, who stated the patient’s pain reassessment should have been performed within one hour of pain medication intervention. 2. Review of the hospital’s P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed the ED Primary RN responsibilities include to assure subsequent vital signs and reassessment are completed at least every two hours for the ESI Levels 2 and 3 patients or more frequently based on patient’s condition and changes. a. Patient 2’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0927 hours. Patient 2’s medical record showed the patient came to the ED on 1/1/24 at 1412 hours. Review of the Tier 2 Triage - Text dated 1/1/24 at 1421 hours, showed Patient 2’s chief complaint included headache, dizziness, and nausea. The patient’s ESI level was 3. Review of the Vital Signs flowsheet showed Patient 2 was assessed for the vital signs on 1/1/24 at 1421, 1700, 1830, and 1954 hours. The patient’s vital signs were not access every two hours on 1/1/24 from 1421 hours to 1700 hours. On 7/8/24 at 0927 hours, the Sr. Director of Critical Care confirmed the above findings. b. Patient 5’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1110 hours. Patient 5’s medical record showed Patient 5 came to the ED on 3/21/24 at 1432 hours and transferred to other hospital on 3/22/24 at 1145 hours. Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed the patient had left side lower jaw swelling for a month. The patient’s ESI level was 3. Review of the Vital Signs flowsheet showed Patient 5 was assessed for the vital signs on 3/21/24 at 1451 and 2100; on 3/22/24 at 0036, 0335, 0649, and 1041 hours. The patient’s vital signs were not access every two hours as per the hospital’s P&P. During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 5’s vital signs were not assessed as per the hospital’s P&P. c. Patient 8’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0932 hours. Patient 8’s medical record showed the patient came to the ED on 5/10/24. Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient’s ESI level was “3.” Review of the Vital Signs flowsheet showed Patient 8 was assessed for the vital signs on 5/11/24 at 0221, 0533, and 0800 hours. The patient’s vital signs were not access every two hours as per the hospital’s P&P. During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 8’s vital signs were not assessed as per the hospital’s P&P. d. Patient 16’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1050 hours. Patient 16’s medical record showed the patient came to the ED on 6/24/24 at 1232 hours. Review of the Tier 2 Triage - Text dated 6/24/24 at 1237 hours, showed Patient 16 was bought in by ambulance for dizziness and had a history of anemia. The patient’s ESI level was 3. The patient’s pulse was 120 bpm (a normal resting heart rate or pulse ranges from 60 to 100 bpm). Review of the Vital Signs flowsheet showed Patient 16 was assessed for the vital signs on 6/24/24 at 1240 and 1502 hours. The patient’s vital signs were not assessed every two hours as per the hospital’s P&P. During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 16’s vital signs was assessed more than two hours. e. Patient 18’s medical record review was initiated on 7/5/24. Patient 18’s medical record showed the patient came to the on 6/24/24 and transferred to the HLOC on 6/25/24 at 1619 hours. Review of the Tier 2 Triage -Text dated 6/24/24 at 1108 hours, showed Patient 18 complained of mid-sternal pain and shortness of breath. The patient’s ESI level was 3. However, review of Patient 18’s vital signs failed to show the patient’s vital signs were documented at a minimum of every two hours. For example: - Patient 18’s vital signs were documented on 6/24/24 at 1500 hours. However, another vital signs were not documented until 1931 hours. - Patient 18’s vital signs were documented on 6/25/24 at 0800 hours. However, vital signs were not checked again until 1200 hours. Additionally, the next subsequent vital signs were not taken until 1607 hours. On 7/8/2024 at 1246 hours, the above concerns were shared and verified by the Quality Coordinator for ED and Sr. Director of Critical Care. The Quality Coordinator for ED stated Patient 18’s vital signs should have been documented every two hours. f. Patient 20’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1056 hours. Patient 20’s medical record showed the patient came to the ED on 6/24/24 at 0015 hours. Review of the Tier 2 Triage - Text dated 6/24/24 at 0020 hours, showed the chief complaint was that Patient 20 was bought in by ambulance, complained of hearing voice for four days. The patient’s ESI level was 3. Review of the Vital Signs flowsheet showed on 