Madera Community Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 33126 Based on observation, interview, and record review, the hospital failed to protect one of four patients, Patient (Pt) 6’s rights when the hospital identified Pt 6 as a non-English speaker and did not provide interpreter services. This failure had the potential for ineffective communication, which could have led to miscommunication and compromising the quality of care and patient safety. Findings: During a concurrent interview and record review on 2/18/26 at 2:40 p.m. with Nurse Manager (NM) 1, Pt 6’s Electronic Medical Record (EMR) (a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans) was reviewed. The EMR indicated Pt 6 spoke Spanish and needed an interpreter. NM 1 stated Spanish as a primary language is considered a communication barrier. The record review indicated Pt 6 had multiple encounters with staff members with no documentation that an interpreter was used or that Pt 6 agreed to have non-certified Spanish speaking staff (staff that speak Spanish, but have not completed an approved course to interpret medical terminology) translate. NM 1 stated that although the staff might have been Spanish speaking, there should have been documentation that Pt 6 consented to using non-certified staff to translate. During a concurrent interview and record review on 2/18/26 at 2:42 p.m. with NM 1, Pt 6’s EMR indicated on 2/17/26 at 9:11 a.m. Pt 6 walked in to the Emergency Department (ED) and was triaged at 9:17 a.m. The EMR indicated Pt 6 was Spanish speaking and that Pt 6 did not agree to waive interpreter services. The record indicated no documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during triage or while vital signs were taken. During a concurrent interview and record review on 2/18/26 at 2:45 p.m. with NM 1, Pt 6’s EMR indicated on 2/17/26 at 10:46 a.m. during the Medical Screening Exam (MSE), (a check-up done in the ED to figure out if someone has a serious medical problem that needs immediate care) that there was no documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the MSE. During a concurrent interview and record review on 2/18/26 at 2:50 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 10:49 Pt 6 had an Ultra Sound (US) (a test that uses sound waves to make pictures of the inside of your body), without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the US. During a concurrent interview and record review on 2/18/26 at 2:55 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 11:30 a.m. Pt 6 was assessed for pain without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the pain assessment. During a concurrent interview and record review on 2/18/26 at 3:00 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 11:36 a.m. Pt 6’s EMR indicated that pain medication, intravenous fluids (special liquids that go directly into a person’s vein through a small tube called an IV line), and anti-nausea medication were administered without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, while receiving medications. During a concurrent interview and record review on 2/18/26 at 3:00 p.m. with NM 1, Pt’s 6 EMR indicated that on 2/17/26 at 12:06 p.m. a reassessment for Pt 6’s pain was performed without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the reassessment. During an interview on 2/20/26 at 11:41 a.m. with Chief Nursing Officer (CNO), CNO stated that her expectation would be for the staff and physicians to use the interpreter services with encounters that are more than casual conversation. CNO stated that if staff were speaking to Pt 6 in Spanish about medication, treatments, and procedures there should have been documentation that Pt 6 was okay with non-certified Spanish speaking staff translating. During a review of the facility’s policy and procedure (P&P) titled “Interpreter Program Services” dated 01/2025, indicated that “ ...whenever an individual / employee acts as an interpreter, the name of the individual who acted as interpreter and the position, and his relationship to the patient shall be placed in the Medical Record. During a review of a professional reference titled, “Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome.” Found at “Journal of migration and health, 7, 100162. https://doi.org/10.1016/j.jmh.2023.100162”, dated 24 Jan 2023, the reference indicated, “... Utilization of interpreters to facilitate communication between health care providers and non-native speaking patients is essential to provide the best possible quality of care .... Results were indicative of in-person professional interpreter resulting in highest satisfaction and communication, ... In-person Professional interpreter is the interpreter type resulting in greatest satisfaction and best communication outcome for the patients .... In conclusion, professional interpreter is the interpreter type resulting in greatest satisfaction and best communication for the patients, when compared to other types of interpretation or none, and should be used in the ER, in- and out-patient clinics or hospitals, when available ....” During a review of a professional reference titled, “American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians”, found at “https://pubmed.ncbi.nlm.nih.gov/31935351/“, dated Jan 11 2020, the reference indicated, “ ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51620 Based on observation, interview, and record review, the hospital failed to protect one of four patients, Patient (Pt) 6’s rights when the hospital identified Pt 6 as a non-English speaker and did not provide interpreter services. This failure had the potential for ineffective communication, which could have led to miscommunication and compromising the quality of care and patient safety. Findings: During a concurrent interview and record review on 2/18/26 at 2:40 p.m. with Nurse Manager (NM) 1, Pt 6’s Electronic Medical Record (EMR) (a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans) was reviewed. The EMR indicated Pt 6 spoke Spanish and needed an interpreter. NM 1 stated Spanish as a primary language is considered a communication barrier. The record review indicated Pt 6 had multiple encounters with staff members with no documentation that an interpreter was used or that Pt 6 agreed to have non-certified Spanish speaking staff (staff that speak Spanish, but have not completed an approved course to interpret medical terminology) translate. NM 1 stated that although the staff might have been Spanish speaking, there should have been documentation that Pt 6 consented to using non-certified staff to translate. During a concurrent interview and record review on 2/18/26 at 2:42 p.m. with NM 1, Pt 6’s EMR indicated on 2/17/26 at 9:11 a.m. Pt 6 walked in to the Emergency Department (ED) and was triaged at 9:17 a.m. The EMR indicated Pt 6 was Spanish speaking and that Pt 6 did not agree to waive interpreter services. The record indicated no documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during triage or while vital signs were taken. During a concurrent interview and record review on 2/18/26 at 2:45 p.m. with NM 1, Pt 6’s EMR indicated on 2/17/26 at 10:46 a.m. during the Medical Screening Exam (MSE), (a check-up done in the ED to figure out if someone has a serious medical problem that needs immediate care) that there was no documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the MSE. During a concurrent interview and record review on 2/18/26 at 2:50 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 10:49 Pt 6 had an Ultra Sound (US) (a test that uses sound waves to make pictures of the inside of your body), without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the US. During a concurrent interview and record review on 2/18/26 at 2:55 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 11:30 a.m. Pt 6 was assessed for pain without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the pain assessment. During a concurrent interview and record review on 2/18/26 at 3:00 p.m. with NM 1, Pt 6’s EMR indicated that on 2/17/26 at 11:36 a.m. Pt 6’s EMR indicated that pain medication, intravenous fluids (special liquids that go directly into a person’s vein through a small tube called an IV line), and anti-nausea medication were administered without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, while receiving medications. During a concurrent interview and record review on 2/18/26 at 3:00 p.m. with NM 1, Pt’s 6 EMR indicated that on 2/17/26 at 12:06 p.m. a reassessment for Pt 6’s pain was performed without documentation that an interpreter was used, or that Pt 6 agreed to have staff translate, during the reassessment. During an interview on 2/20/26 at 11:41 a.m. with Chief Nursing Officer (CNO), CNO stated that her expectation would be for the staff and physicians to use the interpreter services with encounters that are more than casual conversation. CNO stated that if staff were speaking to Pt 6 in Spanish about medication, treatments, and procedures there should have been documentation that Pt 6 was okay with non-certified Spanish speaking staff translating. During a review of the facility’s policy and procedure (P&P) titled “Interpreter Program Services” dated 01/2025, indicated that “ ...whenever an individual / employee acts as an interpreter, the name of the individual who acted as interpreter and the position, and his relationship to the patient shall be placed in the Medical Record. During a review of a professional reference titled, “Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome.” Found at “Journal of migration and health, 7, 100162. https://doi.org/10.1016/j.jmh.2023.100162”, dated 24 Jan 2023, the reference indicated, “... Utilization of interpreters to facilitate communication between health care providers and non-native speaking patients is essential to provide the best possible quality of care .... Results were indicative of in-person professional interpreter resulting in highest satisfaction and communication, ... In-person Professional interpreter is the interpreter type resulting in greatest satisfaction and best communication outcome for the patients .... In conclusion, professional interpreter is the interpreter type resulting in greatest satisfaction and best communication for the patients, when compared to other types of interpretation or none, and should be used in the ER, in- and out-patient clinics or hospitals, when available ....” During a review of a professional reference titled, “American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians”, found at “https://pubmed.ncbi.nlm.nih.gov/31935351/“, dated Jan 11 2020, the reference indicated, “ ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty...””

“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: 33126 Based on observation and interview, the facility failed to safeguard the confidentiality of patients’ electronic medical records (EMRs), when three of seven opportunities observed in which staff left an active EMR screen open and visible to the public in patient care areas. Visible information included patient identifiers and clinical data. This failure had the potential to allow unauthorized individuals to view protected health information (PHI), failed to maintain the confidentiality of patient clinical records and placed patients at risk for unauthorized disclosure of their protected health information by not securing EMR screens from public view. Findings: During a concurrent observation and interview on 2/17/26 at 10:45 a.m. with Nurse Manager for ED/ICU (NM 3) in the Emergency Department (ED), NM 3 was observed twice to instruct Registered Nurses (RN)’s and Patient Care Technicians (PCT)’s to lock the EMR so that patient information would not be visible. During a concurrent observation on 2/18/26 at 10:13 a.m. with NM 3 and Chief Executive Officer (CEO) in the ED, CEO was observed walking over to a mobile workstation that housed a computer with visible patient’s EMR and locked the EMR to remove visibility of patient information from public view. During a review of the Patient’s Rights poster on 2/18/26 at 11:45 a.m. in the main lobby of the ED dated 01/22, indicated the patient has a right to, “ ... confidential treatment of all communications and records pertaining to the care and the stay in the hospital ...” During an interview on 2/20/26 at 10:03 a.m. with CEO, CEO stated that on the morning of 2/18/26 she did see EMR on a computer in the ED left open when staffed walked away and CEO stated she closed it down. CEO stated her expectation is that patient’s privacy is always maintained, and this includes the EMR. During an interview on 2/20/26 at 11:41 a.m. with the Chief Nursing Officer (CNO), CNO stated her expectation is that all patient information is to be maintained confidential at all times and EMRs should not be left open and visible because patients should be given their right to privacy. During a review of The American Nurses Association Privacy and Confidentiality - Official Position Statement dated 2024 the statement indicated, “ ...the nurse’s duty to maintain confidentiality are foundational to the ethical obligation to respect individuals’ dignity and autonomy. This is a central means to foster and maintain the trusting relationship between health care providers and patients ...” American Nurses Association. (2024). Privacy and confidentiality: Official position statement. American Nurses Association. During a review of the professional article Standards of Care (no date), the article stated that, “ ...privacy and confidentiality are so important to individuals but are also vital to public health”, “ ...patients who trust their health care professionals will not be sharing their personal information are more likely to be willing to open up and be honest about their symptoms and health habits. Doctors and other caregivers cannot do their jobs or provide the best care if they don’t get all the information from their patients ...” Standards of Care. (n.d.). Confidentiality and HIPAA. Standards of Care Health & Medical Information. Retrieved from https://www.standardsofcare.org/confidentiality-and-hipaa/”

“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: 51620 Based on observation and interview, the facility failed to safeguard the confidentiality of patients’ electronic medical records (EMRs), when three of seven opportunities observed in which staff left an active EMR screen open and visible to the public in patient care areas. Visible information included patient identifiers and clinical data. This failure had the potential to allow unauthorized individuals to view protected health information (PHI), failed to maintain the confidentiality of patient clinical records and placed patients at risk for unauthorized disclosure of their protected health information by not securing EMR screens from public view. Findings: During a concurrent observation and interview on 2/17/26 at 10:45 a.m. with Nurse Manager for ED/ICU (NM 3) in the Emergency Department (ED), NM 3 was observed twice to instruct Registered Nurses (RN)’s and Patient Care Technicians (PCT)’s to lock the EMR so that patient information would not be visible. During a concurrent observation on 2/18/26 at 10:13 a.m. with NM 3 and Chief Executive Officer (CEO) in the ED, CEO was observed walking over to a mobile workstation that housed a computer with visible patient’s EMR and locked the EMR to remove visibility of patient information from public view. During a review of the Patient’s Rights poster on 2/18/26 at 11:45 a.m. in the main lobby of the ED dated 01/22, indicated the patient has a right to, “ ... confidential treatment of all communications and records pertaining to the care and the stay in the hospital ...” During an interview on 2/20/26 at 10:03 a.m. with CEO, CEO stated that on the morning of 2/18/26 she did see EMR on a computer in the ED left open when staffed walked away and CEO stated she closed it down. CEO stated her expectation is that patient’s privacy is always maintained, and this includes the EMR. During an interview on 2/20/26 at 11:41 a.m. with the Chief Nursing Officer (CNO), CNO stated her expectation is that all patient information is to be maintained confidential at all times and EMRs should not be left open and visible because patients should be given their right to privacy. During a review of The American Nurses Association Privacy and Confidentiality - Official Position Statement dated 2024 the statement indicated, “ ...the nurse’s duty to maintain confidentiality are foundational to the ethical obligation to respect individuals’ dignity and autonomy. This is a central means to foster and maintain the trusting relationship between health care providers and patients ...” American Nurses Association. (2024). Privacy and confidentiality: Official position statement. American Nurses Association. During a review of the professional article Standards of Care (no date), the article stated that, “ ...privacy and confidentiality are so important to individuals but are also vital to public health”, “ ...patients who trust their health care professionals will not be sharing their personal information are more likely to be willing to open up and be honest about their symptoms and health habits. Doctors and other caregivers cannot do their jobs or provide the best care if they don’t get all the information from their patients ...” Standards of Care. (n.d.). Confidentiality and HIPAA. Standards of Care Health & Medical Information. Retrieved from https://www.standardsofcare.org/confidentiality-and-hipaa/”

“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: 45977 Based on interview and record review, the hospital failed to ensure nursing staff developed and maintained individualized care plan reflecting the needs of the patient and care to be provided for Patient (Pt) 10 admitted with a previous wound when one of 29 patients (Pt 10), did not have a care plan that addressed skin care. These failures had the potential for inconsistent care delivery for Pt 10 and had the potential for not receiving nursing care to reflect their individual needs and goals which could negatively affect patient well-being. Findings: During a concurrent interview and record review on 2/17/26 at 1:42 p.m. with the Nurse Manager of ICU (NM 5), Pt 10’s Electronic Medical Record [EMR -a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans],” “History & Physical [H&P an assessment from physician including medical history and exam],” dated 2/16/22 and the “Face Sheet [FS a document that contains a summary of a patient’s personal information],” were reviewed for Pt 10’s admission dated 2/15/26. The “H&P” indicated Pt 10 had a past medical history of cirrhosis (scarring of the liver, preventing it from filtering blood, processing nutrients and fighting infection) and bleeding esophageal varices (abnormally enlarged veins found in the esophagus, usually as a result of liver disease) and was admitted to ICU for stabilization and blood transfusions. The NM 5 stated, Pt 10’s care plan included problem foci that concentrated on fluid volume overload and dementia. NM 5 stated Pt 10 had old wounds that were healing when admitted with a large wound on the coccyx (buttocks) that was improving. The NM 5 stated the care plan did not address skin care and should have. The NM 5 stated the care plan guides the care of the patient and is necessary to addressing the current and potential problems of the patient. During an interview on 2/20/26 at 11:35 a.m. with the Chief Nursing Officer (CNO), the CNO stated the nurse should make sure to address the problems of the patient as it ensures the patient’s care progresses. The CNO stated, care plans guide the care of the patient and helps guide them to health. During a review of the hospital’s document titled, “Job Description -- Registered Nurse ... “, dated 1/25, indicated, “ ... Planning ... The nurse develops and coordinates a plan of care that prescribes interventions to attain expected patient outcomes. ... The plan is: ... 1. Individualized to patient’s condition and medical needs and based on the assessment data.. ... 2. The nurse identifies expected outcomes with measurable goals and time frames. ... 2. The nurse identifies expected outcomes with measurable goals and time frames. ... “ During a review of professional article titled, “Why are care plans important in healthcare?” located at https://biologyinsights.com/why-are-care-plans-important-in-healthcare, dated January 13, 2026, the article indicated “ ... care plans are a cornerstone of effective healthcare delivery. They provide a structured approach to patient care by outlining individualized goals, interventions, and evaluation criteria ... Initiating care plans early is essential for delivering consistent, high-quality, and patient-focused care across all healthcare environments ...Standardized documentation of the patient’s status prevents critical information from being overlooked during these vulnerable handoffs. By clearly outlining the agreed-upon approach, the care plan prevents conflicting interventions or unnecessary delays in treatment. Maintaining this high level of consistency in routine care is important for process efficiency and safeguarding the patient’s stability across various care environments ...””

“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: 45977 Based on observation, interview, and record review, the staff failed to follow hospital policies and procedures (P&P) when: 1. The temperature for two of two blanket warmers found in the clean utility rooms of the Intensive Care Unit (ICU) (three of 16 days) and the Medical Surgical Unit (one of 16 days) were not monitored in accordance with the documents titled, “[BRAND NAME] Digital Warming Cabinets” and “Job Description - Registered Nurse.” This failure had the potential for the warmer to overheat and become a fire hazard and potential for injury if a patient were to receive a blanket that is too hot. 2. The temperature for the medication room of the ICU was not monitored (three of 16 days) in accordance with the hospital P&P titled, “Medication Temperature Monitoring.” This failure had the potential for medications to be stored outside the manufacturer guidelines and diminish the medication effectiveness. 3. Licensed nurses (LN) did not assess the presence of advance directives ( a legally binding document that outlines medical treatment preferences and appoints someone to make decisions if a person becomes incapacitated) for two (Patients (Pt) 11 and Pt 19) of 29 sampled patients in accordance with the hospital P&P’s titled, “Patient Rights/Responsibilities” and “Documentation Required for Patient Care Services.” This failure had the potential to delay care and/or for patients to not receive medical care according to their preferences should they become unable to communicate. 4. The medication waste bucket was overflowing with wasted medications and intravenous tubing and was not emptied in accordance with the hospital P&P’s titled, “Daily Cleaning, Ancillary Areas” and “Job Description - Registered Nurse.” This failure had the potential to increase the growth of microorganisms and lead to cross contamination to patients. 5. Licensed nurses (LN) did not notify a provider that Pt 10’s respirations were seven per minute and below normal parameters (normal is 12 to 20 respirations per minute) in accordance with the hospital P&P’s titled, “Assessments/Reassessments” and “Documentation Required for Patient Care Services.” This failure had the potential to result in missed diagnoses, delayed treatment, and serious outcomes like intubation (medical procedure involving the insertion of a flexible plastic tube through the mouth or nose into the windpipe to maintain an open airway via mechanical ventilation.) 6. Registered Nurses (RNs) did not ensure one of one Pelvic Exam Carts (a mobile, portable cart containing essential supplies including, but not limited to: Personal Protective Equipment [PPE], Exam Supplies, Diagnostic & Collection Materials, Infection Control & Cleaning Supplies) was locked in the Emergency Department (ED). This failure had the potential for essential supplies and equipment to be unavailable, contaminated, or malfunctioning and not addressing the emergent needs of patients presenting to the ED. Findings: 1. During a concurrent observation, interview and record review on 2/17/26 at 9:15 a.m. with the Nurse Manager of ICU (NM 5), on the ICU, the Blanket warmer “ICU Blanket Warmer Temperature Log”, dated 2/26, was observed. NM 5 stated, the log showed three days missing (February 7, 8 and 13). NM 5 stated, the temperature should be recorded daily and documented on the record. NM 5 stated, it is important to check the Blanket warmer is working and adjust the temperature if needed. NM 5 stated, this is done for safety of the patients. During a concurrent observation, interview and record review on 2/17/26 at 11:20 a.m. with the Nurse Manager of Medical/Surgical Unit (NM 1), on the Medical/Surgical Unit, the Blanket warmer “Blanket Warmer Temperature Log”, dated February 2026, was observed. NM 1 stated, the log was missing one day (February 14). NM 1 stated, the temperature should be recorded daily. NM 1 stated, by checking it daily, we ensure that the warmer is working as it should. During an interview on 2/20/26 at 11:35 a.m. with the Chief Nursing Officer (CNO), the CNO stated the warmers should be checked daily and she expected the nurses to follow the policies. During a review of the hospital’s document titled, “”[BRAND NAME] Digital Warming Cabinets” dated April 12, 2012, indicated, “ ... Warning - Burn Hazard: ... DO NOT exceed 150°F for non-vented closures. ...Temperature of warming cabinet contents may be hotter than the displayed air temperature. For patient safety, in accordance with good medical practice, always check liquid temperature prior to using ... 5.1 Temperature Accuracy ... 5.1.1 Check display temperature accuracy on a periodic basis with a calibrated thermometer placed near fan inlet. “ During a review of the hospital’s document titled, “Job Description -- Registered Nurse ... “, dated 1/25, indicated, “ ... Environmental Safety ... Safety/Security ... Responsible for following through on observed potential and real safety hazards that occur in the department or impact staff in other areas of the hospital, ... Identifies and reports unsafe conditions/occurrences to appropriate individual ... Demonstrates safe and effective use of all equipment. ... “ 2. During a concurrent observation, interview, and record review on 2/17/26 at 9:31 a.m. with the NM 5, in the ICU medication room, the record titled, “Med Room A -- Temperature Log”, dated 2/26, was observed. NM 5 stated, the log showed three days were not filled out (February 7, 8 and 13). NM 5 stated, the temperature should be recorded daily and documented on the record. NM 5 stated, the nurses should check the temperature daily to ensure medications are stored at the correct temperature and not compromised. During an interview on 2/20/26 at 11:35 a.m. with the CNO, the CNO stated the temperature in the medication room should be checked daily. The CNO stated, medications need to be stored in temperature controlled environments. During a review of the hospital P&P titled, “Medication Temperature Monitoring”, dated 5/2025, the P&P indicated, “ ... PURPOSE: To ensure integrity of medications. ... The Pharmacy shall keep a daily log of room temperatures for both the main pharmacy and segregated compounding area. ... “. 