6/25/24, Patient 20 was assessed for the vital signs at 0000 and 0400 hours. At 0600 hours, the patient’s temperature, pulse, blood pressure, and SpO2 were not documented. The patient’s vital signs were not access every two hours as per the hospital’s P&P. During the concurrent interview, the Sr. Director of Critical Care confirmed Patient 20’s vital signs were not assessed every two hours as per the hospital’s P&P. 3. Review of the hospital’s P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed the physician’s orders shall be carried out until the physician discontinues them. a. On 7/3/23, Patient 1’s medical record review was initiated. Patient 1’s medical record showed the patient arrived to the ED via ambulance on 6/24/24, with a chief complaint of weakness and a near syncopal event. Review of the physician’s order dated 6/24/24 at 1521 hours, showed MD 1 ordered to perform orthostatic vital signs. However, review of Patient 1’s medical record failed to show the orthostatic vital signs were performed. During an interview with MD 1 on 7/3/24 at 1448 hours, MD 1 stated MD 1 ordered the orthostatic vital signs for Patient 1 since the patient reported feeling like the patient was going to pass out. MD 1 stated the orthostatic vital signs were usually ordered for patients who clinically presented with light headedness. MD 1 stated if the order was not discontinued by MD 1, the orthostatic vital signs should have been done. On 7/3/2024 at 1448, the Sr. Director of Critical Care was informed of and acknowledged the above findings. b. Patient 2’s medical record review was conducted with the Director of Critical Care on 7/8/24 at 0927 hours. Patient 2’s medical record showed the patient came to the ED on 1/1/24 at 1412 hours. Review of the Tier 2 Triage - Text dated 1/1/24 at 1421 hours, showed Patient 2’s chief complaint included headache, dizziness, and nausea. The patient’s ESI level was 3. Review of the physician’s order dated 1/1/24 at 1501 hours, showed to assess the orthostatic vital signs for the patient. Review of the Orthostatic Vital Signs flowsheet showed on 1/1/24 at 1700 hours, Patient 2 was assessed for SBP and DBP with the sitting and standing positions and was assessed for the pulse with the sitting position. At 1830 hours, the patient was assessed for SBP, DBP, and pulse with the sitting position; and there was no documented evidence to show the patient was assessed for the SBP and DPB with the standing position. An interview and concurrent review of Patient 2’s medical record was conducted with the Director of Quality on 7/8/24 at 1231 hours. The Director of Quality was not able to locate documents to show a completed set of orthostatic vital signs was done for Patient 2 during the ED visit. There was no additional document to show the reason why the physician’s order was not carried or if it was reported to the ordering physician that the orthostatic vital signs were not completed for the patient. 36703 4. Review of the hospital’s P&P titled Communicating with the Primary Care Provider and Discharge Instructions dated 4/19/23, showed it is the responsibility of the RN to assure the patient or legal guardian verbally states understanding of discharge instructions, allow time for questions, and when full understanding it achieved, have the patient or legal guardian sign the last page of the discharge instructions; this indicates the understanding of medications, follow up, specific aftercare, and patient educational materials. The responsibility of the RN also includes to provide the last executed signature age of the discharge instructions to the unit secretary for scanning of the signature into the EHR. On 7/3/23, Patient 1’s medical record review was initiated. Patient 1’s medical record showed the patient arrived to the ED via ambulance on 6/24/2024, with a chief complaint of weakness and a near syncopal event. Review of the ED Patient Summary dated 6/24/24 at 1705 hours, showed a summary of the patient’s discharge diagnosis, name of provider, follow up instructions, and aftercare instructions. However, the last page of the instructions to sign in acknowledgement of Patient 1 receiving written medication orders, follow up instructions, aftercare instructions, and receipt and understanding of education material was left blank. On 7/5/2024 at 0930 hours, the above findings were shared and verified by the Director of Quality. The Director of Quality stated the signed discharge instructions were not found in Patient 1’s medical record. 