3. During a concurrent interview and record review on 2/17/26 at 2:55 p.m. with the NM 5, Pt 11’s “”Electronic Medical Record [EMR a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans],” “History & Physical [H&P an assessment from physician including medical history and exam],” dated 2/16/22 and the “Face Sheet [FS a document that contains a summary of a patients’ personal information],” were reviewed for Pt 11’s admission dated 2/16/26. The “H&P” indicated Pt 11 had a past medical history of hypertension (high blood pressure), and congestive heart failure (when the heart backs up with fluid) and was admitted to ICU for bradycardia (slow heart rate - less than 60 beats per minute with normal being 60 to 100 beats a minute). The NM 5 stated, the screening for advance directives was not present. The NM 5 stated, the nurses should screen all patients for advance directives during the admission process. The NM 5 stated, the policy is for nurses to screen the patients for advance directives. During a concurrent interview and record review on 2/18/26 at 11:40 a.m. with the NM 1, Pt 19’s “[EMR],” “[H&P],” dated 2/13/26 and the “FS,” were reviewed for Pt 19’s admission dated 2/13/26. The “H&P” indicated Pt 19 had a past medical history of seizures, schizoaffective disorder (a chronic mental health condition with symptoms of hallucinations, delusions and disorganized speech combined with elevated or irritable mood and energy). The NM 1 stated, the screening for advance directives had not been done. The NM 1 stated, the nurses should screen all patients for advance directives during the admission process within the first 24 hours of the admission. During an interview on 2/20/26 at 11:35 a.m. with the CNO, the CNO stated the presence of advance directives should be screened within 24 hours of a patient’s admission. The CNO stated, nurses are responsible for screening the patients as part of the admission assessment done by the nurses. During a review of the hospital P&P titled, “Documentation Required for Patient Care Services”, dated 2/2026, the P&P indicated, “ ... PURPOSE: To ensure accurate, complete, and timely documentation of patient care services that meets regulatory requirements, supports safe patient care, and provides a comprehensive record of the nursing process for patients admitted to Medical-Surgical and Telemetry units.. ... 3. Comprehensive Admission Database (Within 24 Hours of Admission) ... Advance Directives ... Presence and type of directive, code status, healthcare decision-maker, copy scanned to EHR ... “. During a review of the hospital P&P titled, “Patient’s Rights/Responsibilities”, dated 2/2026, the P&P indicated, “ ... The right to: ... Assist in accessing and designating a support person or agency to act as needed to assert and protect the patients’ rights. ... Delegate decision making to a specific person/s. The hospital will respect the patients’ wishes to the maximum extent practicable and to the degree permitted by law. ... “. 4. During a concurrent observation, and interview on 2/17/26 at 10:28 a.m. with the NM 1, on the Medical/Surgical unit, on the East Side nurses station, in the medication area, medication waste bucket was observed. The bucket was overflowing with intravenous (IV) tubing and connected to used medication bags. The IV tubing was hanging out of the bucket onto the floor. The bucket had a sticker on the side about four inches from the top of the bucket that indicated, “INCINERATION ONLY ... DO NOT FILL ABOVE THIS LINE ...” NM 1 stated, the staff have filled the bucket beyond the line and it needs to be replaced. NM 1 stated, the staff should have replaced bucket as having medications on the floor could cause cross contamination and an infection control risk to patients and visitors. During an interview on 2/20/26 at 10:50 a.m. with the Infection Prevention Analyst (IPA), the IPA stated the medication waste bucket should not be overflowing and the staff should have it emptied prior to reaching the line on the bucket. The IPA stated, if the bucket is overflowing, it could be an infection control issue and contaminate the floor. During an interview on 2/20/26 at 11:35 a.m. with the CNO, the CNO stated the medication waste bucket should have been emptied and she expected staff to have the bucket emptied. During a review of the hospital P&P titled, “Daily Cleaning, Ancillary Areas”, dated 8/2025, the P&P indicated, “ ... PURPOSE: To provide a consistent procedure for aesthetic and preventative cleaning of ancillary areas and patient support departments.. ... Wear gloves or appropriate PPE [personal protective equipment] remove trash from receptacle ... “. During a review of the hospital’s document titled, “Job Description -- Registered Nurse ... “, dated 1/25, indicated, “ ... Environmental Safety ... Safety/Security ... Responsible for following through on observed potential and real safety hazards that occur in the department or impact staff in other areas of the hospital, ... Identifies and reports unsafe conditions/occurrences to appropriate individual ... Demonstrates safe and effective use of all equipment. ... “ 5. During a concurrent interview and record review on 2/17/26 at 1:42 p.m. with the NM 5, Pt 10’s “”EMR,” “H&P,” dated 2/16/22 and the “FS,” were reviewed for Pt 10’s admission dated 2/15/26. The “H&P” indicated Pt 10 had a past medical history of cirrhosis (scarring of the liver, preventing it from filtering blood, processing nutrients and fighting infection) and bleeding esophageal varices (abnormally enlarged veins found in the esophagus, usually as a result of liver disease) and was admitted to ICU for stabilization and blood transfusions. The NM 5 stated, Pt 10 was on minimum continuous vital signs (vitals signs include the heart rate, respirations, blood pressure and amount of pulse oximetry (oxygen in the blood)) monitoring. The NM 5 stated, the EMR indicated Pt 10 had respirations of 7 per minute (normal respirations are 12 to 20 per minute in an adult) recorded eight times over 2/16/26 and 2/17/26 but the provider was not notified. The NM 5 stated, it was probably incorrect placement of the monitoring equipment but the nurse accepted the vitals signs as accurate and recorded them in the chart. The NM 5 stated, the nurse should have called the provider or corrected the vital signs to accurately reflect Pt 10’s status as per policy. During an interview on 2/20/26 at 11:35 a.m. with the CNO, the CNO stated the nurse should ensure that what is being charted is accurate and if the vitals do not meet the parameters set by the provider then the provider should be called. During a review of the hospital P&P titled, “Assessments/Reassessments”, dated 2/2026, the P&P indicated, “ ... PURPOSE: ... To provide individualized patient care to meet the needs of each patient on admission and throughout the course of the patient’s care ... Assessment data will be utilized to determine appropriate interventions ... It is the responsibility of the RN to notify the physician when there is a change in the patient’s condition. ... “. During a review of the hospital P&P titled, “Documentation Required for Patient Care Services”, dated 2/2026, the P&P indicated, “ ... PURPOSE: ... To ensure accurate, complete, and timely documentation of patient care services that meets regulatory requirements, supports safe patient care, and provides a comprehensive record of the nursing process ... Vital Signs ... Any vital sign outside normal parameters, ... “. During a review of professional article by the American Lung Association titled, “Understanding Vital Signs: The Importance of Your Respiratory Rate” located at https://www.lung.org/blog/respiratory-rate-vital-signs, dated October 16, 2025, the article indicated “ ... The normal respiratory rate for an adult at rest is from 12 to 20 breaths per minute. A respiratory rate under 12 or over 25 breaths per minute is cause for concern. People in an abnormal range may experience tachypnea, or rapid, shallow breathing that signals an underlying condition. ...” 6. During a concurrent observation and interview on 2/17/26 at 10:45 a.m. in room 111 in the ED with Nurse Manager for ED/ICU (NM 3), the Pelvic Exam Cart was observed to be unlocked. NM 3 stated he was not sure why the cart was open, and his expectation was the Pelvic Exam Cart would be locked when not in use. During an interview on 2/20/26 at 11:41 a.m. with Chief Nursing Officer (CNO), CNO stated her expectation was the Pelvic Exam Cart needed to be closed and locked when not being used. CNO stated this could be a safety issue for patients and staff because unlocked carts pose risks such as missing supplies, malfunctioning equipment, and delayed care. During a review of the facility’s policy and procedure titled, Treatment Carts dated 8/25, the policy indicated that, “ ...carts must be locked or secured when not actively in use...”, “ ... and access is limited to authorized personnel only...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 47205 Based on observation, interview, and record review, the hospital failed to ensure that the medical record was accurate, promptly completed, organized, and readily retrievable to reflect interdisciplinary (2 or more disciplines collaborating to accomplish a common goal) care provided to Patient (Pt) 1. This failure resulted in staff inability to provide a clear and coherent account of the patient’s clinical course during admission. The fragmentation (the process or state of breaking or being broken into small or separate parts) and inaccessibility of the record impeded the ability to determine whether appropriate medical and psychological evaluation and treatment were provided, creating risk for delayed diagnosis, inappropriate care, and compromised patient safety. Findings: During a concurrent interview and record review on 2/19/26 at 10:45 a.m., with the Medical Surgical Telemetry Unit Nurse Manager (NM) of Pt 1’s electronic medical record (EMR- a digital version of a patient’s paper chart, containing a clinician’s notes, diagnoses, medications, and test results from one specific practice), pt 1’s EMR indicated Pt 1 was admitted to the Medical Surgical with telemetry (Med-Surg/Tele- unit provides acute care to patients with general medical conditions or post-surgical recovery who also require continuous, remote monitoring of cardiac activity and vital signs) unit for a diagnosis of “hypertensive (high blood pressure) emergency” on 1/4/26 after coming by ambulance, to the Emergency Department (ED) for complaints of nausea and vomiting on 1/3/26. Pt 1’s EMR indicated Pt 1 was made a DNR/DNI (DNR [Do Not Resuscitate] and DNI [Do Not Intubate] are legal, medical orders directing healthcare teams to withhold specific life-prolonging treatments) on 1/9/26 after a next of kin (NoK- a person’s closest living blood relative or legal spouse/partner) was located. Pt 1 had signs of an infection on 1/20/26, antibiotics were started with orders for a urine culture (a laboratory test that detects and identifies bacteria or yeast in a urine sample to diagnose urinary tract infections (UTIs)). A rapid response (RRT- an immediate, organized intervention designed to address critical, time-sensitive situations before they escalate. In healthcare, it is a team summoned to a patient’s bedside to prevent cardiac arrest or ICU transfer.) was called on 1/21/26 resulting in a transfer to the Intensive Care Unit (ICU) at 5:40 p.m. Pt 1 was pronounced dead on 1/21/26 at 6:24 p.m. and death record indicated Pt 1 had “Pulmonary Arrest likely secondary to sepsis (the sudden cessation of breathing caused by severe infection-induced inflammation, typically leading to acute respiratory distress syndrome [ARDS]. Sepsis causes excessive inflammatory response resulting in severe lung injury, fluid accumulation, and failure of oxygen exchange, requiring immediate respiratory support)...” NM 1 stated during the course of Pt 1’s EMR review there were gaps in the documentation, by nursing staff and medical providers, that were concerning. NM 1 stated, she agreed Pt 1’s EMR did not seem to provide a complete and/or possibly accurate picture of the care Pt 1 was provided or as she would expect be present for a patient with Pt 1’s medical condition. During an interview on 2/19/26 at 12:00 p.m., with NM 1, NM 1 stated after learning more about the purpose of the investigation into Pt 1’s hospitalization and having had an opportunity to look into the complaint NM 1 stated she recalled being told Pt 1 had significant social service interaction from social workers due to Pt 1’s psychosocial (the essential emotional, social, and psychological requirements for an individual’s mental well-being, growth, and functional autonomy) needs and the location of a NoK. NM 1 stated she would need to review Pt 1’s chart and then provide a more detailed report of the care provided Pt 1 during his hospital stay. During an interview on 2/19/26 at 4:48 p.m., the Chief Medical Officer (CMO) and the Chief Executive Officer (CEO) informed the CMO and CEO of concern for the accuracy and completeness of Pt 1’s EMR and the EMR not reflecting anticipated and expected documentation of the care Pt 1 received during his hospital admission. The CEO and CMO stated the current EMR application in use at the hospital was one of the challenges the facility faces due to its limitations in reporting and locating data in a timely manner. During an interview on 2/20/26 at 9:12 a.m., with CMO and CEO, the CMO and CEO agreed the EMR was misleading and explained how their review led to their locating essential provider and staff communication not previously available. CMO stated after a complete review of the medical record he shared with his leadership team that all medical decision making was as expected after it was necessary to piece together the events of the course of Pt 1’s hospital admission. CMO stated all discussions, orders, treatment progress and consultations were accounted for and Pt 1’s safety was not ever at risk. CMO and CEO provided a comprehensive review and supporting documentation for surveyor review. CMO stated during review of Pt 1’s EMR, he identified a possible healthcare associated infection and that this was a trigger for the peer review process (a formal, confidential system where professionals evaluate the quality, safety, and appropriateness of care provided by their peers to ensure it meets accepted standards) which will be initiated to include a root-cause analysis (RCA- a structured, systematic problem-solving method used to identify the underlying, fundamental causes of incidents or defects rather than just addressing symptoms) but, “no” this EMR discrepancy would not have been identified as a possible concern without a complaint having initiated an investigation. During an interview on 2/20/26 at 9:40 a.m., with Hospitalist (HOSP- a dedicated physician who manages the comprehensive care of patients solely while they are admitted to the hospital), HOSP stated he began caring for Pt 1 on 1/15/26. HOSP stated Pt 1 was known to him from a connection with a local community general acute care hospital, and as such he had access to a more updated history for Pt 1 than had the hospitalists caring for Pt 1 before 1/15/26. HOSP stated, “no,” [he] did not have any concerns about the medical care provided to Pt 1. HOSP stated he was confident all that should have been done for Pt 1 was done. HOSP stated he did not have any concerns after reviewing Pt 1’s EMR. HOSP described Pt 1 as a medically complex patient with numerous chronic (on-going) illnesses, non-compliant behavior, and socio-economic needs (unhoused, estranged from family) with a poor prognosis therefore it was not unexpected that Pt 1 expired. During an interview on 2/20/26 at 11:41 a.m., with Chief Nursing Officer (CNO) and CEO, CNO stated it is her expectation that surveyor’s should receive patient EHR data in a timely manner [including state and regulatory review] and that medical care provided should be readily available to the interdisciplinary medical care team to ensure patient safety and “continuity of care.” CEO stated regular chart reviews and audits need to continue to ensure the EMR is accurate and clearly reflects the care provided by staff and providers to ensure patient safety. During a review of the hospital policy and procedure (P&P) titled, “Documentation Required for Patient Care Services, dated 2/2026, the P&P indicated “...Purpose: To ensure accurate, complete and timely documentation of patient care services that meets regulatory requirements, supports safe patient care, and provides a comprehensive record of the nursing process for patients admitted to the Medical Surgical and Telemetry units... Policy: All components of the patient care process, plan of care, evaluation, and outcomes will be documented in the patient’s Electronic Health Record (EHR). The documentation will address patient’s physical, psychosocial needs, capabilities, and limitations. Documentation of patient care will occur within the EHR at the time of care delivery or as soon as possible thereafter, using the timeframes specified in this policy...” During a review of the hospital policy and procedure (P&P) titled, “Chart Analysis/Completion,” dated 2/2025, the P&P indicated “...Purpose: To ensure complete, adequate and timely documentation of each medical record...Procedure: B. Review record for missing and/or outdated dictation, reports...” During a review of the facility’s policy and procedure titled, “Patient’s Rights/Responsibilities,” dated 2/2025, indicated, “... Receive care in a safe and secure environment which incorporates current standards of practice for patient environmental safety, infection control and security... “”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 47205 Based on observation, interview, and record review, the hospital failed to ensure that the medical record was accurate, promptly completed, organized, and readily retrievable to reflect interdisciplinary (2 or more disciplines collaborating to accomplish a common goal) care provided to Patient (Pt) 1. This failure resulted in staff inability to provide a clear and coherent account of the patient’s clinical course during admission. The fragmentation (the process or state of breaking or being broken into small or separate parts) and inaccessibility of the record impeded the ability to determine whether appropriate medical and psychological evaluation and treatment were provided, creating risk for delayed diagnosis, inappropriate care, and compromised patient safety. Findings: During a concurrent interview and record review on 2/19/26 at 10:45 a.m., with the Medical Surgical Telemetry Unit Nurse Manager (NM) of Pt 1’s electronic medical record (EMR- a digital version of a patient’s paper chart, containing a clinician’s notes, diagnoses, medications, and test results from one specific practice), pt 1’s EMR indicated Pt 1 was admitted to the Medical Surgical with telemetry (Med-Surg/Tele- unit provides acute care to patients with general medical conditions or post-surgical recovery who also require continuous, remote monitoring of cardiac activity and vital signs) unit for a diagnosis of “hypertensive (high blood pressure) emergency” on 1/4/26 after coming by ambulance, to the Emergency Department (ED) for complaints of nausea and vomiting on 1/3/26. Pt 1’s EMR indicated Pt 1 was made a DNR/DNI (DNR [Do Not Resuscitate] and DNI [Do Not Intubate] are legal, medical orders directing healthcare teams to withhold specific life-prolonging treatments) on 1/9/26 after a next of kin (NoK- a person’s closest living blood relative or legal spouse/partner) was located. Pt 1 had signs of an infection on 1/20/26, antibiotics were started with orders for a urine culture (a laboratory test that detects and identifies bacteria or yeast in a urine sample to diagnose urinary tract infections (UTIs)). A rapid response (RRT- an immediate, organized intervention designed to address critical, time-sensitive situations before they escalate. In healthcare, it is a team summoned to a patient’s bedside to prevent cardiac arrest or ICU transfer.) was called on 1/21/26 resulting in a transfer to the Intensive Care Unit (ICU) at 5:40 p.m. Pt 1 was pronounced dead on 1/21/26 at 6:24 p.m. and death record indicated Pt 1 had “Pulmonary Arrest likely secondary to sepsis (the sudden cessation of breathing caused by severe infection-induced inflammation, typically leading to acute respiratory distress syndrome [ARDS]. Sepsis causes excessive inflammatory response resulting in severe lung injury, fluid accumulation, and failure of oxygen exchange, requiring immediate respiratory support)...” NM 1 stated during the course of Pt 1’s EMR review there were gaps in the documentation, by nursing staff and medical providers, that were concerning. NM 1 stated, she agreed Pt 1’s EMR did not seem to provide a complete and/or possibly accurate picture of the care Pt 1 was provided or as she would expect be present for a patient with Pt 1’s medical condition. During an interview on 2/19/26 at 12:00 p.m., with NM 1, NM 1 stated after learning more about the purpose of the investigation into Pt 1’s hospitalization and having had an opportunity to look into the complaint NM 1 stated she recalled being told Pt 1 had significant social service interaction from social workers due to Pt 1’s psychosocial (the essential emotional, social, and psychological requirements for an individual’s mental well-being, growth, and functional autonomy) needs and the location of a NoK. NM 1 stated she would need to review Pt 1’s chart and then provide a more detailed report of the care provided Pt 1 during his hospital stay. During an interview on 2/19/26 at 4:48 p.m., the Chief Medical Officer (CMO) and the Chief Executive Officer (CEO) informed the CMO and CEO of concern for the accuracy and completeness of Pt 1’s EMR and the EMR not reflecting anticipated and expected documentation of the care Pt 1 received during his hospital admission. The CEO and CMO stated the current EMR application in use at the hospital was one of the challenges the facility faces due to its limitations in reporting and locating data in a timely manner. During an interview on 2/20/26 at 9:12 a.m., with CMO and CEO, the CMO and CEO agreed the EMR was misleading and explained how their review led to their locating essential provider and staff communication not previously available. CMO stated after a complete review of the medical record he shared with his leadership team that all medical decision making was as expected after it was necessary to piece together the events of the course of Pt 1’s hospital admission. CMO stated all discussions, orders, treatment progress and consultations were accounted for and Pt 1’s safety was not ever at risk. CMO and CEO provided a comprehensive review and supporting documentation for surveyor review. CMO stated during review of Pt 1’s EMR, he identified a possible healthcare associated infection and that this was a trigger for the peer review process (a formal, confidential system where professionals evaluate the quality, safety, and appropriateness of care provided by their peers to ensure it meets accepted standards) which will be initiated to include a root-cause analysis (RCA- a structured, systematic problem-solving method used to identify the underlying, fundamental causes of incidents or defects rather than just addressing symptoms) but, “no” this EMR discrepancy would not have been identified as a possible concern without a complaint having initiated an investigation. During an interview on 2/20/26 at 9:40 a.m., with Hospitalist (HOSP- a dedicated physician who manages the comprehensive care of patients solely while they are admitted to the hospital), HOSP stated he began caring for Pt 1 on 1/15/26. HOSP stated Pt 1 was known to him from a connection with a local community general acute care hospital, and as such he had access to a more updated history for Pt 1 than had the hospitalists caring for Pt 1 before 1/15/26. HOSP stated, “no,” [he] did not have any concerns about the medical care provided to Pt 1. HOSP stated he was confident all that should have been done for Pt 1 was done. HOSP stated he did not have any concerns after reviewing Pt 1’s EMR. HOSP described Pt 1 as a medically complex patient with numerous chronic (on-going) illnesses, non-compliant behavior, and socio-economic needs (unhoused, estranged from family) with a poor prognosis therefore it was not unexpected that Pt 1 expired. During an interview on 2/20/26 at 11:41 a.m., with Chief Nursing Officer (CNO) and CEO, CNO stated it is her expectation that surveyor’s should receive patient EHR data in a timely manner [including state and regulatory review] and that medical care provided should be readily available to the interdisciplinary medical care team to ensure patient safety and “continuity of care.” CEO stated regular chart reviews and audits need to continue to ensure the EMR is accurate and clearly reflects the care provided by staff and providers to ensure patient safety. During a review of the hospital policy and procedure (P&P) titled, “Documentation Required for Patient Care Services, dated 2/2026, the P&P indicated “...Purpose: To ensure accurate, complete and timely documentation of patient care services that meets regulatory requirements, supports safe patient care, and provides a comprehensive record of the nursing process for patients admitted to the Medical Surgical and Telemetry units... Policy: All components of the patient care process, plan of care, evaluation, and outcomes will be documented in the patient’s Electronic Health Record (EHR). The documentation will address patient’s physical, psychosocial needs, capabilities, and limitations. Documentation of patient care will occur within the EHR at the time of care delivery or as soon as possible thereafter, using the timeframes specified in this policy...” During a review of the hospital policy and procedure (P&P) titled, “Chart Analysis/Completion,” dated 2/2025, the P&P indicated “...Purpose: To ensure complete, adequate and timely documentation of each medical record...Procedure: B. Review record for missing and/or outdated dictation, reports...” During a review of the facility’s policy and procedure titled, “Patient’s Rights/Responsibilities,” dated 2/2025, indicated, “... Receive care in a safe and secure environment which incorporates current standards of practice for patient environmental safety, infection control and security... “”

“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: 47205 Based on interview and record review, the hospital failed to maintain a complete and accurate Emergency Department (ED) Central Log (ED Log) for each individual who comes to the emergency department seeking assistance when the ED Logs did not accurately reflect patient information such as chief complaint (reason for coming to the ED) and disposition (the final decision or destination for a patient upon discharge from the ED), had errors and/or omissions, and were not provided in a timely manner (within 20 minutes) for surveyor review in accordance with hospital policy and procedure (P&P) titled, “Emergency Medical Treatment And Labor Act (EMTALA) and Transfer”, dated 2/2025, and regulatory requirements. This failure resulted in the potential for the central log discrepancies to lead to inaccurate/erroneous data collection affecting hospital operations (for example: staffing, scheduling, and training), and patient care outcomes. Findings: During a concurrent interview and record review on 1/28/26 at 2:40 p.m., with the Chief Executive Officer (CEO), the January 2026 ED central log was reviewed. The CEO was advised the log submitted did not have the arrival time and contained frequent errors such as missing chief complaint, chief complaint of “Left without Being Seen (LWBS-when a patient leaves the ED before being seen by a provider)” and unclear disposition status types specifically “SP” which the CEO stated stood for “still a patient.” The CEO stated she would have the report corrected to provide the arrival time and correct the SP disposition. The CEO stated SP was not an acceptable disposition status for an ED log. During an interview on 1/29/26 at 9:12 a.m., with the CEO, the CEO was informed that that the surveyors were still waiting for the submission of the ED logs requested on 1/28/26, only January’s ED Central log had been provided. CEO stated she was not sure why the logs requested (September 2025 through January 2026) had not been submitted in a timely manner. During an interview on 1/29/26 at 1:12 p.m., with the CEO, the CEO was informed that the surveyors were still waiting for the submission of logs requested on 1/28/26. The CEO stated she would follow up and ensure the outstanding requested logs (September, November, and December) were provided right away. During a concurrent interview and record review on 1/30/26 at 11 a.m. with the emergency department assistant manager (EDAM), the ED Central Log dated 1/10/26 indicated Patient (Pt) 2 arrived by ambulance at 00:56 (12:56 a.m.) on 1/10/26. Review of Patient (Pt) 2’s medical record dated 1/10/26 indicated Pt 2 arrived to the ED by ambulance at 1:44 a.m. Review of the Patient Care Report (PCR- Record of pre-hospital care provided by Emergency Medical Services [EMS] personnel) dated 1/10/26 indicated EMS transported Pt 2 by ambulance and arrived at the hospital at 1:42 a.m. on 1/10/26 and then care was transferred to the ED staff. The EDAM stated the arrival time on the ED Log was incorrect. During a concurrent interview and record review on 1/30/26 at 12 p.m. with the EDAM, the ED Central Log dated 12/4/25 indicated Pt 1 came to the ED by ambulance with a chief complaint of osteomyelitis (inflammation of bone tissue due to infection with bacteria or fungi) on 12/4/25 at 12:58 p.m. and was transferred to a psychiatric hospital on 12/5/25 at 00:10 (12:10 a.m.). Review of Pt 1’s medical record dated 12/4/25 indicated Pt 1’s chief complaint was “purulent drainage [pus] to right arm following hardware placement” and Pt 1 actually left against medical advice (AMA-choosing to leave the hospital before the treating physician recommends discharge) on 12/4/25 at 9:16 p.m. The EDAM stated the disposition type (transfer), and the date and time of disposition (12/5/25 at 12:10 a.m.) on the ED Log are all incorrect. During an interview on 2/2/26 at 2:15 p.m. with the CEO, the CEO stated the accuracy of the ED Log needed to be improved. The CEO stated because there were so many errors they will have to reconcile the ED Log daily in order to ensure it is accurate. During a review of the hospitals P&P titled, “Emergency Medical Treatment & Active Labor Act (EMTALA) and Transfer” dated 2/2025, the P&P indicated, “POLICY: ...13. ... J. Central Log The disposition of the patient must be logged in each department’s (or any off campus clinical services location where EMTALA regulations apply) permanent central log. Logs must be kept for a period of five (5) years and retrievable within twenty (20) minutes. The clinical manager of each unit where EMTALA regulations apply is responsible for the accuracy and completeness of the information contained in the log... 2. ED Log Date, Time of ER [ED] Arrival, Name, Age, Sex, Address, Medical Record # [number], Mode of Entry, Service of MD [Medical Doctor], PMD [Primary Medical Doctor], ER MD, DX [diagnosis], Attending Physician, Services Provided, Disposition, Date & Time Discharged/ Transferred, Method of Transportation, Refusal of Tx [treatment], or AMA [Against Medical Advice] (if applicable)...””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47205 Based on interview, clinical record review, and hospital policy review, the hospital failed to ensure licensed nurses (LNs) followed policies and procedures (P&P) when: 1. LNs failed to ensure three out of 21 Patients (Pt 1, Pt 2, and Pt 7) had their pain levels assessed, addressed, or reassessed in accordance with the hospital P&Ps titled, “Pain Assessment and Reassessment Policy”, and “Care of the Patient in the Emergency Department: Triage [quick look to determine order patients are seen] to Discharge”. (Refer to A-0398 Finding 1) 2. Emergency Department (ED) nurses did not document a physical assessment for two of five sampled patients (Pt 1 and Pt 2), and Medical Surgical (MS) nurses did not complete physical assessments within one hour of admission to the MS Unit for two of four sampled patients (Pt 4 and Pt 9), in accordance with the hospital’s P&Ps titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, and “Assessments / Reassessments”. (Refer to A-0398 Finding 2) 3. ED nurses failed to assess the vital signs (VS- blood pressure, breathing rate, heart rate, temperature, and pain score) 30 minutes before the discharge (sending home) of two out of six sampled patients (Pt 2, and Pt 8), in accordance with the hospital’s P&P titled, “Identifying and Evaluation of the High Alert ED Patient at Discharge”. (Refer to A-0398 Finding 3) 4. ED nurses failed to provide discharge instructions, and education reflecting their primary diagnosis, chief complaint, follow up care, care at home, discharge medications, prescriptions and referrals, for one of five sampled ED patients (Pt 1) in accordance with the hospital’s P&P titled, “Identifying and Evaluation of the High Alert ED Patient at Discharge,” and “Care of the patient in the Emergency Department: Triage to Discharge.” (Refer to A-0398 Finding 4) 5. The hospital failed to ensure that nursing staff followed physician orders and appropriately responded to significant clinical changes for one of 13 sampled patients (Pt 9) when MS nurses did not obtain, and document daily weights and the hospital did not follow the P&P titled, “Physician Order”, and “Assessments / Reassessments.” (Refer to A-0398 Finding 5) 6. The facility failed to follow the hospital P&P titled, “Downtime procedures for [electronic medical record system]”, “Identifying and Evaluation of the High Alert ED Patient at Discharge”, and “Abbreviations in the Medical Record” when ED nursing staff did not documented accurately and completely during electronic medical record (EMR) downtime for two of three sampled patients (Pt 1, and Pt 2) and unapproved abbreviations were used for one of 21 patients (Pt 9). (Refer to A-0398 Finding 6) 7. Licensed Nurses (LNs) did not adhere to restraint documentation requirements per hospital P&P titled “Restraints for Management of Violent and Non-Violent Behavior” dated 2/25 for one of 3 patients sampled, Patient (Pt) 20. (Refer to A-0398 Finding 7) 8. Licensed Nurses (LNs) failed to develop Pt 4’s CP to address his kidney stones, urinary tract infection (UTI-infection in any part of the urinary system), and urinary retention (unable to urinate). (Refer to A-0396 Finding 1) 9. LNs failed to develop Pt 10’s CP to address his wound care; (Refer to A-0396 Finding 2) 10. LNs failed to develop Pt 17’s CP to address her UTI; (Refer to A-0396 Finding 3) 11. LNs failed to develop Pt 19’s CP to address her risk for developing hospital acquired skin injury. (Refer to A-0396 Finding 4) The cumulative effect of these system problems resulted in the hospital’s inability to provide quality nursing care in a safe setting.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47205 Based on observation, interview, and record review, the hospital failed to have an active Infection Prevention and Control program which adhered to nationally recognized infection prevention and control guidelines for the surveillance, prevention, and control of HAIs (hospital acquired infections) and other infectious diseases, when: 1. Facility staff did not decontaminate, perform high level disinfection (HLD- a process that destroys all microorganisms, except for a large number of bacterial spores, and is used on semi-critical medical devices like endoscopes and store endoscopes in accordance with professional standards and manufacturer’s instructions for use (IFU). Endoscopy Technician (ET) 1 performed decontamination of used endoscope by lifting the endoscope above the water line and in the process cross contaminated a clean table used to dry the endoscope prior to beginning the HLD process. The physical configuration of the sinks within the decontamination room did not permit sufficient space for ET 1 to keep the endoscope fully submerged while decontaminating in accordance with professional standards of practice. ET 1 did not appropriately don PPE during the process of decontaminating the endoscopes. The endoscopes were not appropriately hung in the cabinet. Ten scopes were fitted into a cabinet that was meant to support eight endoscopes. The endoscopes did not freely hang without touching and instead were hung and folded to fit into the cabinet and not in accordance with the manufacturer’s. (Refer to A750 Finding 1) On 10/2/2025 at 4:06 p.m.,because of the serious potential harm to patients undergoing endoscopic procedures related to not practicing the professional standards for Endoscope disinfection and storage, hospital-wide failure of not following the principles of Infection Control and Prevention, not having a comprehensive systemic approach to ensure effective infection control practices, surveillance, prevention monitoring and a system to maintain professional standards of practice, an Immediate Jeopardy (IJ- a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was cited under the Code of Federal Regulations (CFR) §482.42(a)(3), at A-0750 with the hospital Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Risk Management Manager (DRM), Director of Quality/Infection Prevention (DQ/IP), and Sterile Processing Supervisor (SPS) notified and provided with the IJ template. On 10/3/25 at 10:30 a.m., the hospital submitted an IJ Plan of Removal (PoR- documents the immediate action an entity will take to prevent serious harm from occurring or recurring) (Version One) which was evaluated and deemed unacceptable. On 10/4/25 at 4:18 p.m. the survey team validated, by direct observation, the processing of endoscopes from beginning to end and all steps followed professional standards; and actions related to the IJ had been implemented. On 10/4/25 at 4:45 p.m. the hospital submitted an IJ PoR (Version Two). IJ PoR (Version 2) was evaluated and the hospital CEO, CNO, and RM were notified that PoR (Version Two) was accepted. The IJ Plan of Removal included but was not limited to the following: immediately educate and validate competencies related to appropriate PPE and proper hand hygiene, Endoscopy staff were re-educated on proper decontamination processes per professional standards, discontinued the use of the current endoscopy processing room facility identified the SPD decontamination room as the new location to process endoscopes, endoscope transport and reprocessing workflows were revised and implemented, implementation of audits conducted by the infection preventionist, new endoscope cabinets were installed and disinfected per manufacturer instructions, a visual aide was added to the cabinets to identify the capacity. All items were validated onsite via interview, observation and record review. On 10/4/25 at 4:50 p.m., the IJ was lifted, onsite with the CEO, CNO, Chief Operating Officer (COO), and RM in attendance. After removal of the IJ, the hospital remained in substantial noncompliance. 2. Two of two transvaginal probes (an ultrasound probe connected to a computer is inserted into the vagina and is gently moved to show different organs) were not stored according to the manufacturer IFUs and in accordance with national standards for infection prevention. (Refer to A750 Finding 2) 3. During an observation on 9/30/25 at 9:50 a.m., One of two dialysis machines (filters a patient’s blood to remove waste products and excess fluid when the kidneys [bean-shaped organs located on either side of the spine] are not functioning properly) located in the hospital’s Medical Surgical (MS) Unit, in room 228, where patients receive dialysis treatment was not cleaned and sanitized following dialysis for Patient (Pt) 15 on 9/29/25 at 5 p.m., per hospital Policy and Procedure (P&P) , negatively effecting one of one dialysis patients, Pt 15. (Refer to A750 Finding 3) 4. A soiled wash cloth was observed hanging from a shower curtain rod in a shared patient shower room located at the Central Station on the MS unit, with the potential to negatively affect the health of 50 of 50 patients in the MS unit. (Refer to A750 Finding 4) 5. A dirty, unlabeled graduated cylinder (container used to measure urine output), was sitting on the back of the toilet in a patient shared bathroom, with the potential to negatively affect the health of two of two patients. (Refer to A750 Finding 5) 6. Licensed Nurses (LNs) failed to change the soiled dressing covering for one of one sampled patient’s (Pt 5) intravenous (IV-into a vein) site (where a flexible plastic tube, or cannula, is inserted into a vein to deliver fluids, medications, or blood directly into the bloodstream), in accordance with hospital P&P titled, “Intravenous Therapy” and CDC guidelines for infection control. (Refer to A750 Finding 6) 7.One of one 500 milliliter (mL- a unit of measurement) bag (a flexible plastic container filled with fluids for medical use, most commonly for intravenous (IV) therapy ) of Lactated Ringer’s (LR- a type of fluid used to replace electrolytes (minerals in the body that carry an electrical charge when dissolved in water) intravenous (IV- a way to give fluids directly into the vein) fluid was lying on the counter in the Emergency Department (ED) medication preparation room with the protective overwrap (a plastic bag to protect the solution from contaminants) removed, not stored in accordance hospital P&P titled “Intravenous Therapy.” (Refer to A750 Finding 7) As a result of these failures all patients, visitors and staff were at risk for transmission of infections (refers to the way germs infect a susceptible (at risk) person) and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality patient care in a safe and sanitary environment.”

“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: 49884 Based on observation, interview, and record review the hospital failed to ensure that one of 15 patients (Pt 5) had the right to make informed decisions about their care when patient (Pt) 5 was not informed of her care plan (CP-a document that outlines a patient’s health conditions, treatments and other information to guide their care and ensure consistent care), not involved in its creation, and the physician did not introduce themselves before or after a physical assessment in accordance with the hospital’s Policy and Procedure titled, “Patient’s Rights and Responsibilities”, and “Admission Data Base & Care Plan Management”. These failures caused Pt 5 to feel nervous and confused about the care being provided and had the potential for the patient to not have the right to participate in their care and treatment process. Findings: During a concurrent interview and record review on 10/1/25 at 2:12 p.m. with the Licensed Clinical Informatics Analyst (LCIA) 1, Pt 5’s History and Physical (H&P- an assessment from physician including medical history and exam) and “Patient Summary Report”, dated 9/30/25 were reviewed. Pt 5 arrived in the Emergency Department (ED) on 9/30/25 with complaints of abdominal pain and was admitted to the hospital as an inpatient on 9/30/25 for diverticulitis (a condition where small pouches [diverticula] in the wall of the large intestine [colon] become inflamed or infected) of the intestines. LCIA 1 stated Pt 5 was moved to the Medical Surgical (MS) Unit (area in the hospital for patients who are not critically ill but require close monitoring) on 9/30/25 at 11:20 a.m. During a concurrent observation and interview on 10/1/25 at 5:10 p.m. with Pt 5 in Pt 5’s Medical Surgical (MS) Unit hospital room, Pt 5 was observed in her hospital room lying on her back with her left arm outstretched and intravenous (IV-where a flexible plastic tube, or cannula, is inserted into a vein to deliver fluids, medications, or blood directly into the bloodstream) fluids infusing into the IV site in her left antecubital space (AC- area on front of elbow joint). Patient 5 stated she arrived at the Emergency Department (ED) with severe stomach pain. The ED physician offered her a choice between staying as an inpatient or going home after diagnosing a ruptured diverticulum (a tear or break in the wall of a diverticulum, which is a small, bulging pouch that forms in the colon), prompting her to stay. Initially, the physician mentioned a 23-hour observation (a period of close monitoring in a hospital setting for up to 23 hours to determine if inpatient admission is necessary) but later admitted her as an inpatient. Pt 5 reported a lack of updates on her treatment plan, though someone (she did not remember who) mentioned the possibility of surgery. Pt 5 stated her nurse did not ask her what her treatment goals were. Pt 5 stated her goal was no stomach pain and to go home. Pt 5 stated that around noon on 10/1/25 a physician entered her room, did not introduce himself, briefly asked about her condition, and conducted a quick exam, before leaving. He was in the room for only a few minutes. Patient 5 stated her blood was drawn three separate times without receiving any results. Pt 5 stated the uncertainty about her treatment plan led to increased worry. During an interview on 10/7/25 at 11:15 a.m. with Nuse Manager (NM) 1, NM 1 stated nursing staff were expected to include the patient in care planning because the problems, interventions, and goals of a care plan were patient centered. NM 1 stated nurses were encouraged to do a change of shift report at the patient’s bedside, (this was not done for Pt 5) so patients were aware of their treatment plans, and any test results. NM 1 stated all hospital staff as well as physicians were expected to introduce themselves to patients, so the patient felt comfortable with who was giving them care. NM 1 stated patients knowing the name of their caregivers, and their treatment plan was their right. During an interview on 10/8/25 at 11:21 a.m. with the Chief Nursing Officer (CNO), the CNO stated staff and physicians were expected to introduce themselves before providing care to the patient. The CNO stated, The CNO stated, patients had a right to know and participate in their treatment plan. During a review of the hospital’s P&P titled, “Admission Data Base & Care Plan Management” dated 8/24, indicated, “ ...To assess patient conditions and identify at-risk factors upon admission, ensuring coordinated multidisciplinary (professionals from different fields (like doctors, nurses, therapists, pharmacists, and social workers) working together) care throughout the hospitalization. ...To facilitate patient education by promoting collaboration and communication among the multidisciplinary healthcare team, including but not limited to the patient/family, physician, nursing staff ...The Registered Nurse is responsible for delegating the collection of data and in collaboration with other members of the health care team and developing an individualized plan of care for each patient based on patient problems and needs and using nursing diagnoses and assessments ...” During a review of the facility’s P&P titled, “Patient’s Rights/Responsibilities” dated 2/25, indicated, ... All patients have the right to the following ... The right to considerate, respectful care given by competent personnel, which optimizes the patient’s comfort and dignity while contributing to a positive patient self-image. ...Know the name of the provider responsible for the patient ’ s care and the identity and function of all individuals providing their care, treatment, and services. ...Participate with the providers in the development, implementation, and revision of the patient plan of care-both inpatient and outpatient, including the discharge plan and pain management plan. ...Receive information about current health status, diagnosis, prognosis, care needs, outcomes, recovery, ongoing healthcare needs and future health status. ...Be involved in all aspects of care and take part in decisions about care ...” During a review of the professional reference titled, “Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes”, dated 10/24/19, the professional reference indicated, “ ...Personalized care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care. ... Often used with medically complex patients, personalized care plans have been effective in improving outcomes when integrated into routine care8 and are now mandated by the Centers for Medicare and Medicaid Services for chronic care management reimbursement ...””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 49884 Based on observation, interview, and record review, the hospital failed to provide privacy curtains (physical barriers used to create temporary, private spaces), or privacy screens for three of five sampled patients (Pt 4, Pt 5, and Pt 7) in the Emergency Department’s (ED) shared hospital environment in accordance with the hospital’s policy and procedure (P&P) titled, “Patient Rights/Responsibilities”. These failures had the potential to violate Patient Pt 4, Pt 5, and Pt 7’s right to privacy and the potential to breach confidentiality (kept secret or private), increase the potential spread of pathogens (germs), and increase stress due to lack of personal private space. Findings: During a concurrent observation and interview on 9/30/25 at 9:42 a.m. with Pt 4, in the Emergency Department (ED) lobby, Pt 4 was observed kneeling on the floor of the ED, with his head in his hands and his elbows on a chair, a wheelchair was near him. Pt 4 had tears coming from his eyes, he was grimacing and whimpering. Pt 4 stated he had just arrived in the ED lobby, and his family was at the registration window trying to get him registered to be seen. Pt 4 said he was having left side stomach pain, back pain, and chest pain. Pt 4 stated he had kidney stones in the past and they hurt a lot, but he was in the most pain he had ever experienced. During a concurrent observation and interview on 9/30/25 at 9:58 a.m. with the Chief Nursing Officer (CNO) in the ED, patients were observed receiving care through the rooms’ glass windows in the green zone (low acuity, quick in and out care), blue zone (high or mid acuity), and red zone (high acuity and trauma). The green zone had six recliners with patients; privacy curtains were available but not closed. Pt 7 was on a gurney in the hall in front of the green zone’s windows, visible to patients inside. The blue zone had three private rooms with open curtains, making patients visible. In the red zone, Pt 4 and Pt 5 were in bays with open curtains receiving care. The CNO confirmed that curtains should be closed, and patients in the hallway should have a privacy screen during care. During a concurrent observation and interview on 9/30/25 at 10:05 a.m., with Pt 7, in the ED hallway, Pt 7 was lying on his back on a gurney in street clothes, with gauze bandages wrapped around his left leg and left forearm. Pt 7’s hospital gurney was directly in front of the green zone bay of windows. Pt 7 stated he went to the ED after being attacked by two dogs. Pt 7 stated his bandages were applied while lying on the gurney, and no screens were up. During a concurrent observation and interview on 9/30/25 at 10:35 a.m. with Pt 5 in the ED red zone in bay three, Pt 5 was observed in a hospital gown lying on her left side with family at bedside. Pt 5 stated she came to the hospital for stomach pain and was waiting for test results. Pt 5 stated the privacy curtains were left open when nursing staff completed tasks, but they were closed when the patient was changing into a gown. During a concurrent interview and record review on 10/1/25 at 2:12 p.m. with Licensed Clinical Informatics Analyst (LCIA) 1, Pt 5’s Electronic Medical Record (EMR) was opened for review. The documents titled, History and Physical (H&P- an assessment from physician including medical history and exam) and “Patient Summary Report”, dated 9/30/25 were reviewed. Pt 5 arrived in the Emergency Department (ED) on 9/30/25 with complaints of abdominal pain and was admitted to the hospital as an inpatient on 9/30/25 for diverticulitis (a condition where small pouches (diverticula) in the wall of the large intestine (colon) become inflamed or infected) of the intestines. LCIA 1 stated Pt 5 was moved to the Medical Surgical (MS) Unit (area in the hospital for patients who are not critically ill but require close monitoring) on 9/30/25 at 11:20 a.m. During a concurrent interview and record review on 10/1/25 at 3 p.m. with LCIA 1, Pt 4 ’ s electronic medical record (EMR) was opened for review. Pt 4 ’ s EMR document titled “History and Physical (H&P- an assessment from physician including medical history and exam)”, dated 9/30/25, indicated, Pt 4 arrived in the ED on 9/30/25 at 9:44 a.m. with complaint of chest and stomach pain. Pt 4 reported a sudden onset of severe, sharp, stabbing pain in the chest that radiated into his back and down into his stomach. The pain was described as intense, unlike any pain he had experienced before, and was associated with sweating, clammy skin, and a general feeling of weakness. Pt 4 had a past medical history (PMH) of high blood pressure and kidney stones. During a concurrent interview and record review on 10/1/25 at 4:20 p.m. with Licensed Clinical Informatics Analysist (LCIA 1), Pt 7’s EMR was opened for review. The “Patient Summary Report (PSD- a summary of all of a patients care during an ED visit)”, and “ED Assessment (physician ’ s assessment in the ED)” dated 9/30/25, were reviewed. The “ED Assessment” indicated, Pt 7 was brought in by the ambulance with complaint of dog bites in the morning while walking down the street. During a review of the facility’s P&P titled, “Patient ’ s Rights/Responsibilities” dated 2/25, indicated, ... All patients have the right to the following ... The right to considerate, respectful care given by competent personnel, which optimizes the patient’s comfort and dignity while contributing to a positive patient self-image. ...Be interviewed, examined, treated, and have care discussed in places designated to protect privacy. ...Have your personal privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly ...” During a review of the professional reference titled, “Privacy and Confidentiality in Emergency Medicine: Obligations and Challenges”, dated 7/28/06, indicated, “ ...Ensuring and preserving patients’ privacy, confidentiality, and modesty are long-standing professional obligations of physicians rooted in tradition, religion, ethics, law, and philosophy. ...obligations are the recognition of the dignity and worth of patients as individuals and the inherent right of human beings to control their own affairs. Despite the structural problems in carrying out these duties in the crowded, rushed, and often open environment of the emergency department, emergency personnel should strive to do so. These duties are not absolute, and physicians and other health care professionals should understand when it is acceptable, and even desirable, to override them because of conflicting, greater duties. In the final analysis, however, circumstances requiring a breach of confidentiality are rare, and circumstances justifying the invasion of physical privacy are even rarer ...””