5. Review of the hospital’s P&P titled ED Triage, Assessment and Reassessment Standards dated 12/6/23, showed a physical assessment of systems related to the primary complaint will be done as a primary responsibility of the RN. Patient 17’s medical record review was initiated on 7/5/2024. Patient 17’s medical record showed the patient came to the ED on 6/24/24. Review of the ED Physician Note dated 6/24/2024 at 1051 hours, showed Patient 17 presented with abdominal pain. Associated symptoms were decreased oral intake and constipation. Patient 17 reported having no bowel movements for several days. Patient 17 reported having a diverting left colostomy placed. However, further review of Patient 17’s medical record failed to show an assessment of Patient 17’s colostomy. On 7/8/2024 at 1228 hours, the Sr. Director of Critical Care was informed of and acknowledged the above findings. The Sr. Director of Critical Care stated it should be expected to assess the patient’s colostomy if the patient also presented with abdominal pain.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred four of 20 sampled patients (Patients 5, 8, 11, and 20) when the Patient Transfer Summary forms were not completed for Patients 5, 8, 11, and 20 as per the hospital’s P&P. These failures had the potential to result in poor clinical outcomes and serious adverse event for patients receiving ED services in the hospital. Findings: Review of the hospital’s P&P titled EMTALA dated 10/15/21, showed appropriate transfer means a transfer that complies with all the following requirements: * The hospital provides medical treatment within its capacity to minimize risks to the individual’s health and in the case of a woman in labor, the health of the unborn child, the medical record will reflect the vital signs and condition of the individual at the time of the transfer. * The hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency medical condition of the individual, including - Records related to the individual’s emergency condition. - The individual’s information written consent to transfer or the physician certification. * The transfer is effected using qualified personnel and transportation equipment, including the use of medically appropriate life support measures. Review of the Patient Transfer Summary form showed the following: * The Physician section showed there are two check boxes. - For the first check box: if it is checked, it indicates “Emergency condition treated and stabilized....Based upon my examination and the information available to me at this time, I have concluded that with reasonable medical probability, the above referenced patient transport will create no medical hazard to the patient, or that the medical benefits reasonably expected from the transfer out weight the associated risks or that the patient and /or patient’s representative has required the transfer against medical advice.” - For the second check box: if it is checked, it indicates “An emergency condition exist and the patient is not able to be stabilized prior transfer because:...the specialty service or specialty physician required is not available...Based on the reasonable risk and benefits to the patient and based upon the information available at this time of the patient’s examination, the medical benefits reasonably expected from the provision of appropriate emergency medical care at another facility outweigh the increased risk, If any, to the individual’s medical condition.” * The UnitSec/Primary RN section showed the patient’s record /valuables/belongings received by:... NAME _________SIGNATURE_________ that should be signed by the transport personnel who receives the patient. On 7/8/24 at 0933 hours, when asked for process of transferring the ED patients, the Director of Quality stated the Patient Transfer Summary was used for each transfer. It was the provider’s responsibility to complete the “Physician” section for evaluation of the patient’s condition and discussion of the transfer risk vs. benefits to the patient or the patient’s representative. The physician would document on the “Physician” section. On 7/8/24, review of medical records for Patients 5, 8, 22, and 20 was conducted with the Sr. Director Critical Care and the Director of Quality, 1. Patient 5’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1110 hours. Patient 5’s medical record showed Patient 5 came to the ED on 3/21/24 at 1432 hours and transferred to the HLOC on 3/22/24 at 1145 hours. Review of the Tier 2 Triage - Text dated 3/21/24 at 1456 hours, showed the patient had left side lower jaw swelling for a month. The patient’s ESI level was 3. Patient 5’s medical record showed the patient received pain medication, IV antibiotic, and an incision and drainage (I&D) procedure during the ED staying. Review of the History