“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: 47205 Based on observations, interviews, and record reviews, the hospital failed to develop and maintain individualized care plans (CP-a document that outlines a patient’s health conditions, treatments and other information to guide their care and ensure consistent care) for 4 of 20 sampled patients (Patient [Pt] 4, Pt 10, Pt 17, and Pt 19 that accurately reflect their specific needs and goals as required by hospital policy when: 1. Licensed Nurses (LNs) failed to develop Pt 4’s CP to address his kidney stones, urinary tract infection (UTI-infection in any part of the urinary system), and urinary retention (unable to urinate); 2. LNs failed to develop Pt 10’s CP to address his wound care; 3. LNs failed to develop Pt 17’s CP to address her UTI; and, 4. LNs failed to develop Pt 19’s CP to address her risk for developing hospital acquired skin injury. These failures had the potential for inconsistent care delivery for Pt 4, Pt 10, Pt 17, and Pt 19 and could result in not receiving nursing care tailored to their individual needs and goals, which might impact patient well-being. Findings: 1. During a concurrent observation and interview on 9/30/25 at 9:42 a.m. with Pt 4, in the Emergency Department (ED) lobby, Pt 4 was observed kneeling on the floor of the ED, with his head in his hands and his elbows on a chair, a wheelchair was near him. Pt 4 had tears coming from his eyes, he was grimacing and whimpering. Pt 4 stated he had just arrived in the ED lobby, and his family was at the registration window trying to get him registered to be seen. Pt 4 said he was having left side stomach pain, back pain, and chest pain. Pt 4 stated he had kidney stones in the past and they hurt a lot, but he was in the most pain he had ever experienced. During a concurrent observation and interview on 10/1/25 at 3 p.m. with the Licensed Clinical Informatics Analysist (LCIA) 1, Pt 4’s electronic medical record (EMR) was reviewed. Pt 4’s EMR document titled “History and Physical (H&P- an assessment from physician including medical history and exam)”, dated 9/30/25, indicated, Pt 4 arrived in the ED on 9/30/25 at 9:44 a.m. with complaint of chest and stomach pain. Pt 4 reported a sudden onset of severe, sharp, stabbing pain in the chest that radiated into his back and down into his stomach. The pain was described as intense, unlike any pain he had experienced before, and was associated with sweating, clammy skin, and a general feeling of weakness. Pt 4 had a past medical history (PMH) of high blood pressure and kidney stones. Pt 4 was admitted to the hospital as an inpatient on 9/30/25 at 7:55 p.m. for a urinary tract infection, blood in the urine, kidney stones, and hydronephrosis (urine builds up in the kidney due to a blockage in the urinary tract). LCIA 1 indicated Pt 4 was moved to the Medical Surgical (MS- a hospital department that provides care for patients with diverse medical and surgical conditions,) Unit on 9/30/25 at 8 p.m. The EMR document titled “Patient Plan of Care - Additional Problems/Interventions” dated 10/1/25, had one CP initiated for “Ineffective Breathing Pattern (insufficient oxygen intake)” with interventions including open airway, normal vital signs, and optimal breath sounds. No other CPs were initiated for Pt 4’s primary diagnosis of kidney stones and UTI or presenting problems like urinary retention. The LCIA stated nursing staff should have created a CP to address his issues like infection. During an interview on 10/7/25 at 11:11 a.m. with Nurse Manager (NM) 1, NM 1 stated LN’s were expected to create individualized CPs. LN’s should plan their shifts based on patient needs, with the care plan serving as the roadmap. Each CP must be tailored to the unique needs of the patient, involving the patient and their caregiver in setting interventions and goals. During an interview on 10/8/25 at 11:15 a.m., the Chief Nursing Officer (CNO) stated that nursing staff should tailor the CP and interventions to each patient’s condition. During a review of the hospital’s policy and procedure (P&P) titled, “Admission Data Base & Care Plan Management” dated 8/24, indicated, “ ...The Registered Nurse (RN) is responsible for delegating the collection of data and in collaboration with other members of the health care team and developing an individualized plan of care for each patient based on patient problems and needs and using nursing diagnoses and assessments ...” During a review of the professional reference titled, “Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes”, dated 10/24/19, the professional reference indicated, “ ...Personalized care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care. ... Often used with medically complex patients, personalized care plans have been effective in improving outcomes when integrated into routine care8 and are now mandated by the Centers for Medicare and Medicaid Services for chronic care management reimbursement ...” 2. During an interview on 9/30/25 at 10:26, with Pt 10. in Pt 10’s room, Pt 10 stated he was in the hospital for a rectal abscess (a painful, pus-filled pocket of infection near the anus [an opening where solid waste leaves the body] or rectum [the final, straight portion of the large intestine that connects to the anus], often caused by blocked glands that become infected). Pt 10 explained the rectal abscess was surgically removed and he was on antibiotics. During a review of Pt 10’s clinical document titled, “PATIENT INFORMATION,” indicated, Pt 10 was admitted to the facility on 9/25/25, for a gluteal abscess (collection of pus, causing a hard lump, in the buttocks area). During a concurrent interview and record review on 10/6/25 11:53 a.m., with licensed clinical informatics analyst (LCIA) 1 of Pt 10’s clinical record, Pt 10’s clinical record did not indicate a CP had been developed for Pt 10’s surgical wound care. LCIA 1 explained there should have been a CP in place in order for staff to meet Pt 10’s needs. LCIA further explained the importance of the CP was to ensure staff were addressing Pt 10’s wound and issues that could affect healing. During a review of the hospital’s P&P titled, “Admission Data Base & Care Plan Management” dated 8/24, indicated, “ ... The Registered Nurse (RN) is responsible for delegating the collection of data and in collaboration with other members of the health care team and developing an individualized plan of care for each patient based on patient problems and needs and using nursing diagnoses and assessments ... Review the plan of care every shift, as needed, and update or complete interventions as indicated ...” 3. During a concurrent interview and record review on 10/7/25 at 12 p.m., with LCIA 1 of Pt 17’s clinical record, Pt 17’s clinical record did not indicate a CP for Pt 17’s primary diagnosis of a Urinary Tract Infection (UTI - an infection in any part of the urinary system, which includes the kidneys [bean-shaped organs located on either side of the spine], ureters [thin, muscular tubes that carry urine from the kidneys to the bladder], bladder [a hollow, muscular organ located in the lower abdomen that stores urine until it is expelled from the body through the urethra], and urethra [a tube-like structure that carries urine from the bladder to the outside of the body]). LCIA confirmed there was not a CP for Pt 17’s UTI. During a record review of Patient 17’s clinical document titled, “Admission History & Physical,” (H&P), the H&P indicated, “Reason(s) for Continued Hospti [hospital stay]: ... UTI requiring ... antibiotics ...” During a concurrent interview and record review on 10/7/25 at 3:50 p.m., with Nurse Manager (NM) 1, of Pt 17’s clinical record, NM 1 confirmed there was not a CP initiated for Pt 17’s primary diagnosis of UTI. NM 1 explained the importance of having CP in place was the CP’s drive the care of the patient and initiate treatment goals. NM 1 further explained the risk of not having a CP in place for a UTI was a risk of complications of infection such as sepsis [a life-threatening condition that occurs when the body’s immune system overreacts to an infection]. During a review of the hospital’s P&P titled, “Admission Data Base & Care Plan Management” dated 8/24, indicated, “ ... The Registered Nurse (RN) is responsible for delegating the collection of data and in collaboration with other members of the health care team and developing an individualized plan of care for each patient based on patient problems and needs and using nursing diagnoses and assessments ... Review the plan of care every shift, as needed, and update or complete interventions as indicated ...” 4. During a record review of Patient 19’s clinical document titled, “Admission History & Physical,” (H&P), dated 9/30/25, the H&P indicated, “...56 year old with a previous medical history of mentally delay and mitochondrial disorder (caused by defects in mitochondria, which are energy factories found inside almost all the cells in the body and can affect one part of the body or many parts, including the brain, muscles, kidneys, heart, eyes, and ears) brought in by EMS (Emergency Medical Services/Ambulance) from home to ED with a chief complaint of foul vaginal discharge and odor that began this morning... Per nurse note, patient is bedbound d/t (due to) progressing mitochondrial disorder... Disposition -Admit to ICU (Intensive Care Unit) for ongoing management of septic shock (a life-threatening condition that occurs when the body’s immune system overreacts to an infection, leading to severe damage to organs and systems) requiring vasopressors (a drug that constricts blood vessels, increasing blood pressure when it is dangerously low)...” During a concurrent interview and record review on 10/7/25 at 2:42 p.m., with Clinical Nurse Educator (CNE) of Pt 19’s clinical record, CNE stated Pt 19’s clinical record did not indicate a CP for skin integrity had been initiated until 10/7/25 at 10:52 a.m. according to Pt 19’s “Care Activity - Plan of Care” report. CNE stated after review of Pt 19’s clinical record, a CP should have been initiated after the LN identified Pt 19 was at risk for development of skin injury [on 9/30/25] per hospital P&P. During a concurrent interview and record review on 10/7/25 at 2:45 p.m., with CNE, of Pt 19’s EMR, the “Admission Braden Scale Score (BSS- tool used to assess a patient’s risk for developing pressure ulcers; a total BSS ranges from 6 to 23, with lower scores indicating higher susceptibility to pressure ulcers) indicated Pt 19’s BSS was “13... with the RN documenting “WNL (within normal/defined limits- no skin integrity concerns)” on admission to the ICU on 9/30/25 at 5:54 p.m. On 9/30/25 at 8:00 p.m., night shift RN documented Pt 19’s BSS was 13; indicating Pt 19 was at “Moderate Risk (score of 13 or 14 = Moderate Risk with the LN documenting “...Right medial thigh redness” and skin was “not WNL.” On 10/1/25 day shift RN documented “Right medial thigh redness” and added new skin concern of “medial buttocks skin tear.” On 10/2/25 Pt 19 was seen by the hospital Wound Nurse (WN) per hospital P&P. On 10/7/25 nursing staff added skin integrity to Pt 19’s plan of care. CNE stated the staff missed an opportunity to develop a skin integrity CP after identifying Pt 19 was at risk for skin integrity impairment on 9/30/25. CNE stated pt 19’s clinical record showed nursing assessments were done but not acted upon. CNE stated LN’s should have initiated a pressure injury prevention and treatment CP that included the interventions to address Pt 19’s wound and skin care at time of assessed risk. During an interview on 10/8/25 at 11:15 a.m., with the Chief Nursing Officer (CNO) stated that nursing staff should tailor the CP and interventions to each patient’s condition. During a review of Pt 19’s “Nurse Notes (NN)” dated 10/2/25 at 11:40 p.m., the NN indicated “...patient was seen today for wound care evaluation due to new admission. Explained to the patient that a skin assessment is standard for all new admissions. Skin assessment completed. A small skin tear was noted to the left buttock, a lesion like with scabbing to the right thigh, and a nephrostomy drain to the left lateral side of the body. Pictures were taken and will be placed in pts (patient’s) chart. Interventions, placed zinc barrier cream to the buttocks and placed a border foam dressing to the skin tear for protection. No other findings were noted... Will continue with plan of care.” During a review of the hospital “Wound Care Management and Prevention and Prevention” P&P dated 2/25, the P&P indicated “...PURPOSE: To provide an organization-wide policy and procedure for the prevention, care and treatment of patients with wounds, promoting positive outcomes for patients and cost-effective care by the facility. The organization strives to prevent skin break down in all settings.... POLICY:... 4. Skin will be assessed for existing wounds, pressure injuries, and or moisture associated dermatitis (MAD) on admission, each shift and upon receiving the patient when they are transferred to another patient care area. Admissions assessments will be conducted by two members of the nursing staff (Ex. RN/ RN or RN/ CS) to help ensure accuracy within 8 hours of admission, within 4 hours of receiving transfer from other patient care areas. Both nurses inspect and assess each patient and then cosign electronic medical records... 6. assessment is within 24 hours of admission to inpatient care. Document all newly discovered wounds after the 24-hour admission window. A. After initial assessment, the RN will create wound documentation in (brand name) documentation application for each wound and/or pressure injury. B. Skin breakdown, wounds, and MAD will be assessed during dressing changes and documented. C. Subsequent RN/LVN assessments or interventions will be charted in the proper area. 7. The RN will initiate a care plan for pressure injury when Braden Score is 16 or less, or when an actual wound or pressure injury is identified upon assessment. 8. Plan of care should be individualized to the patients’ needs with specific interventions and outcomes... PROCEDURE: 1. SKIN / RISK ASSESSMENT A comprehensive assessment appropriate to the setting is performed by Nursing at admission and as indicated throughout the episode of care including Integumentary assessments. All patients admitted to in-patient or observation status will receive a complete nursing assessment, including integumentary (skin) evaluation, performed by qualified nursing personnel. This ensures early identification of existing wounds and supports continuity and quality of care. Assessments include risk of breakdown, evaluation of skin, and of existing wounds including: 1. Visual inspection of the skin. 2. Braden Scale- Inpatient: Completed on admission/observation, daily, and as indicated by patient status change throughout the admission. a. Score ? 16 without wound - implement Early Intervention and Prevention Measures - Patient is high risk for skin breakdown. b. Score ? 16 with a wound - implement Early Intervention and Prevention Measures and document skin disruptions. Notify MD of wound(s) if not already aware and obtain orders. Clarify etiology if possible...3. Evaluation of contributing factors such as nutrition, mobility, co-morbidities, medications, cognition, continence of bowel and bladder etc. 4. Determine if wound is pressure related, non-pressure related, skin tear, or extremity wound. 5. If Early Intervention and Prevention Measures are required, the Licensed Clinician implements them immediately appropriate to the setting...a. Inpatient- Ealy intervention measures are incorporated into the Nursing Care Plan and implemented... 2. EARLY INTERVENTION AND PREVENTION MEASURES Preventative measures will be implemented as soon as the patient is identified as at risk. Measures below are written for implementation in the inpatient setting. 1. Turning and Repositioning...2. Application of pressure reduction devices...3. Skin care and reduction of excess moisture...4. Nutritional status...5. Laboratory Values... 6. Vitamin and mineral supplementation... 7. Pain- Uncontrolled pain inhibits wound healing and must be addressed...” During a review of the hospital’s P&P titled, “Admission Data Base & Care Plan Management” dated 8/24, indicated, “ ... The Registered Nurse (RN) is responsible for delegating the collection of data and in collaboration with other members of the health care team and developing an individualized plan of care for each patient based on patient problems and needs and using nursing diagnoses and assessments ... Review the plan of care every shift, as needed, and update or complete interventions as indicated ...” During a review of a professional reference titled, “Integrating Personalized Care Planning into Primary Care (IPC)”, dated 10/24/19, electronically retrieved on 10/17/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC7018887/#:~:text=Personalized%20care%20planning%2C%20a%20process%20to%20collaboratively,increasingly%20important%20to%20providing%20high%2Dquality%2C%20patient%2Dcentered%20care.&text=Often%20used%20with%20medically%20complex%20patients%2C%20personalized,Medicaid%20Services%20for%20chronic%20care%20management%20reimbursement. the “IPC” indicated, “ ... Personalized [individualized] care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care ... Often used with medically complex patients, personalized care plans have been effective in improving outcomes when integrated into the routine care and are now mandated by the Centers for Medicare and Medicaid Services for chronic care management reimbursement ...”.”

“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: 33126 47205 Based on interview, clinical record review, and hospital policy review, the hospital failed to ensure licensed nurses (LNs) followed policies and procedures (P&P) when: 1. LNs failed to ensure three out of 21 Patients (Pt 1, Pt 2, and Pt 7) had their pain levels assessed, addressed, or reassessed in accordance with the hospital P&Ps titled, “Pain Assessment and Reassessment Policy”, and “Care of the Patient in the Emergency Department: Triage [quick look to determine order patients are seen] to Discharge”. This failure caused patients to receive inadequate pain management and had the potential for LNs to not recognize a change in condition timely. 2. Emergency Department (ED) nurses did not document a physical assessment for two of five sampled patients (Pt 1 and Pt 2), and Medical Surgical (MS) nurses did not complete physical assessments within one hour of admission to the MS Unit for two of four sampled patients (Pt 4 and Pt 9), in accordance with the hospital’s P&Ps titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, and “Assessments / Reassessments”. These failures had the potential to cause patient harm by delayed or missed diagnoses, worsening health, unnecessary or more intensive treatments, and inadequate pain management. 3. ED nurses failed to assess the vital signs (VS- blood pressure, breathing rate, heart rate, temperature, and pain score) 30 minutes before the discharge (sending home) of two out of six sampled patients (Pt 2, and Pt 8), in accordance with the hospital’s P&P titled, “Identifying and Evaluation of the High Alert ED Patient at Discharge”. This failure had the potential to result in missed diagnoses, delayed treatment, and serious outcomes like readmission. 4. ED nurses failed to provide discharge instructions, and education reflecting their primary diagnosis, chief complaint, follow up care, care at home, discharge medications, prescriptions and referrals, for one of five sampled ED patients (Pt 1) in accordance with the hospital’s P&P titled, “Identifying and Evaluation of the High Alert ED Patient at Discharge”, and “Care of the patient in the Emergency Department: Triage to Discharge”. This failure had the potential to delay coordinated healthcare among various providers, increase the risk of readmission, and possibly lead to avoidable negative health outcomes. 5. The hospital failed to ensure that nursing staff followed physician orders and appropriately responded to significant clinical changes for one of 13 sampled patients (Pt 9) when MS nurses did not obtain, and document daily weights and the hospital did not follow the P&P titled, “Physician Order”, and “Assessments / Reassessments.” These failures resulted in missing actual weight records for five of the six days of admission. Additionally, MS nurses failed to recognize and report a documented weight loss of 9.8 pounds for Pt 9 between 9/20/25 and 9/21/25, which represents a significant change in condition requiring physician notification and clinical intervention. 6. The facility failed to follow the hospital P&P titled, “Downtime procedures for [electronic medical record system]”, “Identifying and Evaluation of the High Alert ED Patient at Discharge”, and “Abbreviations in the Medical Record” when ED nursing staff did not documented accurately and completely during electronic medical record (EMR) downtime for two of three sampled patients (Pt 1, and Pt 2) and unapproved abbreviations were used for one of 21 patients (Pt 9). This failure had the potential to cause poor patient outcomes due to a lack of communication, medical errors, and delayed care. 7. Licensed Nurses (LNs) did not adhere to restraint documentation requirements per hospital P&P titled “Restraints for Management of Violent and Non-Violent Behavior” dated 2/25 for one of 3 patients sampled, Patient (Pt) 20. This failure resulted in Pt 20’s needs while restrained to not be met and a Registered Nurse (RN) assessment not to have been documented in Pt 20’s EMR and had to potential to cause injury or harm to Pt 20. Findings: 1. During a concurrent observation and interview on 9/30/25 at 10:05 a.m. with Pt 7 in the ED hallway, Pt 7 was observed lying on his back on a gurney. He stated he went to the ED by ambulance after being attacked by two dogs. He had bandages on his arm and leg, but the wound on his back was uncovered. The wound on his back was a red half circle approximately 3.5 to 4 inches in length. Pt 7 stated the bites hurt a lot, and he was given some pain medicine in the ambulance, but he had not received any pain medicine in the ED yet. During a concurrent interview and record review on 10/1/25 at 4:20 p.m. with Licensed Clinical Informatics Analyst (LCIA 1), Pt 7’s EMR was opened for review. The “Patient Summary Report (PSD- a summary of all of a patients care during an ED visit)”, and “ED Assessment (physician’s assessment in the ED)” dated 9/30/25, were reviewed. The “ED Assessment” indicated, Pt 7 was brought in by ambulance with complaint of dog bites. Pt 7 was administered 1 gram (g- a unit of measurement) of acetaminophen (a mild pain medication) in the ambulance through the intravenous (IV- a medical procedure where a needle or tube is used to deliver fluids, medications, or nutrients directly into a person’s vein) line. The “PSD” indicated, Pt 7 arrived in the ED on 9/30/25 at 8:47 a.m. Pt 7’s triage (the process of evaluating and prioritizing patients to determine the urgency of their medical needs) assessment from 9/30/25 at 9:46 a.m. indicated, a reported numerical pain score of 7 out of 10 (severe). On 9/30/25 at 9:54 a.m. Pt 7’s ED physical assessment indicated a reported pain score of 7 out of 10. Pt 7’s EMR did not have any nursing notes reporting Pt 7’s pain level to the physician or requesting pain medications. Pt 7 was discharged from the ED on 9/30/25 at 3:20 p.m. The “PSD” indicated Pt 7 had no pain medications administered during the ED visit. LCIA 1 stated Pt 7’s pain should have been addressed. LCIA 1 stated Pt 7 was in pain and ED nurses should have documented reporting the pain to the physician, to get an order for medication or documented a pain medication refusal from Pt 7. During a phone interview on 10/2/25 at 6:59 p.m. ., with Pt 1 and Pt 2, Pt 1 stated she and her husband (Pt 2) arrived at the ED on 7/1/25 after a car accident. A semi-truck hit their stopped car, causing them to hit the car in front of them. Both airbags were deployed. Pt 1 experienced chest pain, difficulty breathing, and a cracking sound in her chest. Pt 2 had chest pain, difficulty breathing, neck pain, and hand injury. The patients arrived in the same ambulance around 4 p.m., and Pt 1 noted the ED was “very busy”. The patients were placed together in the same room. Pt 1 and Pt 2 reported 10 out of 10 pain (worst possible) and chest spasms (sharp pain that comes and goes) to the triage nurse. The nurse informed the patients no pain medication could be given until their Computed Tomography (CT - medical imaging procedure using X-Rays and a computer to create detailed pictures inside the body) scans were completed, and the physician received the results. Pt 1 repeatedly requested pain medication and eventually refused to complete the CT scan until she received it. Pt 1 stated the CT scans were completed by 9 p.m. but the results were not received until after midnight. Pt 1 stated, the CT scan completed at the hospital did not show a broken bone for her, but her primary physician ordered another scan when she returned home less than a week later, and the scan indicated a broken breastbone. Pt 2’s CT scan showed a broken breastbone. Pt 1 stated, nursing staff did not address continued reports of severe pain, and Pt 1 waited seven hours between doses. Pt 2 stated, he also reported severe pain multiple times and received pain medication first around 9 p.m. and then again eight hours later. Pt 1 described the experience as stressful and traumatic. During a concurrent interview and record review on 10/6/25 at 2:52 p.m. with the Clinical Nurse Educator (CNE), Pt 2’s handwritten paper medical record documents from the ED visit on 7/1/25 to 7/2/25 were reviewed. The “Registration Record” dated 7/1/25 at 4:03 p.m., indicated Pt 2 was a 79-year-old brought into the ED by ambulance (BIBA) after a car accident. The “RN’s History & Progress Form Emergency Department (RNHP- Nurse’s exams and documentation of care for ED visit) Triage” dated 7/1/25 at 4:49 p.m., indicated Pt 2 was in a car accident and was hit from behind. Pt 2 complained of soreness to the back of the neck, shortness of breath, and chest pain, rated as 10 out of 10 (worst possible). Pt 2 had a past medical history (PMH) of asthma (chronic lung condition where airways become swollen making it hard to breathe), Post Traumatic Stress Disorder (PTSD- an anxiety problem after seeing or experiencing a traumatic event), and a knee replacement. The document titled, “RNHP Triage” did not have an Emergency Severity Index (ESI-5-level system used in emergency rooms to quickly categorize patients by how urgent their condition) number assigned but should have had an ESI of two (High-Risk) based on clinical presentation. The “Emergency Department Chart -Provider (EDCP- Physician’s exam and care during ED visit)” dated 7/1/25 to 7/2/25 indicated Pt 2’s history of present illness (HPI) as “having problems breathing, said chest hurts because of seat belt.” The HPI indicated Pt 2’s car was hit from behind and the airbags came out. The “EDCP” indicated a left-hand laceration (cut) measuring 1.5 centimeters (cm-a unit of measurement) wide and 3 cm long, and chest wall tenderness upon examination. The “Pain Reassessment”, undated, indicated at 9:11 p.m. and 9:50 p.m. (undated entry), Pt 2 reported 10 out of 10 aching midsternal (center of the breastbone) pain. Pt 2 reported 9 out of 10 (severe) midsternal pain at 10:20 p.m., and at 4:45 a.m. The “E.R. Medication Administration Record (MAR)”, undated, indicated nursing staff administered 4 milligrams morphine (a strong pain medication) through an IV at 9:55 p.m. (undated entry) and on 7/2/25 4:56 a.m. The medical record indicated no pain assessments were completed from 10:20 p.m. to 4:45 a.m., six hours and 25 minutes later. The “Radiology Report” dated 7/1/25 indicated Pt 2 had a CT of the chest, stomach, and pelvis (bowl shaped structure at the lower end of the trunk that connects the spine to the legs), showing a nondisplaced obliquely oriented distal sternal body fracture (a break at an angle at the lower part of the breastbone). The “E.D. Additional Narrative Nurse’s Notes (EDNN)”, undated Pt 2 requested pain medication at 9 p.m. for breastbone pain. Nurses did not document any other communication with the physician relating to pain or requesting pain medications. The CNE stated nursing staff should have treated or notified the physician of Pt 2’s continued severe pain reports and should document all patient care in the medical record. The “E.D. Discharge Nurse’s Notes”, undated”, indicated, at 10:20 a.m., a nurse discharged Pt 2 from the ED by taxi to a hotel. Pt 2 was in the ED for a total of 17 hours and 31 minutes, received pain medication twice, and reported severe pain five times. During a concurrent interview and record review on 10/6/25 at 3:57 p.m. with the CNE, Pt 1’s handwritten paper medical record dated 7/1/25 to 7/2/25 was reviewed. The “Registration Record”, dated 7/1/25 at 4:03 p.m., indicated Pt 1 was a 77-year-old brought in after a car accident. The “RNHP Triage”, dated 7/1/25 at 4:49 p.m., showed a complaint of pain to the middle of the chest, the right side of the ribs, and pain in the back, rated as 10 out of 10. Pt 1 was assigned an ESI of three. The “RNHP” triage, dated 7/1/25, noted a PMH of tachycardia-bradycardia (heart rhythm disorder where the heart rate alternates between being too fast (tachycardia) and too slow (bradycardia) syndrome, and reactive hypoglycemia (blood sugar drops after eating). The “EDCP” dated 7/1/25 to 7/2/25 detailed HPI of a truck hitting Pt 1’s car from behind, with airbags deployed, causing chest pain from the seat belt. The “EDCP” indicated chest wall tenderness upon examination. The “Pain Reassessment” and “MAR” “undated”, indicated Pt 1 reported pain levels of 10 out of 10 at 7:46 p.m., and nurses administered 4 mg morphine (a strong pain medication) by IV. Nurses documented a reassessment pain level of seven out of 10 at 8:46 p.m., with no additional pain medications given. The CNE stated nurses should have informed the physician that Pt 1 was still in pain after medication administration. Pt 1 reported a pain level of 10 out of 10 at 1:50 a.m. (no date), and received 4 mg morphine by IV, and a lidocaine patch (numbing medication) at 1:58 a.m. Nurses reassessed Pt 1’s pain at 2:50 a.m. as two (mild) out of 10. No documentation indicated a pain assessment from 2:50 a.m. to 8 a.m., 5 hours later. The “Radiology Report”, dated 7/1/25, showed Pt 1 had a CT scan of the chest, stomach, and pelvis, indicating no broken bones. The “EDNN”, with only one entry dated 7/1/25, indicated Pt 1 requested pain medication at 7:30 p.m. (no date) and at 1:35 a.m. (no date). Pt 1’s nurses did not document any other communication with the physician regarding pain or requesting pain medications for Pt 1. The CNE stated nursing staff should have treated or notified the physician of Pt 1’s continued pain. The CNE emphasized that nursing staff should document all patient care in the medical record. The “E.D. Discharge Nurse’s Notes”, “undated”, indicated, at 10:20 a.m., a nurse discharged Pt 1 from the ED by taxi to a hotel. Pt 1 spent 17 hours and 31 minutes in the ED, receiving IV pain medication twice and a numbing patch once, but documentation showed reports of severe pain four times. During a review of Pt 1’s CT scan document from hospital B, dated 7/4/25, the CT scan document indicated, the hospital completed a CT scan of Pt 1’s chest, stomach, and pelvis with contrast (a substance (like a dye) given to a patient to make certain internal body structures and abnormalities more visible during an imaging test) and the physician’s impression was “fracture deformity of the distal sternal body may be acute [a sudden break in the lower breastbone often caused by significant chest trauma like a car accident]”. During a review of Pt 1’s CT scan from hospital B on 7/4/25, it was noted that a CT scan of the chest, stomach, and pelvis with contrast revealed a possible acute fracture deformity of the distal sternal body, likely due to significant chest trauma. During an interview on 10/7/25 at 3:35 p.m. with Nurse Manager (NM) 3, NM 3 stated pain should be assessed with VS, and should be reassessed after medication administration. NM 3 stated pain should be treated or at least advise the physician when the patient was in pain. NM 3 stated pain control helped with anxiety and patient satisfaction. During an interview on 10/8/25 at 11:20 a.m., with the Chief Nursing Officer (CNO), the CNO stated nurses should assess pain with vital signs as the fifth vital sign. The CNO emphasized that pain is subjective and should be addressed based on the patient’s reported pain level. Patients had a right to pain control, and it was a nurse’s duty to advocate for their patients. The physician should have been notified when a patient was in pain and requested pain medication. During a review of the hospital’s P&P titled, “Pain Assessment and Reassessment Policy”, dated, 4/25 indicated, “ ... PURPOSE: To establish a standardized process for the assessment, documentation, management, and reassessment of pain in all patients receiving care in the acute care hospital. This policy ensures timely identification of pain, effective interventions, and ongoing monitoring to improve patient comfort and outcomes. ... Nursing Staff: to Perform pain assessments upon admission, with vital signs, at shift change, and: Before administering pain medications (pharmacologic [medications]). Within 60 minutes after pain intervention Document pain score, location, quality, duration, interventions, and reassessment. Notify providers of uncontrolled or worsening pain During a review of the hospital’s P&P titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, dated 02/25, indicated, “ ...All patients will have a nursing assessment completed by a Registered Nurse at least once or more during their ED stay based on their ESI level of care and as needed ... ESI Level 2 ... Acuity ...High risk situation, ...Reassessment ...Roomed Immediately and reassessed hourly or more if condition warrants it. ...ESI level 3 ... Reassessment every 2 hours or more if condition warrants it and on discharge ...”. During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional],” dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “ ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute [sudden onset] pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic [poisonous] to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological [mental or emotional state of a person] effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and institutional [facility] priority as a key driver of patient outcomes...” 2. During a concurrent observation and interview on 9/30/25 at 9:42 a.m. with Pt 4, in the Emergency Department (ED) lobby, Pt 4 was observed kneeling on the floor of the ED, with his head in his hands and his elbows on a chair, a wheelchair was near him. Pt 4 had tears coming from his eyes, he was grimacing and whimpering. Pt 4 stated he had just arrived in the ED lobby, and his family was at the registration window trying to get him registered to be seen. Pt 4 said he was having left side stomach pain, back pain, and chest pain. Pt 4 stated he had kidney stones in the past and they hurt a lot, but he was in the most pain he had ever experienced. During a concurrent interview and record review on 10/1/25 at 3 p.m. with LCIA 1, Pt 4’s electronic medical record (EMR) was reviewed. Pt 4’s EMR document titled “History and Physical (H&P- an assessment from physician including medical history and exam)”, dated 9/30/25, indicated, Pt 4 arrived in the ED on 9/30/25 at 9:44 a.m. with complaint of chest and stomach pain. Pt 4 reported a sudden onset of severe, sharp, stabbing pain in the chest that radiated into his back and down into his stomach. The pain was described as intense, unlike any pain he had experienced before, and was associated with sweating, clammy skin, and a general feeling of weakness. Pt 4 had a past medical history (PMH) of high blood pressure and kidney stones. Pt 4 was admitted to the hospital as an inpatient on 9/30/25 at 7:55 p.m. for a urinary tract infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract and multiply), blood in the urine, kidney stones, and hydronephrosis (urine builds up in the kidney due to a blockage in the urinary tract). LCIA 1 indicated Pt 4 was moved to the Medical Surgical (MS- a hospital department that provides care for patients with diverse medical and surgical conditions,) Unit on 9/30/25 at 8 p.m. The EMR document titled “Physical Assessment,” dated 10/1/25 at 11:53 a.m., indicated MS nursing staff completed Patient 4’s physical assessment 15 hours and 53 minutes after admission to the MS Unit. LCIA 1 stated nursing staff should complete a physical assessment as soon as possible after admission to the Unit. During a concurrent interview and record review on 10/3/25 at 12:03 p.m. with LCIA 2, Pt 9’s electronic medical record (EMR) was reviewed. The document titled, “H&P”, dated 9/15/25, indicated a 56-year-old patient arrived in the ED with a fever and altered mental status (AMS-change in a person’s awareness or thinking), weakness, confusion, and fever. Pt 9 was positive for UTI. The H&P indicated Pt 9 was admitted to the hospital as an inpatient on 9/15/25 at 1:12 a.m. for sepsis (a life threatening blood infection) caused by UTI. The document titled “Nurse Notes”, dated 9/15/25 at 4:16 a.m., indicated Pt 9 was moved to the inpatient MS Unit at 3 a.m. The document titled, “Physical Assessment”, dated 9/15/25 indicated MS nurses completed a head-to-toe physical assessment at 10 a.m., seven hours after admission to the MS Unit. The P&P titled “Assessments / Reassessments”, was reviewed, LCIA 2 validated physical assessments should be completed within one hour of admission to the MS Unit. LICA 2 stated nurses needed to assess the condition and stability of their patients upon arrival in the unit. During a concurrent interview and record review on 10/6/25 at 2:52 p.m. with the CNE, Pt 2’s handwritten paper medical record documents, from the ED visit on 7/1/25 to 7/2/25 were reviewed. The “RNHP Triage”, dated 7/1/25 indicated, a triage nursing assessment at 4:49 p.m. no ESI assigned. Pt 2’s document titled “EDNN”, undated at 7:30 p.m., nursing staff documented Pt 2 was alert, no nursing assessment documented. The CNE validated Pt 2’s medical record had no RN physical assessments, during the ED visit. The CNE stated ED nurses should assess and reassess patients based on acuity. The CNE stated all patients were supposed to receive a physical assessment by a Registered Nurse (RN), after the triage assessment. During a concurrent interview and record review on 10/6/25 at 3:57 p.m. with the CNE, Pt 1’s handwritten paper medical record documents, from the ED visit on 7/1/25 to 7/2/25 were reviewed. The “RNHP Triage”, dated 7/1/25 indicated, a triage nursing assessment at 4:46 p.m., with an ESI of 3. Pt 1’s document titled “EDNN”, 7/1/25 at 6:45 p.m., indicated nursing staff inserted an IV for blood work, no nursing assessment documented. The CNE validated Pt 1’s medical record had no RN physical nursing assessments, during the ED visit the CNE stated ED nurses should assess and reassess patients based on acuity. The CNE stated all patients were supposed to receive a physical assessment by a Registered Nurse (RN), after the triage assessment. During an interview on 10/7/25 at 11:20 a.m., with Nurse Manager (NM)1 she stated, nursing staff should perform a physical assessment within one hour of a patient’s arrival in the MS Unit. NM 1 emphasized that the assessment was crucial for determining the patient’s plan of care and establishing a baseline. During an interview on 10/8/25 at 11:25 a.m. with the CNO, the CNO stated the ED RN’s should assess, treat, and plan for the care of the ED patients. The expectation was for ED RN’s to perform physical assessments according to the policy. The CNO stated the expectation for MS nursing staff was for a physical assessment to be completed within one hour, and reassessments were expected to be completed once per shift or as needed, when there was a change in patient’s condition. During a review of the facility’s policy and procedure titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, dated 02/25, indicated, “ ... All patients will have a triage assessment completed by a Registered Nurse (RN), who has obtained triage certification, when presenting to the ED and assigned an ESI level of care at that time. 2. All patients will have an initial nursing assessment completed by an RN during their stay in the Emergency Department. Ongoing reassessment will be based on their ESI level and or a change in their condition or on discharge. Ongoing reassessment includes vital signs, physical assessment and evaluation of the treatments given to the patient. ... ESI Level 1 requires immediate lifesaving interventions. Roomed immediately and reassessed hourly or more if condition warrants it. ...Level 2 High risk situation, AMS [Altered Mental Status-confusion], severe pain or distress. Roomed Immediately and reassessed hourly or more if condition warrants it, severe pain or distress. ...Level 3 Less urgent, stable. Require treatment but will not cause harm if not treated immediately. Reassessment every 2 hours or more if condition warrants it and on discharge. ...Level 4 Non urgent. Requires treatment, but a delay of over several hours will not cause harm. Reassessment every 4 hours and on discharge. ...Level 5; Referred ...” During a review of the facility’s policy and procedure titled, “Assessments / Reassessments”, dated 8/24, indicated, ... Each patient who receives services will have an initial RN assessment that is to be documented in the Electronic Health Record (EHR) ... Assessment and reassessment by department ...Department/Discipline: Nursing-Medical Surgical: Initial Assessment: RN assessment is completed within one hour of admission and documented within 8 hours of the initial physical assessment Intervention and Admission Data Base Intervention in [name of hospital EMR] ...” During a review of the professional reference titled, “Nursing Admission Assessment and Examination,” dated 5/28/23, the professional reference indicated, “ ...The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual’s unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. ... Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered ...” 3. During a concurrent interview and record review on 10/6/25 at 2:13 p.m. with the CNE, Pt 8’s handwritten medical record documents, dated 7/1/25 to 7/3/25 were reviewed. The document titled, “Registration Record”, dated 7/1/25 at 2:56 p.m. indicated, Pt 8 arrived in the ED by ambulance for a 5150 hold (a temporary, involuntary 72-hour psychiatric hold for individuals posing a danger to themselves or others, allowing for evaluation and crisis intervention). The “RNHP” triage, dated 7/1/25 at 3:30 p.m. indicated, Pt 8 was placed on a 5150 hold for danger to self and danger to others, and Pt 8 refused triage VS. The document titled “EDCP”, dated 7/1/25 indicated Pt 8’s diagnosis was “psychiatric disturbance”. The document titled, “ED Discharge Nurse’s Notes”, dated 7/3/25 at 2 a.m. indicated Pt 8 was discharged to home with family in stable (not getting worse or improving significantly) condition. The document titled, “ED Provider Progress Record”, dated 7/2/25 at 11:45 p.m., indicated a Mental Health provider cleared Pt 8 for discharge home. The document titled, “EDNN”, dated 7/2/25 to 7/3/25, indicated Pt 8 had VS taken on 7/3/25 at 11:45 p.m. The CNE validated no other VS were taken after 7/2/25 at 11:45 p.m., and the physician discharged Pt 8 on 7/3/25 at 2 a.m. The CNE stated hospital policy was for staff to complete a set of VS 30 minutes prior to discharge, to ensure the VS were stable. During a concurrent interview and record review on 10/6/25 at 2:52 p.m. with the CNE, Pt 2’s handwritten paper medical record documents, from the ED visit on 7/1/25 to 7/2/25, were reviewed. The “EDNN”, undated, indicated Pt 2’s last set of VS were taken at 8 a.m. The document titled, “ED Discharge Nurses Notes”, undated, indicated Pt 2 was discharged to a hotel by taxi in “improved condition”, with a pain score of one to three (mild) at 10:40 a.m. The CNE stated the “EDNN” did not have a date on the form, but Pt 2 arrived in the ED on 7/1/25 at 4:49 p.m. and was discharged on 7/2/25 at 10:40 p.m. per physician note. The CNE stated hospital policy was for staff to complete a set of VS no more than 30 minutes before discharge, to ensure the VS were stable. During a review of the facility’s policy and procedure titled, “Identifying and Evaluation of the High Alert ED Patient at Discharge”, dated 02/25, indicated, “ ...High Alert patients for discharge from the ED can include but are not limited to: ...Clinically Complex (many medical issues, repeat ED visits and hospitalization). ...Physically violent or verbally abusive behavior displayed during admission. ...Discharge Vital signs must be completed within 30 minutes of discharge ...” During a review of the professional reference titled, “Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes”, dated 8/8/16, indicated, “ ...Vital sign instability on discharge is associated with increased risk-adjusted rates of 30-day mortality [death] and readmission. ...Discharge guidelines should include vital sign criteria for judging stability on discharge in order to improve disposition planning and post-discharge patient safety ...” 4. During a telephone interview on 10/2/25 at 7:30 p.m. with Pt 1, Pt 1 stated nursing staff did not provide appropriate discharge paperwork about her injury, follow-up care she would require, education, or any information to give to her primary physician. Pt 1 stated nursing staff made a copy of her husband’s (Pt 2) discharge paperwork and gave each of them the same discharge paperwork. Pt 1 stated her care, and treatment was different than her husband’s and she should have received her own discharge paperwork. During a concurrent interview and record review on 10/6/25 at 3:57 p.m. with the CNE, Pt 1’s handwritten paper medical record documents, from the ED visit on 7/1/25 to 7/2/25, were reviewed. The discharge document titled, “Emergency Department Aftercare Sheet (EDAS)”, undated, was left blank. The CNE stated the document should have included discharge instructions, follow-up information, and a patient and witness signature. The CNE stated the physician should have filled it out, and the nurse should have explained it to Pt 1 before they left the ED. The CNE stated discharge instructions were important because patients use them for their own care and to show their primary physician. During an interview on 10/8/25 at 11:21 a.m. with the CNO, the CNO stated nursing staff should provide discharge education, and the paper discharge documents should be given to the patient. The CNO stated the document helped patients or caregivers manage their health and prevents readmission for the same issues. During a review of the facility’s policy and procedure titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, dated 02/25, indicated, “ ...Teaching is performed by the RN with the patient/family/parents. It is important for health care providers to understand the health literacy [ability of individuals to obtain, process, and understand basic health information and services needed to make informed health decisions] of their patient. Patient’s understanding of education is critical. Patient education methods include discussion, printed material, and teach back methods. ... Patient will be provided a copy of discharge instruction that reflect principal diagnosis and/or chief complaint, follow up care, care at home, discharge medications / Rx [prescription] and referrals ....” During a review of the professional reference titled, “Empowering patients: simplifying discharge instructions”, dated 9/14/21, indicated, “ ...Patients who do not have enough information about their discharge plans have decreased treatment compliance, decreased patient safety, increased emergency department (ED) recidivism [return of previous illness], and poor satisfaction ...” 5. During a concurrent interview and record review on 10/3/25 at 12:03 p.m. with LCIA 2, Pt 9’s electronic medical record (EMR) was reviewed. The “Physician Order (PO)” dated 9/15/25 at 1:01 a.m. indicated Pt 9 needed daily weighing. The “Cumulative I&O [Intake and Output]” document, dated 9/15/25 to 9/21/25, showed an RN estimated Pt 9’s weight as 58 kilograms (kg- a unit of measurement- 127.6 pounds) on 9/15/25 without using a scale. Nursing staff did not weigh Pt 9 on 9/16/25, 9/17/25, or 9/18/25. On 9/19/25, Certified Nursing Assistant (CNA) staff recorded Pt 9’s weight as 62.3 kg (137 pounds) using a bed scale. The weight dropped to 57.8 kg (127.1 pounds) by 9/21/25, indicating a 9.7-pound loss. Pt 9’s EMR did not indicate the CNA reported the weight to the RN, or that the RN re-weighed, addressed, or reported the weight loss to the physician. Pt 9 was discharged on 9/21/25 at 2:17 p.m. LICA 2 stated staff should have weighed the patient daily. LCIA 2 stated the CNA should have reported the weight loss to the primary RN, and the RN should have assessed Pt 9 and informed the physician. During an interview on 10/7/25 at 11:25 a.m. with NM 1, NM 1 stated the CNA should document accurate information, and was expected to verify information if there was a large discrepancy. The CNA was supposed to report any fluctuations in weight to the RN. The primary RN was responsible for the patient, and if anything in the documentation appeared abnormal follow up with the patient right away. NM 1 stated someone should have addressed Pt 9’s weight loss, and if the data was accurate, the physician should have been notified prior to discharge. During an interview on 10/8/25 at 10:44 a.m. with Registered Dietician (RD) 1, RD 1 stated, the expectation was for the dieticians to get a notice when patients had a drop in weight, something in the medical record system requesting a consultation or a phone call. RD 1 stated the dietician department had not received many notices relating to patient weight loss. RD 1 stated nursing staff should recognize that a drop in weight was a reason to assess a patient and contact the physician. RD1 stated the expectation was for staff to obtain the patient’s weight by scale and not just a reported weight. RD 1 stated weight loss could negatively affect healing. During an interview on 10/8/25 at 11:28 a.m. with the CNO, the CNO stated nursing staff should validate patient’s weight when documentation indicated weight loss. The CNO stated the expectation was to report weight loss to the physician. During a review of the facility’s policy and procedure titled, “Physician Order”, dated 02/25, indicated, “ ... A physician order is a directive given by a licensed physician or other authorized healthcare provider that instructs clinical staff on how to manage and provide care to a patient. This includes diagnostics, tests, treatments, medications, procedures, and other healthcare interventions that are necessary for patient care. ...Nursing and clinical staff: Responsible for confirming orders, executing, and documenting orders as per established protocols ...” During a review of the facility’s policy and procedure titled, “Assessments / Reassessments”, dated 02/25, indicated, “ ...It is the responsibility of the RN to notify the physician when there is a change in the patient’s condition ...” Review of Registered Nursing.org Professional Reference titled, “Does a Nurse Always Have to follow a Doctor’s Orders?” dated 1/30/23, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, “ ...nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern (I.E., medication not indicated for patient and/or task conflicts with facility policy/protocol) or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed “neglect.” During a review of a professional reference titled, “Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study,” dated 2/16/23, the professional article indicated, “ ... Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans, such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections ... Documenting routine practices is essential for the continuity of patient care, ... communication among healthcare professionals and better patient diagnoses and treatments ... it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely ... Poor documentation practice affects patient management, continuity of patient care and medicolegal issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality. It leads to adverse patient outcomes, medication errors and patient deaths. Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices ...”. 6. During a concurrent interview and record review on 10/6/25 at 2:52 p.m. with the CNE, Pt 2’s handwritten paper medical record documents, from ED visit of 7/1/25 to 7/2/25 were reviewed. The CNE validated Pt 2’s downtime documentation was lacking important information to ensure accurate medical records. The “EDNN” were largely undated, including VS, Pain Assessments, medication administration, and discharge nursing notes. The “ED Discharge Nurse’s Note, undated, indicated Pt 2 had an IV removed, but no documentation of the insertion, or removal assessment was in the medical record. The CNE stated all patient care should be documented in the medical record. The CNE stated all documentation in the medical record should be dated, timed and initialed, to know when communication, interventions, and assessments were completed. During a concurrent interview and record review on 10/6/25 at 3:57 p.m. with the CNE, Pt 1’s handwritten paper medical record documents, from the ED visit of 7/1/25 to 7/2/25 were reviewed. The “EDNN” were largely undated, including VS, Pain Assessments, medication administration, and discharge nursing notes. The “ED Discharge Nurse’s Note”, undated, indicated Pt 1 had an IV removed, but no documentation of a removal assessment was in the medical record. The CNE stated all patient care should be documented in the medical record. The CNE stated documentation in the medical record should be dated, timed and initialed, to know when communication, interventions, and assessments were completed. The discharge document titled, “Emergency Department Aftercare Sheet (EDAS)”, undated, was left blank. The document should have included discharge instructions, follow-up info, and a patient and witness signature. The CNE stated the physician should have filled it out, and the nurse should have explained it to Pt 1 before they left the ED. The CNE stated discharge instructions were important because patients use them for their own care and to show their primary physician. During a concurrent interview and record review on 10/6/25 at 10:15 a.m. with the CNE, Pt 9’s EMR was opened for review. The “Patient Summary” notes, dated 9/14/25 at 7:20 p.m. indicated Pt 9 was BIBA “restless and attempting to get “oob”. When asked what “oob” meant, the CNE stated, “I guess oob is Out of Bed”. The CNE stated “oob” was not an approved abbreviation. The CNE stated nurses were expected to write out the entire word and only use approved abbreviations. The CNE stated the approved abbreviations list was located on the hospital’s intranet, and nursing staff were educated not to use abbreviations during the onboarding (introducing a new employee to the hospital procedures) process. During a review of the hospital’s P&P titled, “Downtime procedures for [electronic medical record system]”, dated 02/25, indicated, “ ...All documents must be signed and dated with time ...” During a review of the hospital’s P&P titled, “Abbreviations in the Medical Record”, dated 9/24, indicated, “ ... To ensure only approved abbreviations are used in the medical record ...”. The abbreviation OOB (out of bed) was not in the approved abbreviation list. During a review of the hospital’s P&P titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, dated 02/25, indicated, “ ...Document assessment and interventions in the ED nursing documentation area for assessment/interventions. ...Document/update the treatment plans, as necessary. ... Document any referral services required to promote quality patient care ...” During a review of the professional reference titled, “Medical Record Documentation: Time is of the Essence” dated 3/23/25, the professional reference indicated, “ ...According to Medicare, “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record” ... Good documentation practices are vital and include: (1) whether it is a late or delayed entry; (2) the date and time of the note; (3) the date and time of service; (4) the type and method of service; (5) details of the encounter; and (6) any instructions given to the patient ...” During a review of the professional reference titled, “Inappropriate Medical Abbreviations”, dated 5/22/23, the professional reference indicated, “ ... To prevent any misunderstanding and jeopardize patient safety, the Joint Commission now requires healthcare institutions to develop a list of approved and not approved medical abbreviations. In addition, there should be a system or an audit process to ensure that there is compliance. The healthcare institution must ensure that the medical abbreviation in the approved list is also not on the Do not use a list or vice versa. Further, if a medical abbreviation is permitted, then it can have only one universal meaning. For example, DOA can mean Date of Admission or Dead on Arrival. The Joint Commission also recommends that healthcare institutions not use abbreviations on any patient-related documents. It is important to ensure that the patient and the family can understand the information provided to them without having to guess. Often patients have difficulty understanding discharge instructions, which can affect their ability to look after themselves or follow instructions ...” 7. During a concurrent interview and record review on 10/7/25 at 4:18 p.m. with Clinical Nurse Educator (CNE) of Pt 20’s EMR, the H&P dated 9/9/25 indicated, “...22 year old...history of uncontrolled type 1 diabetes mellitus (a chronic autoimmune disease where the body’s immune system mistakenly attacks and destroys the beta cells in the pancreas. These beta cells are responsible for producing insulin, a hormone that regulates blood sugar levels), methamphetamine (illicit drug) use disorder, frequent admissions at “general acute care hospital (GACH)” for DKA (Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that occurs when the body does not have enough insulin to use glucose (sugar) for energy) septic shock (a life-threatening condition that occurs when a severe infection leads to dangerously low blood pressure and organ dysfunction), respiratory failure. Pt was found down in the street and brought in by EMS (Emergency Medical Services/Ambulance) with altered mental status...Upon arrival to the Emergency Department (ED) patient is acutely ill-appearing, moaning, agitated...Plan Reason(s) for Continued Hospti: [hospitalization]...Management of DKA...Face to Face Eval Restraints Time Order Expires 2159...” CNE stated a review of the nursing documentation in Pt 20’s clinical record indicated an order for Non-Violent restraints to Pt 20’s wrists was ordered at 5:57 p.m. on 9/29/25. CNE stated nursing notes in Pt 20’s clinical record indicated the soft wrist restraints were applied on 9/29/25 at 5:57 p.m., and last reassessed in the ED at 6:53 p.m. CNE stated next nursing assessment of Pt 20’s bilateral soft wrist restraints was done in the ICU at 11:00 p.m. CNE stated Pt 20 went to CT (DEFINE) at 9:59 p.m. and arrived to Intensive Care Unit (ICU) at 11:00 p.m. CNE stated, there is no nursing documentation of nursing restraint reassessment between 6:53 p.m., until next documented assessment at 11:00 p.m. which is approximately 4 hours. CNE stated hospital policy requires a nursing restraint assessment every 2 hours. Copies of nursing notes and provider orders for restraints requested. During a review of Pt 20’s “Restraints: Adult/Violent/OBV Q1H” report dated 9/29/25 the report indicated “...Start Time...17:58 (5:58 p.m.)...Restraint Order Status: Initial Order...New Order Must be Obtained every 4 Hours!...Behavior requiring restraint: Interference w/Treatments...Reason for Restraints; Stop remove tubes/lines...Method of Restraint: Soft Wrist/Ankle...Location of Restraint 4-point (both legs and arms)...” Requested provider orders for all restraints was not provided. During an interview on 10/8/25 at 11:30 a.m., with the CNO, the CNO stated it was her expectation that RN’s followed hospital policy and documented in the patient record. During a review of hospital P&P titled “Restraints for Management of Violent and Non-Violent Behavior” dated 2/25, the hospital P&P indicated “...PROCEDURE: Restraint for Management of Non-Violent Behavior: 9. The Registered Nurse will assess the patient at application of the restraint and at least every 2 hours thereafter. Documentation of the restraint will be completed on the “Non-Violent (medical) Restraint Intervention” by completing the following sections: a. Date and Time of Restraint Application b. Alternatives used to modify behavior (check all that were attempted and found to be ineffective prior to application) i. Companionship ii. Comfort iii. Environmental iv. Diversionary v. Interference vi. Other c. Type of Restraint used: Soft ankle or wrist d. Sign of injury associated with application requires documentation in the EHR. e. Care Plan goal for patients with restraint due to a medical reason: To discontinue restraint as soon as possible when the patient behavior necessitating use of the restraint ceases or until other alternative interventions implemented are effective. f. Documentation of patient assessment every 2 hours by utilizing the key on the restraint intervention to include the following: i. Status check: visual inspection of the patient and body surface areas to ensure safety, signs of any injury associated with restraint. ii. Assess need for nourishment and hydration and offer as needed iii. Skin circulation iv. Assess need for hygiene and elimination and offer as needed v. Physical and mental status and comfort vi. Readiness for discontinuation of restraint assessed. Patient and/or family educated about changes necessary for use/release of restraint vii. Privacy and warmth maintained viii. Range of Motion and position change 10. Vital signs and assessment of cardiac and respiratory status will be at least every 4 hours or more frequently if patient condition warrants. 11. The RN may assign a trained staff member to perform the 15-minute monitoring for non-violent restraints. However, the RN must do the actual assessment at least every 2 hours for patients in non-violent restraints...””