and Physical examination dated 3/22/24 at 0657, showed Patient 5 had osteomyelitis of jaw. The plan was to transfer the patient to HLOC for OMFS evaluation. Review of Patient 5’s Patient Transfer Summary showed the following: * The Physician section showed the following: - The description section was blank. - The sections of transport personnel, the hospital personnel accompanying were blank. - The box to indicate if the emergency condition treated and stabilized was blank. - The box to indicate if emergency conditions exist and the patient is not able to be stabilized prior to transfer was bank. * The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient’s records/valuable/belongings were received, was blank. During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings. 2. Patient 8’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 0932 hours. Patient 8’s medical record showed the patient came to the ED on 5/10/24. Review of the Tier 2 Pediatric Triage dated 5/10/23 at 2347 hours, showed Patient 8 complained of non-radiating abdominal pain. The patient’s ESI level was 3. Review of the ED Clinical Summary dated 5/11/24 at 0821 hours, showed Patient 8 was transferred to other hospital. The diagnosis was acute appendicitis. The patient was transferred on 5/11/24 0821 hours. Review of Patient 8’s Patient Transfer Summary showed the following: * The Physician section showed the following: - The description section was blank. - The boxes of “Stable:” or “Other;” were not checked. - The box to indicate if the emergency condition treated and stabilized was blank. - The box to indicate if emergency conditions exist and the patient is not able to be stabilized prior to transfer was bank. * The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient’s records/valuable/belongings were received, was blank. During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings. 3. Patient 11’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1100 hours. Patient 11’s medical record showed the patient came to ED on 2/1/24 1813 hours and transferred to other facility on 2/2/25 at 1010 hours. Review of the Tier 2 Triage - Text dated 2/1/24 at 1825 hours, showed Patient 11’s chief complaint included suicidal ideation. The patient’s ESI level was 2. Review of the Social Work Psychosocial Assessment dated 2/1/24 at 2350 hours, showed Patient 11 was placed on 5150 Hold for suicide ideation. Review of the ED Note - Physician dated 2/2/24 at 0747 hours, showed Patient 11 was stable, medically cleared, and transfer to other psychiatric facility. Review of Patient 11’s Patient Transfer Summary showed the following: * The Physician section showed the physician signed the form on 2/2/24 at 0930 hours. However, the Physician section was blank. * The UnitSec/Primary RN section showed the Name and Signature sections to show by whom the patient’s records/valuable/belongings were received, was blank. Review of the Patient Transfer Acknowledgement dated 2/2/24, showed the Patient Signature section showing “”72 hr involuntary hold.” During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings. 4. Patient 20’s medical record review was conducted with the Sr. Director of Critical Care on 7/8/24 at 1056 hours. Patient 20’s medical record showed the patient came to the ED on 6/24/24 at 0015 hours and transferred to other facility on 6/25/24 at 1700 hours. Review of the Tier 2 Triage - Text dated 6/24/24 at 0020 hours, showed the chief complaint was that Patient 20 was bought in by ambulance, complained of hearing voice for four days. The patient’s ESI level was 3. Review of the Consultation Notes dated 6/24/24 at 0941 hours, showed Patient 20’s chief complaint was hearing voice for four days. The patient’s family member reported the patient had been sitting in the heat, talking to herself, and having outbursts. The plan was to place the patient on 5150 and transfer the patient to psychiatric facility. Review of Patient 20’s Patient Transfer Summary showed the following: * The Care Management section showed the box of “Resource (HIGHER LEVEL OF CARE)” was checked. The Description section showed “5150.” * The Physician section showed the following: - The Description section was blank. - The sections of the Transport Personnel and the hospital Personnel Accompany was blank. - The sections of “MD DISCUSSED THIS PATIENT WITH DR.” and “ACCEPTING MD. DATE/TIME:” were blank. Review of the Patient Transfer Acknowledgement dated 6/25/24, showed the section of the patient signature showing “Pt is on 5150.” During the concurrent interview with the Sr. Director of Critical Care, the Sr. Director of Critical Care confirmed the findings.”