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 33126 Based on observation and interview, the hospital failed to ensure all drugs were kept in a secure area and locked when: 1. One of two intravenous therapy carts (IV cart is a mobile cart designed to organize and transport supplies for medical procedures that involve administering fluids, medications, or nutrients directly into a vein) were unlocked and unattended. This failure had the potential for needles, syringes (a tube with a nozzle and piston or bulb for sucking in and injecting liquid into a thin stream), and IV fluids (sterile solutions administered directly into a patient’s vein through a small, flexible tube called a catheter) to be accessed by unauthorized persons, which could result in harm or injury. 2. One of one pediatric cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) Crash Carts (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was unlocked and unattended in the Emergency Department (ED). This failure had the potential for unauthorized access to the medications used for CPR and may cause patient harm due to the crash cart not being stocked in the event of an emergency. 3. Two of four Anesthesia carts (a mobile, specialized storage unit used in healthcare to organize and secure all necessary medications and equipment for administering anesthesia) in the Operating Room Department (OR) were unlocked and unattended. This failure had the potential for unauthorized access to medications and supplies used for anesthesia to be accessed by unauthorized persons which could result in unauthorized use, harm and/or injury. Findings: 1. During a concurrent observation and interview on 9/30/25, at 9:50 a.m. with the Chief Nursing Officer (CNO), in the area between the registration/triage area and the main ED, near the automated medication dispensing machine, an IV cart was unlocked. The IV cart contained needles, syringes and IV fluids (sterile solutions administered directly into a patient’s vein through a small, flexible tube called a catheter). The CEO stated when not in use, the cart(s) should be locked to prevent any unauthorized access to the cart. During a review of the hospital’s Policy and Procedure (P&P) titled, “Medication Security”, dated 8/24, indicated, “ ...All drugs, except those intended for crash cart use, will be stored in lockable storage or secured areas such as [automated dispensing machine] medication carts, cabinets, or medication rooms ...” 2. During a concurrent observation and interview on 9/30/25, at 10:15 a.m. with the CNO in the ED, a Pediatric crash cart was unlocked and unattended. The CNO stated the logbook (book with signatures indicating cart is stocked and ready for use) did not have any notation why the cart was unlocked. The CNO stated the cart must remain stocked and locked because an emergency could come into the unit at any time, and the items in the cart were necessary to perform successful CPR. The CNO stated the cart also should not be left open due to the medications such as epinephrine (adrenaline) that were stocked in the cart. During a review of the hospital’s P&P titled, “Medication Security”, dated 8/24, indicated, “ ...Crash cart drugs will be stored in containers closed with seals which allows the Pharmacist to determine if the package has been opened ...” 3. During a concurrent observation and interview on 9/30/25, at 10:42 a.m. with the Chief Executive Officer (CEO) and Manager of Surgery (SM), and Anesthesia Technician (AT) 1, in the OR department, Anesthesia Cart #07742 and Anesthesia Cart 2, no identifying cart number listed, were unlocked and unattended. The Anesthesia carts contained needles, syringes and IV fluids and had the potential to contain medications used for anesthesia procedures. The SM and CEO both stated the cart should be locked to prevent anyone without the access code from getting into the cart. OR staff explained the locking mechanisms are a known challenge and do not work as intended. CEO acknowledged the hospital had an opportunity to establish a process to ensure maintenance of the cart(s) to include the routine inspection of batteries and removal of other obstacles preventing the carts from operating as intended. SM and AT 1 stated an unlocked cart could result in unauthorized access to supplies and medications used during anesthesia and had the potential to cause harm or injury to staff and or patients in the OR. During an interview on 10/8/25 at 11:00 a.m., with CEO and CNO, CEO stated although the anesthesia cart is ultimately used by an anesthesiologist, her expectation is that the CNO ensures staff monitor and ensure all carts (crash cart, IV carts, etc.) with regulated supplies such as medications, needles, syringes, fluids, etc.) are locked when not in use to prevent access to supplies which could result in harm to staff and patients. During a review of the hospital’s Policy and Procedure (P&P) titled, “Medication Security”, dated 8/24, indicated, “ ...All drugs, except those intended for crash cart use, will be stored in lockable storage or secured areas such as [automated dispensing machine] medication carts, cabinets, or medication rooms ...””

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 33126 Based on observation and interviews,the facility failed to maintain secure access to locked medication rooms when the Emergency Department (ED) medication room was unsecured. The door was equipped with a push button lock but could be pushed open. This failure had the potential to result in unauthorized access to medications in the locked medication room. Findings: During a concurrent observation and interview on 9/30/25 at 9:55 a.m., with the Chief Nursing Officer (CNO) in the ED corridor between the registration and triage area and the main ED, a medication room was unlocked. The medication room door was equipped with a push button lock, but the door was easily pushed open. The doors to the corridor were unsecured and all staff could access the area. The cabinets in the room were not locked and intravenous fluid (IV - sterile solutions administered directly into a patient’s vein through a small, flexible tube called a catheter) medications were stored in the cabinet. The CNO stated the room should be locked and medications should be secured. During a review of the hospital’s policy and procedure titled, “Medication Security”, dated 8/24, indicated, “ ...All drugs stored in [hospital] shall be accessible only to authorized personnel. ...When unattended, the medication carts and medication rooms are to be locked ...” During a review of a professional reference titled, “Hospital Medication Security: A guide to protecting controlled substances (HMS)”, dated 9/26/24, the “HMS” indicated, “ ... Without medication access control systems and surveillance, medications can be stolen or tampered with, leading to potential overdoses, medication errors, or the use of unsafe drugs...”.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 33126 Based on observation, interview, and record review the facility failed ensure equipment was maintained at an acceptable level of safety when: 1. Oxygen cylinders (a metal container that holds compressed oxygen gas under high pressure, used for medical or purposes) on the Medical Surgical (MS) Unit, in the Medical Surgical (MS) Unit Oxygen Storage room, were not stored safely when six oxygen cylinders were not stored in an oxygen cylinder stand (a device used to securely hold an oxygen tank upright, preventing it from tipping over, which could cause damage or an accident); and, 2. Deflation of two of two patients’ (Pt 5 and Pt 17) pressure relieving mattresses were not addressed in a timely manner, according to the hospital’s Policy and Procedure (P&P) titled, “Equipment or Medical Device Problems, Failure and User Errors”. These failures had the potential to cause injury to patients and/or staff on the MS Unit, negatively affecting their health and well-being. Findings: During a concurrent observation and interview on 9/30/25 at 10:43 a.m., with Nurse Manager (NM) 1, NM 1 confirmed four full oxygen cylinders, one partially filled oxygen cylinder, and one empty oxygen cylinder were stored without an oxygen cylinder stand. NM 1 explained the oxygen cylinders should have been stored in oxygen cylinder stands. NM 1 further explained the importance of the storing oxygen cylinders in oxygen cylinder stands for safety. NM 1 stated injuries could happen if the oxygen cylinders were stored outside of oxygen cylinder stands. During an interview on 10/8/25 at 12 p.m., with the Chief Nursing Officer (CNO), the CNO stated the oxygen cylinders should have been in oxygen cylinder stands. The CNO explained the oxygen cylinders should have been in oxygen cylinder stands to prevent injury and for safety. The CNO further explained if one of the full oxygen cylinders fell over there was a risk for explosion, it was a hazard. During a review of the facility policy titled, “Medical Gas Cylinders,” dated 8/2024, indicated, “ ... To provide a clear direction for a safe and reliable method of ordering, storing and using Medical Cylinder gases ... Storing of medical gas cylinders will be in areas designated for storage in racks and chained to the wall to prevent them from falling over ...” 2. During a concurrent observation and interview on 10/1/25 at 5:10 p.m., with Pt 5 in her hospital room, Pt 5 was lying on her back in a hospital gown with an inflatable mattress topper that was completely flat. Pt 5 stated the mattress topper was electronic and air was forced into the mattress allowing the mattress to relieve pressure in alternating areas of the bed. Pt 5 stated the topper had been flat for the entire day. Pt 5 stated the machine began beeping then went flat. Pt 5 stated she reported the issue to nursing staff, who attempted troubleshooting and when that did not work, was told maintenance would be in to fix it, but no one came. Pt 5 stated the physician put her on bedrest (limiting physical activity by staying in bed) and when the mattress topper worked the bed didn’t feel as hard. During a concurrent interview and record review on 9/30/25 with the Licensed Clinical Informatics Analyst (LCIA) 1, Pt 5’s History and Physical (H&P- an assessment from physician including medical history and exam) and “Patient Summary Report”, dated 9/30/25 were reviewed. Pt 5 arrived in the Emergency Department (ED) on 9/30/25 with complaints of abdominal pain and was admitted to the hospital as an inpatient on 9/30/25 for diverticulitis (a condition where small pouches (diverticula) in the wall of the large intestine (colon) become inflamed or infected) of the intestines. LCIA 1 stated Pt 5 was moved to the Medical Surgical (MS) Unit (area in the hospital for patients who are not critically ill but require close monitoring) on 9/30/25 at 11:20 a.m. The document titled, “Activity Order”, dated 9/30/25, indicated, Pt 5 was on bedrest with bathroom privileges for 12 hours then could begin getting out of bed as tolerated (gradually as their body allows). During an interview on 10/7/25 at 5:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated the mattress topper should have been replaced after troubleshooting was unsuccessful. The CNO stated the pressure-relieving mattress helped to prevent skin breakdown (damage). During an interview on 10/7/25 at 11:15 a.m. with Nurse Manager (NM) 1, NM 1 stated the expectation was for nursing staff to exchange all malfunctioning equipment immediately. NM 1 stated the mattress should be inflated to prevent the risk of skin breakdown. During a review of the hospital’s P&P titled, “Equipment or Medical Device Problems, Failure and User Errors”, dated 9/25, indicated, “ ... It is the policy of [Facility Name] to ensure that equipment problems, including failures and user errors that have or may have an adverse effect on safety and/or the quality of care are acted upon in efficient and timely manner ...” During an interview on 10/7/25 at 1:37 p.m., family member (FM) 1 regarding Pt 17, FM 1 stated during Pt 17’s hospital stay in August 2025 her bed kept deflating down to the metal. FM 1 stated it was uncomfortable for Pt 17 and Pt 17’s bed kept deflating down to the metal all night. FM 1 stated Pt 17’s mattress was not changed until the morning. During a record review of Pt 17’s clinical document titled, “Archived Notes,” containing nursing notes, indicated, “ ... 08/14/25 0243 [2:43 a.m.] ... Patient is using air mattress to prevent any pressure injury and was complaining of bed mattress not inflating properly ...” Further review of “Archived Notes,” indicated, “ ... 08/14/25 0539 [5:39 a.m.] ... Patient was c/o [complaining of] bed/air mattress, writer fix(ed) the setting for inflation ... patient was unsatisfied stating that ’ I am upset ... this bed keeps bothering me, I don ’ t deserve to be treated like that ... ’ maintenance called. Maintenance fix(ed) the bed again ...” Further review of “Archived Notes,” indicated, “ ... 08/14/25 0647 [6:47 a.m.] Patient was still complaining about bed, writer change(d) the bed along with mattress ...” During a concurrent interview and record review on 10/7/25 at 2:31 p.m., with licensed clinical informatics analyst (LCIA) 1, LCIA confirmed the above notes indicating issues with Pt 17’s bed on 8/14/25. During an interview on 10/8/25 at 10:01 a.m., with the Chief Nursing Officer (CNO), the CNO stated all mattresses on the medical surgical unit were standard inflatable mattresses. The CNO explained if there was an issue with a mattress the nurse or certified nursing assistant would put in a ticket to maintenance to address the issue. The CNO further explained her expectation was for the mattress to be changed and/or the issue with the mattress to be resolved within 30-60 minutes to ensure the patient is comfortable. During a review of the hospital’s P&P titled, “Equipment or Medical Device Problems, Failure and User Errors”, dated 9/25, indicated, “ ... It is the policy of [Facility Name] to ensure that equipment problems, including failures and user errors that have or may have an adverse effect on safety and/or the quality of care are acted upon in efficient and timely manner ...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47205 Based on observation, interview, and record review, the hospital failed to ensure a system was in place for identifying, investigating, and controlling infections and communicable (a condition that can be transmitted from one person to another through direct or indirect contact) diseases in accordance with internal policies and procedures, and nationally recognized infection control practices, guidelines, and regulations when: 1. Hospital staff did not decontaminate (to rid of contamination), perform high level disinfection (HLD- a process that destroys all microorganisms (tiny living things that are found all around us), except for a large number of bacterial spores (a dormant (inactive) form of bacteria), used on semi-critical medical devices like endoscopes (an instrument which can be introduced into the body to give a view of its internal parts) in accordance with professional standards and manufacturer instructions for use (IFU). Endoscopy Technician (ET) 1 performed decontamination of used endoscope by lifting the endoscope above the water line and in the process cross contaminated a clean table used to dry the endoscope prior to beginning the HLD process. The physical configuration of the sinks within the decontamination room did not permit sufficient space for ET 1 to keep the endoscope fully submerged while decontaminating. ET 1 did not appropriately don Personal Protective Equipment (PPE- refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) during the process of decontaminating the endoscopes. The endoscopes were not appropriately hung in the cabinet. Ten scopes were fitted into a cabinet that was meant to support eight endoscopes. The endoscopes did not freely hang without touching and instead were hung and folded to fit into the cabinet and not in accordance with the manufacturer IFU. Because of the serious potential harm to all patients undergoing endoscopic procedures related to facility staff not adhering to professional standards of HLD, decontamination techniques, and not storing endoscopes according to professional standards, an Immediate Jeopardy (IJ- a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was cited on 10/2/25 at 4:06 p.m., under Code of Federal Regulations (CFR) §482.42(a)(3), at A-0750 (Surveillance/Prevention/Control of HAI (Hospital Acquired Infection)/Sanitary Environment) with the hospital Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Risk Management Manager (RM), Director of Quality/Infection Prevention (DQ/IP), and Sterile Processing Department (SPD- responsible for the thorough cleaning, disinfecting, and sterilizing of reusable surgical instruments and medical equipment) Supervisor (SSPD) were notified and provided with the IJ template; noting Endoscopy procedures were to cease until an acceptable Plan of Removal (PoR) was submitted, evaluated, and accepted. , On 10/3/25 at 10:30 a.m., the hospital submitted an IJ Plan of Removal (PoR) Version One, which was evaluated and deemed unacceptable. On 10/4/25 at 4:45 p.m. the hospital submitted an IJ PoR, Version Two, and it was evaluated. The hospital CEO, CNO, and RM were notified that PoR Version Two was accepted. The IJ PoR submitted by the hospital included but was not limited to the following: immediately educate and validate competencies related to appropriate PPE and proper hand hygiene (the process of cleaning and disinfecting hands to remove microorganisms and prevent the spread of infections) Endoscopy staff were re-educated on proper decontamination processes per professional standards, discontinued the use of the current Endoscopy processing room facility identified the SPD decontamination room as the new location to process endoscopes, endoscope transport and reprocessing (the multi-step process of cleaning and disinfecting or sterilizing a used endoscope to make it safe for reuse on another patient) workflow’s were revised and implemented, implementation of audits conducted by the infection Preventionist (IP- a healthcare professional who specializes in preventing the spread of infections within facilities like hospitals, long-term care centers, and schools), new endoscope cabinets were installed and disinfected per manufacturer instructions, a visual aide was added to the cabinets to identify the capacity. All items were validated onsite via interview, observation and record review. On 10/4/25 at 4:50 p.m., the IJ was lifted, onsite with the CEO, CNO, Chief Operating Officer (COO), and RM in attendance. After removal of the IJ, the hospital remained in substantial noncompliance. 2. Two of two transvaginal probes (an ultrasound probe connected to a computer is inserted into the vagina and is gently moved to show different organs) were not stored according to the manufacturer IFUs and in accordance with national standards for infection prevention. These failures resulted in not ensuring transvaginal being processed in accordance with professional standards and infection control standards and placed all patients who needed an endoscopic procedure at risk of harm and possible infection. These facility practices were not supported by the Association of periOperative (the period of time around the surgical operation) Registered Nurses (AORN), the Association for the Advancement of Medical Instrumentation (AAMI- primary source of national and international standards for the medical device industry and guidance for healthcare technology and sterilization professionals), Centers for Disease Control and Prevention (CDC) and the American Society for Gastrointestinal (relating to stomach and intestines) Endoscopy (ASGE) professional standards and had the potential to cause harm by the spread of infections or cross-contamination (when bacteria or other microorganisms are unintentionally transferred from one object to another) to patients and staff. 3. During an observation on 9/30/25 at 9:50 a.m., One of two dialysis machines (filters a patient’s blood to remove waste products and excess fluid when the kidneys [bean-shaped organs located on either side of the spine] are not functioning properly) located in the hospital’s Medical Surgical (MS) Unit, in room 228, where patients receive dialysis treatment was not cleaned and sanitized following dialysis for Patient (Pt) 15 on 9/29/25 at 5 p.m., per hospital Policy and Procedure (P&P), negatively effecting one of one dialysis patients, Pt 15. 4. A soiled wash cloth was observed hanging from a shower curtain rod in a shared patient shower room located at the Central Station on the MS unit, with the potential to negatively affect the health of 52 of 52 patients in the MS unit. 5. A dirty, unlabeled graduated cylinder (container used to measure urine output), was sitting on the back of the toilet in a patient shared bathroom, with the potential to negatively affect the health of two of two patients. 6. Licensed Nurses (LNs) failed to change the soiled dressing covering for one of one sampled patient’s (Pt 5) intravenous (IV-into a vein) site (where a flexible plastic tube, or cannula, is inserted into a vein to deliver fluids, medications, or blood directly into the bloodstream), in accordance with hospital P&P titled, “Intravenous Therapy” and CDC guidelines for infection control. 7.One of one 500 milliliter (mL- a unit of measurement) bag (a flexible plastic container filled with fluids for medical use, most commonly for intravenous (IV) therapy ) of Lactated Ringer’s (LR- a type of fluid used to replace electrolytes (minerals in the body that carry an electrical charge when dissolved in water) intravenous (IV- a way to give fluids directly into the vein) fluid was lying on the counter in the Emergency Department (ED) medication preparation room with the protective overwrap (a plastic bag to protect the solution from contaminants) removed, not stored in accordance hospital P&P titled “Intravenous Therapy.” As a result of these failures all patients, visitors and staff were at risk for transmission of infections (refers to the way germs infect a susceptible (at risk) person) and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: 1. During a concurrent observation and interview on 9/30/25 at 11:22 a.m., with CEO, Manager of Surgery (SM) and ET 1, in the clean storage room, ET 1 unlocked the clean storage cabinet’s roll-top door where a total of 10 endoscopes were crowded into the cabinet. ET 1 stated he is aware that the endoscope storage did not meet hospital P&P and accepted national standards for endoscope storage. ET 1 stated he has reported the need for a cabinet that can properly accommodate the number of endoscopes the hospital has in service (10 total endoscopes) but did not recall when and to whom he made this report. SM stated she was not aware that endoscopes were being stored inappropriately. CEO stated she was not aware of the current practice and acknowledged the cabinet was overcrowded with endoscopes touching one another and/or cabinet surface(s). CEO acknowledged the overcrowding rendered the “clean” endoscopes contaminated and were not to be used on patients until they were removed, reprocessed, and then hung in the clean endoscope cabinet per hospital P&P, manufacturer IFUs, and accepted national standards. A request was made for the Endoscopy Scope Clean Storage cabinet manufacturer’s IFUs. During a review of hospital P&P titled “Processing Flexible and Semi-Rigid Endoscopes” dated 8/24 Revised 4/25, the P&P indicated “...Storage of Endoscopes a. After HLD is complete, endoscopes are to be stored horizontally in the endoscope cabinet. The storage cabinets should be large enough to allow endoscopes to hang vertically without coiling, touching each other or touching the bottom of the cabinet. Vertical hanging promotes complete drying. b. Before hanging, detach all accessories, including the air/water valve c. Distal end (part that is farther away from the center of the body than another part) of the endoscope needs to be padded to prevent damage d. Fill out the tag which includes your initials, date processed. e. Endoscopes can be stored for a maximum of 7 days. If not used, the scope needs to be reprocessed. f. After hanging the endoscope in the drying cabinet, close the door and lock it. g. Make sure all logs have been completed for all endoscopes processed. During a review of a product information sheet provided by the hospital titled “brand name” Scope Cabinet with Roll-Top Door, undated, the information sheet indicated “... Interior Configuration... 92”h x 36”w cabinet holds 8 ... scopes...” During a concurrent observation and interview on 9/30/25 at 11:32 a.m., with CEO, Manager of Surgical Services (MSS) and ET 1 stated the Endoscopy Scope Clean Storage cabinet was cleaned regularly and provided a cleaning log for September. ET 1 stated cleaning consisted of removal of all scopes, wiping down surfaces with “brand name” sanitizing wipes, allowing a dwell time (the specific amount of time a disinfectant must remain visibly wet on a surface to effectively kill the pathogens listed on its label) of 2 minutes. A request was made for the Endoscopy Scope Clean Storage cabinet manufacturer IFUs and associated hospital P&Ps. Hospital staff could not provide evidence (cabinet IFU) to demonstrate staff were cleaning the endoscope storage cabinet(s) in accordance with manufacturer IFUs and national standards. During a review of a document provided by the hospital titled “Brand Name” Drying Cabinet, undated, the document indicated, “... 3. Cabinet Maintenance & Upkeep A. Interior Cleaning -Wipe internal walls, hangers and drip tray weekly with hospital-grade disinfectant...allow surfaces to dry fully to prevent residue and airflow obstruction. -Regulatory Tie-In: AAMI ST91 Annex F requires documented cleaning of storage environments...D. Preventive Inspections -Monthly/Quarterly: Verify blower fan operation, inspect vent pathways, and confirm hanger integrity. -Documentation: Log inspection date, unit serial number, and corrective actions...” During a review of hospital P&P “Cleaning of Endoscope Cabinet” dated 2/25 Revised 10/25, the P&P indicated “... POLICY: The cabinets that are used to store endoscopes must have a regular cleaning protocol...In addition, the storage cabinet must be cleaned and disinfected on a regular basis. 1) Outside of Endoscope Cabinet needs to be wiped down daily. 2) Once a month the cabinet needs to be terminally cleaned, which includes wiping the inside of the cabinet including the slots, drip tray and the outside of the cabinet... 3) Cleaning logs will be kept and monitored to ensure the cleaning is completed. 4) During monthly cleaning all scopes will be removed from the cabinet placed in enclosed bins and reprocessed before returning to the cabinet...” During a concurrent observation and interview on 9/30/25 at 1:20 p.m., with ET 1, Manager of Surgery (MS), and CEO, in the Endoscopy SPD room (located in the Operating Room (OR) and accessed through OR room 5). ET 1 explained this room was where staff cleaned and disinfected soiled endoscopes. ET 1 stated dirty endoscopes were processed at the sink, which is considered “dirty” and where the manual disinfection process is done. ET 1 was observed to select a clean disposable gown, from a supply cart on the “clean” side of the room. ET 1 stated a gown is part of the PPE to be used when manually disinfecting a soiled endoscope. ET 1 put the surgical gown on which was noted to not fit appropriately, leaving his sides and back uncovered. ET 1 stated he uses the gowns provided with most not fitting him due to his height and weight. CEO stated that gowns, in sizes to accommodate staff were stocked and available to staff. CEO stated she was not sure why ET 1 did not put on an appropriately sized gown. CEO stated it is her expectation that staff use the appropriate PPE as indicated by the job to be done. CEO stated it is her expectation that staff adhere to hospital P&P and national standards to prevent the spread of infection to staff, patients and visitors. During an observation and interview on 9/30/25 at 1:30 p.m. in the Endoscopy SPD room, with CEO and Manager of Surgery (MS) and ET 1, ET 1 demonstrated the steps for manual disinfection of a soiled endoscope. ET 1 put on PPE, then filled sink 1 of the dual compartment sink with four gallons of water with auto injection of cleanser (an automated system that injects a cleaning chemical into another system or fluid stream), and placed the soiled endoscope into sink 1 after inspection of the endoscope for any leaks. ET 1 was observed to lift and scrub the endoscope above the water line. ET 1 stated that due to his height and weight, he couldn’t perform the manual scrubbing without lifting the endoscope up above the water line. Once manual scrubbing was done, ET 1 moved the endoscope to sink 2 for a clean water rinse (filled to the 4-gallon mark in sink). ET 1 performed hand hygiene, and put a clean gown on, leaving sides and back uncovered. ET 1 lifted the clean endoscope out of sink 2, turned around and placed the clean endoscope on the “clean” table for drying and preparation for high-level disinfection (HLD). ET 1 placed the clean endoscope into the “brand name” HLD machine for its 29-minute disinfection cycle. ET 1 verbalized that once the HLD was complete, the scope would be transported to the clean storage room for storage in the endoscope storage cabinet. A request was made for the “brand name” HLD manufacturer IFUs and hospital P&P ’ s related to endoscope processing procedure/protocol. During a review of hospital P&P titled “Processing Flexible and Semi-Rigid Endoscopes” dated 8/24 revised 4/25, the P&P indicated “...PURPOSE: To establish clear and effective guidelines for the appropriate cleaning, high level disinfection (HLD)/liquid chemical sterilization process and storage of flexible endoscopes. The cleaning, disinfection, and sterilization processes of endoscopes follow the critical/semi-critical device classification... PROCEDURE: ...4. Decontamination: Manual Cleaning of Endoscope... b. Prepare fresh water and detergent using to [brand name] detergent device. a. The sink or basin must be at least 16 inches by 16 inches by 8 inches to ensure complete submersion of the endoscope during cleaning and disinfection...” During a concurrent observation and interview on 10/1/25 at 5:26 p.m., with CEO, DQ/IP, and SM, in the Endoscopy SPD room, sinks were measured and were not to AAMI standards. Sink 1 and sink 2 measured 16 inches by 16 inches, and 7.5 inches deep. Sink dimensions prevented ET 1 from ensuring the endoscope was fully submerged and scrubbed below the water line during the manual cleaning phase. This placed staff and equipment at risk of splashing and exposure to contaminants being aerosolized (transforming a substance into tiny particles or droplets suspended in air), and contaminating staff and clean equipment. The DQ/IP stated the newly appointed Infection Prevention Analyst (IPA) conducts weekly rounding of the OR and Endoscopy units. DQ/IP confirmed the hospital follows AAMI (Association for the Advancement of Medical Instrumentation (sets national standards for cleaning and using medical equipment)) in the OR and SPD units. DQ/IP stated she was not aware the endoscopes were being stored incorrectly, that PPE was not being utilized per hospital P&P, or that the current workflow in the Endoscopy SPD reprocessing room was placing staff and patients at risk for infection. During a review of the professional standard titled, “Association for the Advancement of Medical Instrumentation (AAMI) ST79” dated 2017, the standard indicated “...3.3.6.1.1 Design considerations, the decontamination area/room should a) be physically separate from all other processing areas and from areas in which clean or sterilization procedures are carried out, with any connecting doors and pass-through windows remaining closed. NOTE-In non-hospital health care facilities, clinics, and dental or medical offices, it might not be possible to physically separate the decontamination area from the clean work area. In such cases, procedural barrier separation, although not generally desirable, could be adequate, provided that work practices prevent splashing, the production of aerosols, and the contamination of clean items and work surfaces; that work practices promote the changing of PPE when personnel complete decontamination activities and perform clean (e.g., high-level disinfection) activities; and that ventilation and air handling systems move air from the clean side of the room to the decontamination side of the room and not the reverse. b) be accessible from a service corridor; c) have a door providing access to the clean work room (a pass-through window is also convenient for delicate instrumentation and water-sensitive equipment that have been manually decontaminated); d) have three-section sinks that are approximately 36 inches (91 centimeters [cm]) from the floor and 8 to 10 inches (20 to 25 cm) deep; include attached solid counters or adjacent work surfaces on which to place soiled and clean items separately; and are large enough to allow a tray or container basket of instruments to be placed flat for pretreatment or manual cleaning; and have two-section sinks available for soaking and rinsing prior to cleaning; e) have instrument air available; f) have recessed and sealed lights and other fixtures to prevent the accumulation of dust or soil and to facilitate cleaning; g) have a source of critical water for final rinsing (see AAMI TIR34). h) have a lift dedicated to the transport of contaminated items, if applicable; and i) be designed for the following workflow: from the receiving of soiled items; to the removal of linens, fluids, and trash; to manual decontamination tasks (e.g., sorting); to the automatic washer or pass-through window. Rationale: Airborne microbial and particulate contamination (the presence of harmful or undesirable biological and non-biological matter suspended in the air) is likely to be high in the decontamination area/room because of the type of work done there (e.g., staging of grossly soiled items (o prepare and contain them for safe and proper transport to a designated decontamination area, right at the location where they were used) and equipment before cleaning, manual cleaning that produces aerosols, and, in some facilities, trash and linen handling from surgical case carts). Contamination can also be spread by personnel who indiscriminately touch environmental surfaces, other devices, or other personnel with contaminated hands. Regular cleaning is necessary to control environmental contaminants. Physical enclosure of the decontamination area is necessary because contaminated aerosols, droplet nuclei (tiny particles that represent the dried residue of droplets), and dust particles can be carried from “dirty” to “clean” areas by air currents... 4.2.1 General considerations Workflow should be unidirectional (moving or operating in a single direction) from the decontamination area to the clean area and then to the storage area. Workflow patterns should be designed to contain contaminants, prevent damage to endoscopes, and minimize employee exposure to pathogens (tiny organisms that can make you sick if they get inside your body) and toxic chemicals. Ergonomic (relating to or designed for efficiency and comfort in the working environment) factors affecting worker safety and comfort should be considered when designing work areas. For example: Counters, sinks and work surfaces should be: height-adjustable or positioned at heights that accommodate the average height of employees and the tasks to be performed at each location; and sufficient to accommodate the endoscope length. Anti-fatigue mats should be: used in areas where prolonged standing is required; and constructed of materials capable of withstanding frequent cleaning. Work area design also should allow adequate space for all functions and should promote efficiency by minimizing distances between related areas. A pass-through window at counter height between the decontamination area and clean processing area is recommended. Rationale: Adherence to these functional design recommendations can help contain potential contaminants within the processing area and prevent cross-contamination or recontamination. Designing the area to facilitate efficient workflow and to provide adequate space for necessary equipment can enhance efficiency and reduce the potential for cross-contamination. Considering ergonomic factors during the design phase can help prevent worker injury. A pass-through window that can be closed is convenient for devices that have been manually decontaminated to be passed over to the clean side for processing. Having a window that can be closed maintains the air pressure requirements as well as maintaining the integrity of the clean side...” During a review of the Center for Disease Control’s (CDC-creates national public health and infection prevention guidelines) document titled “Guideline for Disinfection and Sterilization in Healthcare Facilities” dated 2008, the document indicated “devices must be cleaned and reprocessed according to the manufacturer IFUs. Failure to follow the manufacturer directions can lead to device damage, inadequate disinfection or sterilization, and patient harm.” 2. During an interview on 10/6/25 at 9:04 a.m., with the DQ/IP the DQ/IP stated that the hospital followed the following national infection control guidelines: a. AORN - Association of Perioperative Registered Nurses (sets national safety rules for operating rooms). b. AAMI - Association for the Advancement of Medical Instrumentation (sets national standards for cleaning and using medical equipment). c. CDC- (creates national public health and infection prevention guidelines). During a concurrent observation and interview on 10/6/25 at 2:02 p.m., in the Radiology (a branch of medicine that uses special machines and pictures to look inside a body) Department Ultrasound Room 1, with an ultrasound technician (UST - a trained healthcare worker who uses special equipment to take pictures of the body) two coiled, touching transvaginal probes ([brand name - Operating Manual Endo cavitary Transducer] TVP - a small, smooth, wand like tool placed in the vagina that doctors use to get a clearer look at a woman ’ s internal organs [company name-) were observed in a drawer. The UST stated that after a TVP was sterilized in a Trophon (a machine used to perform HLD of transvaginal probe) machine, the TVPs were stored in a drawer ready for use with the next patient. The UST stated, “that is how we have always done it”. During an interview on 10/6/25 at 2:30 p.m., on the patio, with DQ/IP. The DQ/IP stated she was responsible for auditing HLD in the hospital. The DQ/IP viewed a photo taken 10/6/2025 at 2:02 p.m., of the TVPs stored in a cabinet drawer. The DQ/IP stated, “oh my goodness”, clean TVPs should not be stored in a drawer, bent, and touching. The DQ/IP stated, “first of all that ’ s not part of the cleaning process and there is an increased risk of contamination when things are stored together and touching”. The DQ/IP stated drawer storage created a potential for cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and “has the potential to damage the integrity of the equipment”. The DQ/IP validated the Trophon machine was a form of HLD occurring in the Radiology Department. The DQ/IP stated her expectations were that TVPs be stored in a cabinet for designed for TVPs, hanging, and not touching. A request was made for the TVP manufacturer IFUs. During a review of the IFU titled “[brand name] “Operating Manual Endo cavitary Transducer 11C3 (a special ultrasound probe) [undated]”, the IFU indicated, “ ...4. Use Conditions 4.1 Use Environment use the transducer in an environment that satisfies the following conditions: Not exposed to direct sunlight or X-ray. No sudden changes in temperature. No dust. No excessive vibration. Away from sources of heat ... Storage and Transportation ... (1) Store or transport the transducer under the ambient conditions (the surrounding environmental factors that influence a system or object, including temperature, humidity, light, and sound) desired in section 4 ... (2) Between examinations, it is recommended that the transducer be kept in a sterile environment...”. During an interview on 10/7/25 at 9:30 a.m., with the Infection Prevention Analyst (IPA), the IPA stated there was no audit tool for the Radiology Department, it was not on the infection prevention “radar.” During a concurrent observation and interview on 10/7/25 at 2:05 p.m., in the Radiology Department, Ultrasound Room 1 with DQ/IP, UST, and the COO the Operating Manual Endo cavitary Transducer 11C3 IFU was reviewed. The DQ/IP and the COO validated the IFU indicated TVPs should be stored in a sterile environment. UST stated she thought the processed TVPs were sterile because there was a plastic cover over the probe and proceeded to open a drawer in Ultrasound Room 1 where several plastic covers were observed. The TVPs were not stored in a sterile environment after cleaning. The DQ/IP validated the TVP covers were in the drawer and stated the plastic covers were not sterile and the IFU was not followed. The DQ/IP stated “to be honest I wasn ’ t looking for the probes” during IP HLD rounds, “they were not on my radar”. The DQ/IP stated she did not have documentation that showed infection prevention rounds were performed in the Radiology Department. Several requests for IP rounding in the Radiology Deparment were requested. No documents provided During an interview on 10/8/25, at 11:25 a.m., with the CEO, the CEO stated her expectation that the infection prevention department have a routine schedule for high-risk areas. The CEO stated she expected weekly rounding in HLD areas, the rounding in the Radiology Department was not documented therefore it was not done. The CEO stated it was her expectation that all manufacturer IFUs were followed for equipment used in the hospital and that all HLD areas are observed weekly. During a review of the hospital ’ s policy and procedure titled “Infection Control and Surveillance Program”, dated 5/25, the P&P indicated that “ ...Infection Control is responsible for coordinating the overall program in accordance with Title 22 and Title 8 of the State Department of Health Services and OSHA. Compliance with Senate Bill 739 by reporting directed information via National Healthcare Safety Network (NHSN) for the Centers for Disease and Control. The duties of Infection Control include establishing a systematic surveillance system to prevent and control Hospital Acquired infections (HAI’s), coordinating education and training programs to meet the needs of the specific clinical departments ...”. The review of CDC document titled “Guideline for Disinfection and Sterilization in Healthcare Facilities”, dated 2008 stated “devices must be cleaned and reprocessed according to the manufacturer IFUs. Failure to follow the manufacturer directions can lead to device damage, inadequate disinfection or sterilization, and patient harm.” 3. During an observation, in the medical surgical units dialysis room, a red/rust colored splatter was observed to be located on two areas of the bibag connector (part on a dialysis machine that holds a disposable bag of dry sodium bicarbonate powder [baking soda] which the dialysis machine draws water through for an on demand sterile bicarbonate solution) and the shunt door (a physical interlock that ensures proper fluid handling and machine safety before and during a dialysis treatment) of the Medical Surgical (MS) Unit ’ s dialysis machine (filters a patient’s blood to remove waste products and excess fluid when the kidneys [bean-shaped organs located on either side of the spine] are not functioning properly); During a concurrent observation and interview on 9/30/25 at 9:52 a.m., with nurse manager (NM) 1, in the MS Unit’s Dialysis Room, one of two dialysis machines (the dialysis machine on the left as you enter the room) contained a red/rust colored substance splattered on the front of the machine at the bibag connector and on the right hand side of the dialysis machine on the shunt door NM 1 confirmed the red/rust colored areas of splatter on the dialysis machine. During a concurrent observation and interview on 9/30/25 at 9:55 a.m., with Registered Nurse (RN) 5, in the MS Unit’s Dialysis Room, RN 5 stated the last patient to receive dialysis was on 9/29/25 at 5:00 p.m. (Patient [Pt] 15). RN 5 stated the dialysis machine was cleaned after every patient and that after Pt 15 on 9/29/25 at 5:00 p.m., he had cleaned the dialysis machine. RN 5 walked over to the dialysis machine on the left of the MS Unit’s Dialysis Room and confirmed there were red/rust colored splatter on two areas of the dialysis machine. RN 5 explained, “I missed the blood here [pointing to the bibag connector] and the spots there [shunt door].” During an interview on 10/8/25 at 11:02 a.m., with the DQ/IP stated the expectations, prior to dialysis treatment, were for the environment in the dialysis room to clean and the dialysis machine ready to be used. The DQ/IP explained that following dialysis the dialysis machine should be cleaned and sanitized. The DQ/IP further explained her expectations were there should not be any bloodlike substances anywhere on the dialysis machine. The DQ/IP stated bloodlike substance left on the dialysis machine after cleaning and sanitizing pose a risk to patients and staff for exposure to infections. During a review of the dialysis machines user manual titled, “Hemodialysis Machine Operator ’ s Manual,” dated 2008-2024, indicated, “ ... The exterior of the dialysis machine should be cleaned after every treatment ...” During a review of the facility’s policy titled, “External Disinfection of Dialysis Machines with 1:100 [1 part bleach to 100 parts water] Dilution of Bleach Wipe,” dated 5/2025, indicated, “ ... Ensure disinfecting of surface of dialysis machine after every patient use ... Apply the moistened towel etc., [sic] starting from top and cleaning to the bottom of the equipment ...” 4. During a concurrent observation and interview on 9/30/25 at 10:58 a.m., with NM 1, a soiled washcloth was observed in the central station shower room hanging on the shower rod. NM 1 explained the washcloth should not be there. NM 1 further explained another patient could use the soiled washcloth and it was an infection control issue. During an interview on 10/8/25 at 11:04 a.m., with the DQ/IP, the DQ/IP stated she would not expect to see soiled washcloths in the MS shower rooms. The DQ/IP explained soiled washcloths left in the MS shower room pose a risk for exposure to bodily fluids and infection. During a review of the facility’s policy and procedure titled, “Patient’s Rights/Responsibilities,” dated 2/2025, indicated, “... Receive care in a safe and secure environment which incorporates current standards of practice for patient environmental safety, infection control ...” 5. During a concurrent observation and interview on 9/30/25 at 10:08 a.m., with NM 1, on the MS Unit, in room 225’s shared bathroom, an unlabeled graduated cylinder(a tall, cylindrical glass or plastic container with a flat base and markings along its side, used to precisely measure the volume of a liquid) containing yellow/yellow stains was noted to be on the back of the toilet in room 225’s shared bathroom. NM 1 explained the dirty, unlabeled graduated cylinder should not be in the shared bathroom in room 225. NM 1 further explained it was an infection control issue. During an interview on 10/8/25 at 11:16 a.m., with the DQ/IP, the DQ/IP stated there should be no shared equipment in the shared bathroom and the graduated cylinder should have been labeled with a patient name. During a review of the facility’s policy and procedure titled, “Patient’s Rights/Responsibilities,” dated 2/2025, indicated, “... Receive care in a safe and secure environment which incorporates current standards of practice for patient environmental safety, infection control ...” 6. During a concurrent interview and record review on 10/1/25 at 2:12 p.m. with Licensed Clinical Informatics Analyst (LCIA) 1, Pt 5’s Electronic Medical Record (EMR) was opened for review. The document titled, “History and Physical (H&P- an assessment from physician including medical history and exam)” and “Patient Summary Report”, dated 9/30/25 were reviewed. Pt 5 arrived in the Emergency Department (ED) on 9/30/25 with complaints of abdominal pain and was admitted to the hospital as an inpatient on 9/30/25 for diverticulitis (a condition where small pouches (diverticula) in the wall of the large intestine (colon) become inflamed or infected) of the intestines. LCIA 1 stated Pt 5 was moved to the Medical Surgical (MS) Unit (area in the hospital for patients who are not critically ill but require close monitoring) on 9/30/25 at 11:20 a.m. During a concurrent observation and interview on 10/1/25 at 5:10 p.m. with Pt 5 in Pt 5’s Medical Surgical (MS) Unit hospital room, Pt 5 was observed lying on her back with her left arm outstretched. IV fluids infused into the IV catheter (flexible plastic tube) site in her left antecubital space (AC - area on front of elbow joint). An IV catheter was also inserted into the right AC with no infusion running. A clear plastic dressing covered the left IV site, and red fluid was visible around the IV insertion site under the dressing and inside the connecting parts between the catheter and IV tubing (hub). Tape secured the left catheter hub to each side of the catheter, but both ends of the tape were lifting. Pt 5 repeatedly smoothed down the tape during the interview to re-secure it. Pt 5 stated that staff in the emergency department (ED) inserted both IVs and only used the left arm for infusions. When asked why she kept holding the tubing between the fingers on her left hand with her hand outstretched, she explained that bending her arm caused the IV pump to eventually beep, displaying an occlusion message (line is blocked preventing fluid from entering the bloodstream). She stated that nursing staff would enter the room to reset the pump and ask her to outstretch her arm again. When asked about the red fluid in and around the IV site, Pt 5 stated she believed nursing staff had noticed it, as they had entered the room multiple times to fix the pump. She added that nursing staff thought the red fluid was part of a tattoo on her forearm. Pt 5 clarified that the tattoo was a line, not a puddle of red fluid. She stated she was unaware she could request removal or relocation of the IV due to discomfort from having to keep her arm completely outstretched and straight. Pt 5 expressed a preference for a different IV site and a dressing change, as she felt moisture under the dressing. During an interview on 10/1/25 at 5:30 p.m. with the Chief Nursing Officer (CNO) the CNO stated nursing staff were expected to assess the IV site at least every shift, and change the dressing if soiled, wet, or lifting. The CNO stated keeping the area clean and dry was important to prevent infection. During an interview on 10/1/25 at 5:32 p.m. with Registered Nurse (RN) 1, RN 1 stated she was the main nurse for Pt 5. RN 1 stated she assessed Pt 5 ’ s IV sites in the a.m. and did not notice any blood pooling around the catheter site under the dressing. RN 1 stated she was aware Pt 5 ’ s IV pump alarmed frequently indicating an occlusion on the left arm when IV fluids were running. RN 1 stated that she did not offer to move the IV to a different spot, and she should have. RN 1 stated she should have changed the IV dressing when it was wet or soiled, to prevent IV site infection. During an interview on 10/8/25 at 11:06 a.m. with the DQ/IP, the DQ/IP stated no pooling of fluid should be around the IV site under the dressing. The DQ/IP stated the dressing should be clean, dry, and intact, to reduce the chance of infection. The DQ/IP stated, “don ’ t want anything growing there (no germs growing).” During a review of the facility’s policy and procedure titled, “Intravenous Therapy”, dated 8/2024, indicated, “ ...If transparent dressing is soiled, loosened or wet remove carefully but leave tape that anchors IV needle or catheter in place. Discard in proper manner...” During a review of a professional reference titled, “Guidelines for the prevention of Intravascular (within a blood vessel) Catheter-Related Infections” dated 10/17, the professional reference indicated, “ ...Catheter Site Dressing Regimens 1. Use either sterile gauze or sterile, transparent, semipermeable dressing (a type of wound covering that is designed to allow certain substances to pass through while blocking others) to cover the catheter site ... Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled...” 7. During a concurrent observation and interview on 9/30/25, at 9:53 a.m., with the Chief Nursing Officer (CNO), in the ED medication preparation room, a 500 mL bag of LR IV fluids was observed lying on a counter, with the protective outer packaging removed. The CNO stated that IV fluids should not be left unwrapped on the counter, because there was no way to guarantee sterility (germ free) of the LR. The CNO stated there was no way to know how long the fluids were left on the counter. The CNO stated that leaving the IV fluid on an unsanitized counter also posed an infection risk. The CNO removed the bag, explaining it would be used for training and not for patient care. The CNO expected that nurses should only remove the outer packaging when ready to use the fluids on a patient. During an interview on 10/8/25 at 11:07 a.m. with the DQ/IP, the DQ/IP stated the 500 mL bag of LR IV fluids should not be on a counter with the outer packaging removed. The DQ/IP stated IV fluids set on counters without the protective outer packaging posed an infection risk, because once the packaging was removed the fluid or packaging could be cross contaminated with environmental germs. During a review of the hospital’s P&P titled, “Intravenous Therapy”, dated 8/24, indicated, “ ...Examine bottle/bag for leaks, turbidity [the measure of the cloudiness or “muddiness” in a fluid, caused by a suspension of particles, or particulate matter] Do not use plastic IV bag from clean utility room if outer protective bag has been removed ...” During a review of a professional reference titled, “Reducing levels of medical device contamination through package redesign and opening technique”, dated 11/7/18, the professional reference indicated, “ ...Healthcare associated infections (HAIs), infections patients get while receiving medical treatment, have been categorized among the ten leading causes of morbidity (refers to the state of being ill or diseased) and mortality (signifies the number of deaths that occur within a specific population over a given period) in the United States. ... HAIs can be transmitted directly, from a single person to the patient, or indirectly, through an intermediate object or person. When medical devices serve as a vehicle for indirect transmission, the initial contamination tends to occur from a small number of micro-organisms that are transferred to the device, either from healthcare provider ’ s hands or skin or other environmental sources ... packaging and aseptic technique (a set of practices and procedures used to prevent infection by creating a barrier against microorganisms) both have the potential to play a role in contamination ...””

“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: 49884 Based on interview and record review, the hospital failed to ensure Licensed Nurses (LN) provided necessary care to two of six sampled patients (Pt) in the Emergency Department (ED) when: 1. Pt 2 was not assigned an ESI (a five-level triage system used in emergency departments to prioritize patients based on their condition’s severity and the resources needed for their care. It ranges from level 1 (most urgent, requiring immediate life-saving care) to level 5 (least urgent, needing minimal or no resources) during the triage (the preliminary assessment of patients in order to determine the urgency their need for treatment and the nature of treatment required) assessment according to the hospital P&P titled, “Care of the Patient in the Emergency Department: Triage to Discharge”. 2. Pt 1 did not receive complete and detailed discharge instructions according to the hospital’s policy and procedures (P&P) titled, “Discharge Procedures”. These failures had the potential to cause harm by delaying appropriate medical intervention due to inadequate triage classification and increasing the risk of adverse health outcomes following discharge due to insufficient patient education and follow-up instruction. Findings: 1. During a telephone interview on 10/2/25 at 7 p.m. with Pt 1 and Pt 2, Pt 1 reported that while traveling, they were involved in a car accident on the freeway, resulting in their vehicle being totaled. Both patients sustained injuries: Pt 2 had a large cut to the left hand and a broken sternum (breastbone). Pt 1 stated, upon arrival to the ambulance bay a nurse asked her if she thought Pt 1or Pt 2 should be seen first, and Pt 1 stated due to Pt 2 actively bleeding and both having the same chest pain to see Pt 2 first, since he would require more resources. During an interview on 9/30/25 at 10:27 a.m. with Nurse Manager (NM) 2, NM 2 stated the clinical coordinator (charge nurse) quickly assessed patients arriving by ambulance and assigned the ESI. NM 3 added that the ESI prioritized which patients were seen first. Active bleeding and other symptoms determined the ESI and the order in which patients were treated when multiple arrived simultaneously. During a concurrent interview and record review on 10/6/25 at 2:52 p.m. with the Clinical Nurse Educator (CNE), Pt 2 ’ s handwritten paper medical record documents from the ED visit on 7/1/25 to 7/2/25 were reviewed. The “Registration Record” dated 7/1/25 at 4:03 p.m., indicated Pt 2 was a 79-year-old brought into the ED by ambulance (BIBA) after a car accident. The “RN’s History & Progress Form Emergency Department (RNHP- Nurse’s exams and documentation of care for ED visit) Triage” dated 7/1/25 at 4:49 p.m., indicated Pt 2 was in a car accident and was hit from behind. Pt 2 complained of soreness to the back of the neck, shortness of breath, and chest pain, rated as 10 out of 10 (worst possible) and a cut to the left hand. Pt 2 had a past medical history (PMH) of asthma (chronic lung condition where airways become swollen making it hard to breathe), Post Traumatic Stress Disorder (PTSD- an anxiety problem after seeing or having a traumatic event), and a knee replacement. The “RNHP” triage did not have an ESI number assigned by the RN. The CNE stated the triage nurse should have assigned an ESI number to make sure the physician assessed Pt 2 timely since the ESI helped staff determine who should be seen first, and how many resources Pt 2 required. During an interview on 10/8/25 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated ED patients must have an ESI number assigned during triage to plan for the care of the patient. During a review of the hospital’s P&P titled, “Care of the Patient in the Emergency Department: Triage to Discharge”, dated 2/25, indicated, “ ...All patients will have a triage assessment completed by a Registered Nurse (RN), who has obtained triage certification, when presenting to the ED and assigned an ESI level of care at that time ...” During a review of the professional reference titled, “Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage”, dated 3/1/24, indicated, “ ...Importance: Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately ...” 2. During a telephone interview on 10/2/25 at 7:20 p.m., with Pt 1, Pt 1 stated the nurse did not provide discharge instructions. Pt 1 stated she received no paperwork about her injury, follow-up care, education, or information for her primary physician. During a concurrent interview and record review on 10/6/25 at 3:57 p.m. with the CNE, Pt 1’s complete handwritten paper medical record dated 7/1/25 to 7/2/25 was reviewed. The “Registration Record”, dated 7/1/25 at 4:03 p.m., indicated Pt 1 was a 77-year-old brought in after a car accident. The “RNHP Triage”, dated 7/1/25 at 4:49 p.m., showed a complaint of pain in the middle of the chest, the right side of the ribs, and pain in the back, rated as 10 out of 10. The “Emergency Department Chart- Provider (EDCP)” dated 7/1/25, indicated an History of Present Illness (HPI) of a truck hitting Pt 1’s car from behind, with airbags deployed, causing chest pain from the seat belt. Pt 1 had chest wall tenderness upon examination. The “Radiology Report”, dated 7/1/25, showed Pt 1 had a CT scan of the chest, stomach, and pelvis, indicating no broken bones. The CNE validated the document titled “Emergency Department Aftercare Sheet”, “undated”, was left blank. The CNE stated the “Emergency Department Aftercare Sheet” was important because the document included instructions to the patient about how to care for themselves, any medication that was given, and any follow up medical care needed. During an interview on 10/7/25 at 3:40 p.m. with Nurse Manager (NM) 3, NM 3 stated nurses should ensure the CM referrals were completed prior to patient discharge. NM 3 stated CM helped the patient with D/C planning to ensure patients had the necessary care, and resources after discharge. During an interview on 10/8/25 at 11:21 a.m. with the Chief Nursing Officer (CNO), the CNO stated Pt 1 and Pt 2’s primary (main) nurse should have communicated with the CM team to have an assessment completed, to ensure a safe patient discharge. During an interview on 10/8/25, at 11:21 a.m. with the CNO, the CNO stated Pt 1 should have received discharge education and instructions to help them take care of themselves and avoid readmission. During a review of the hospital’s P&P titled, “Discharge Procedures”, dated 8/24, indicated, “ ...Educating patients and/or their families is essential to promote and improve outcomes from treatment. ...Provide patients with discharge instruction, disease management or other pertinent education or material. ...Provide patients with medication instructions regarding those to be continued, resumed or started based upon providers orders. ...Ensure the patient, guardian and or care giver receives complete and detailed instructions to be followed after discharge. ...Doctors and Nurses are required to give discharge instructions to all patients discharged from the Emergency Department for: 1. Discharge Diagnosis 2. Follow up care 3. Care at home 4. Discharge medications / Rx [prescriptions] 5. Referrals ...” During a review of the professional reference titled, “Empowering patients: simplifying discharge instructions”, dated 9/14/21, indicated, “ ...Patients who do not have enough information about their discharge plans have decreased treatment compliance, decreased patient safety, increased emergency department (ED) recidivism [recurrence or relapse of a disease, condition, or behavior after a period of remission or improvement], and poor satisfaction.”

“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: 37529 Based on observation, interview, and record review, the hospital failed to comply with the regulatory requirements for EMTALA for 6 of 20 patients (Pt 1, Pt 2, Pt 3, Pt 5, Pt 6, and Pt 11) when; 1. Pt 1 came to the emergency department (ED) by ambulance on 6/13/25 at 11:50 a.m. with complaints of a two-week history of shortness of breath, cough, and increasing weakness, which resulted in Pt 1’s inability to stand on her own. Pt 1’s medical history included hypertension (high blood pressure) and chronic kidney disease (CKD). Pt 1’s electrocardiogram (EKG/ECG) in the ambulance indicated,”Device interpretation: Large anterolateral infarct, age undetermined. Tachycardia, right and left atrial enlargement, right bundle branch block”, she was hypotensive (low blood pressure) in the ambulance and was given intravenous fluids. On arrival to the ED, Pt 1’s heart rate was 108 beats per minute (bpm, normal 60-100 bpm), respiratory rate was 50 respirations per minute (rpm, normal 12-20 rpm), she was hypoglycemic (low blood sugar) and the medical screening exam (MSE) was initiated by the ED physician shortly after Pt 1’s arrival. Pt 1 was placed on BiPAP for respiratory support, initial lab tests and vital signs suggested severe sepsis (an emergency medical condition), and one dose of antibiotics was given. When additional lab tests and imaging studies were completed, the results indicated Pt 1 had acute right heart failure (also an emergency medical condition). Despite having two identified Emergency Medical Conditions (EMCs), after the transfer process was initiated at 5:43 p.m., no stabilizing measures were implemented, no intake and output was documented for the entire stay, interpretation of cardiac rhythm was not recorded, vital signs were not recorded for five hours, administration of medication ordered for low blood pressure and heart failure was delayed, and when Pt 1’s blood pressure was not being picked up by the monitor it was not immediately acted upon. No calls to initiate transfer requests were made for a three hour period from 6:29 p.m. until 9:37 p.m., the nursing staff and the physician did not recognize the seriousness of Pt 1’s condition, the physician did not request the on-call cardiologist come into the hospital to consult on Pt 1’s care, and did not consider accessing the resources of the hospital’s intensive care unit for hemodynamic monitoring and specialty care in order to stabilize Pt 1 while the transfer was being arranged. (Refer to 2407 finding 1) 2. Pt 2 came into the Emergency Department (ED) on 7/28/25 for chest pain 10/10, status post pacemaker/Automatic Implantable Cardiovert Defibrillator (PM- provides timed electrical impulses for slow heartbeats/AICD both implanted in the chest monitors heart rhythm and delivers electrical pulses or shock to correct a dangerously fast or irregular heartbeat to prevent cardiac arrest) placement 1 week prior, was assessed and discharged with diagnosis of rib contusion. Pt 2 came back by ambulance less than three hours later and was diagnosed with severe sepsis (a life-threatening stage of a serious infection where the body’s immune response causes organ damage, leading to symptoms like low blood pressure, confusion, difficulty breathing, and reduced urine output) and MI (myocardial infarction- heart attack). (Refer to 2407 finding 2) Because of the actual serious harm to patient 1 (death) and the potential for serious harm to patient 2 related to the hospital’s inability to provide appropriate stabilizing treatment that was within their capability an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2407 42 CFR 482.24(d)(3) on 9/16/25 at 2:50 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), the Chief Operations Officer (COO), the Chief Medical Officer (CMO), Director of Quality (IP/DQ), and Risk Manager (RM). The IJ (immediate Jeopardy) template was provided to the facility. The hospital submitted an IJ Plan of Removal (Version One) on 9/17/25 at 10:01 a.m. and it was unacceptable. The hospital submitted an IJ Plan of Removal (Version Two) on 9/17/25 at 4:54 p.m. which was reviewed and was unacceptable. The hospital submitted an IJ Plan of Removal (Version Three) on 9/18/25 at 1:15 p.m. After consultation with CMS, the Plan of Removal was accepted on 9/18/25 at 1:56 p.m. with the CEO, CNO, and RM. On 9/18/25 the survey team validated all staff currently working were being educated on the IJ for A2407 Stabilizing Treatment, posters were placed in appropriate areas for staff education in the ED, badge buddies were being distributed to all ED staff, testing to confirm material was understood and the hospital had a plan for all staff that work in the ED to be educated before coming back to work. The IJ was removed onsite with the CEO, CNO, and RM in attendance on 9/18/25 at 3:19 p.m. EMTALA violations remained following removal of the IJ. 3. Pt 3 was brought in by ambulance on 7/1/25 after being in a motor vehicle accident (MVA) with a chief complaint of 10/10 chest pain and an open bleeding wound on his left hand. Pt 3 was assigned an ESI of 2, triage started 45 minutes after arrival and MSE started 1.5 hours after arrival to ED. Pt 3’s pain was not treated until almost six hours after arrival to the ED and his hand was not treated for four hours after arrival. (Refer to 2407 finding 3) 4. The facility failed to provide an appropriate Medical Screening Examination (MSE) for 3 out of 20 emergency room patients (Pt 6, Pt 5, and Pt 11) within its capabilities to determine whether an emergency medical condition existed. (Refer to 2406) 5. The facility failed to post visible signage in its emergency department (ED) informing individuals of their rights under the Emergency Medical Treatment and Labor Act (EMTALA) when: There were no Spanish EMTALA signs visible for the Spanish speaking population advising patients of their right to receive a medical screening examination and stabilizing treatment for emergency medical conditions, regardless of their ability to pay or insurance status, and the two signs that were posted were not large enough or placed in conspicuous areas to be able to be easily viewed and read. (Refer to 2402) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner.”

“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: 51620 Based on observation, interview, and record review, the facility failed to post conspicuous signage in its emergency department (ED) informing individuals of their rights under the Emergency Medical Treatment and Labor Act (EMTALA) when: There were no Spanish EMTALA signs visible for the Spanish speaking population advising patients of their right to receive a medical screening examination and stabilizing treatment for emergency medical conditions, regardless of their ability to pay or insurance status, and the the two signs that were posted were not large enough or placed in conspicuous areas to be able to be easily viewed and read. These failures had the potential to not clearly communicate the rights of all emergency room patients. Findings: During an observation on 9/15/2025 at 10:45 a.m. of the emergency department there were no EMTALA signs posted in the waiting area, triage/treatment area, or posted at or near the emergency department entrance. The only EMTALA signs were posted in the ambulance bay passthrough alcove where it was unlikely patients would be able to notice it or have time to read it as they would be pushed by the sign on a gurney and immediately entered into triage. In addition, signs were not large enough where they could easily be read from 20 feet, and they were not placed in conspicuous areas. During an interview on 9/15/2025 at 1:45 p.m. with the Emergency Department Manager (EDM), EDM stated that she was not sure where EMTALA signage should be posted in the department. EDM stated that it would probably be a good idea to have them in different languages. EDM confirmed she did not know what the policy stated regarding the posting not just EMTALA, but all signs, in Spanish. During a record review of the facility’s policy and procedure titled, “Emergency Medical Treatment & Active Labor Act (EMTALA) and Transfer Policy” with a revised date of 2/2025, indicated that the signs must be posted in places where individuals are likely to notice them when they are entering the emergency department, in the waiting room, and treatment areas. In addition, the signs should be visible from 20 feet with clear wording and simple terms. The policy further indicates that because the facility serves many Spanish speaking patients, all signs shall be in English and Spanish. During a review of a professional article titled, “CMS Updates EMTALA Signage for Hospitals” dated 8/29/2024, indicated that, “CMS’ regulations require hospitals that are party to a Medicare provider agreement to follow the guidance that CMS requires regarding EMTALA signage. The article further states that, “Always do what is best for the patient. In the end, EMTALA is about the patients.”Centers for Medicare & Medicaid Services. (2024, August 13). QSO-24-17-EMTALA: Updated model signage for the Emergency Medical Treatment and Labor Act (EMTALA). U.S. Department of Health & Human Services. https://www.cms.gov/files/document/qso-24-17-emtala.docx[1](https://www.cms.gov/files/document/qso-24-17-emtala.docx)”

“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: 51620 Based on observation, interview, and record review, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 3 out of 20 emergency room patients (Pt 6, Pt 5, and Pt 11) within its capabilities to determine whether an emergency medical condition existed. This failure had the potential to result in delayed diagnosis and treatment, placing patients at risk for harm and may have resulted in a delay in identifying and treating a potentially life-threatening condition without appropriate medical intervention. Findings: During a concurrent interview and record review on 9/12/25 at 2:05 p.m. with the Clinical Educator (CED), Pt 6 was assigned an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient’s condition and the resources needed, ESI 1 is the most serious, in order to prioritize care) of 3 when according to the facility’s policy, they should have been assigned a 2. Having an ESI of 2 would have necessitated the emergency department staff to assign these patients to a bed in the Emergency Department (ED). CED stated Pt 6 should have been assigned an ESI of 2 and brought to a bed immediately. The record indicated Pt 6 arrived at the ED via walk-in on 4/8/25 at 7:25 p.m. with complaints of chest pain, shortness of breath, and left arm numbness. The record indicated Pt 6 was seen by the triage nurse at 7:30 p.m. and Serial Troponins (multiple measurements of troponin levels in the blood over time to determine if a cardiac injury has occurred) were not done. Pt 6 was not seen by qualified medical personnel, (physician or mid-level provider), instead Pt 6 was sent back out to the waiting room. No documentation of an Medical Screening Exam (MSE) was found in the medical record. Pt 6 was not called again for another 4 hours. Pt 6 left without being seen (LWBS). CED was unable to locate documentation that staff attempted to call patient at home to encourage patient to return to the hospital. During an interview on 9/12/25 at 2:23 p.m. with Triage Nurse 1 (TRN 1), TRN 1 stated the ESI for Pt 6 should have been assigned a 2 instead of a 3. TRN 1 stated Pt 6 should have been brought back and assigned a bed. TRN 1 stated Pt 6 should not have been sent out to the waiting room because Pt 6 could have been having a medical emergency. During a concurrent interview and record review on 9/15/25 at 10:45 a.m. with Information Technologist (IT) who was navigating the Electronic Medical Record (EMR), and the Emergency Department Manager (EDM), EDM stated that the ESI should have been scored a 2 not a 3, especially given the patient was experiencing left arm pain. EDM stated PT 6 should have been placed in a bed and not sent out to the waiting room. EDM stated that placing a patient out in the waiting room who has chest pain could be detrimental to the safety of the patient. EDM stated it is not their practice to call patients at home that have left before their MSE is performed. After reviewing the facility’s policy and procedure titled, “ED Left Before Intentional Discharge,” with a revised date of 2/2025, EDM stated they should be calling the patients to encourage them to return to be evaluated by the provider. During a concurrent interview and record review on 9/12/25 at 3:30 p.m. with the CED, Pt 5’s EMR for their ED visit on 9/9/25, was reviewed and during triage an ESI of 3 was assigned. The EMR indicated Pt 5 arrived at the ED via walk-in on 9/9/25 at 4:09 p.m. with complaints of Chest pain radiating to the back. The record indicated Pt 5 was seen by the triage nurse at 4:16 p.m. and an ESI of 3 was assigned to Pt 5. The MSE was done at 4:16 p.m. Serial Troponins were not done. Pt 5 was discharged to home at 6:12 p.m. CED stated Pt 5 should have been assigned an ESI of 2 not a 3. During a concurrent interview and record review on 9/15/25 at 4:03 p.m. with EDM, EDM stated that Pt 5’s ESI should have been scored a 2 not a 3 and stated it is important to asses ESIs correctly because this will determine the remainder of the care for patients. EDM stated assigning the incorrect ESI can cause a patient to miss out or be delayed receiving critical treatment. EDM stated she would have expected to see the patient here longer than two hours and would have expected to see serial troponins done. During a concurrent interview and record review on 9/17/25 at 3:49 p.m. with the CED, Pt 11 EMR for their ED visit on 9/9/25 was reviewed and an ESI of 3 was assigned. CED stated Pt 11 should have been assigned an ESI of 2 not a 3. Pt 11’s EMR indicated Pt 11 arrived at the ED via walk-in on 9/9/25 at 9:55 p.m. with complaints of shortness of breath and chest pain rated at a 10 out of 10. The EMR indicated Pt 11 was seen by the triage nurse at 10:02 p.m. and assigned an ESI of 3. The EMR indicated the MSE was done on 9/10/25 at 12:03 a.m. and Serial Troponins were not done. The EMR indicated Pt 11 was discharged to home with a diagnosis of epigastric pain. The EMR indicated Pt 11 returned to the ED approximately 11 hours later on 9/10/25 at 11:28 a.m. with complaints of chest pain. CED stated Pt 11 should have been assigned an ESI of 2 not 3. Pt 11 was seen by the triage nurse at 11:33 a.m. and assigned an ESI of 3. Medical Screening Exam (MSE) done at 12:32 p.m. Serial Troponins were not done. The record indicated Primary impression: Chest wall pain. During a concurrent interview and record review on 9/17/25 at 4:46 p.m. with EDM, EDM stated that the ESI for Pt 11 should have been scored a 2 because of Pt 11’s chest pain and his subsequent return to the ED and should not have been scored a 3. EDM stated she would have expected for the triage nurse to have assigned an ESI of 2 for Pt 11. EDM stated that not having any troponins for Pt 11 is not following proper procedures. During an interview on 9/17/25 at 2:13 p.m. with Cardiologist MD 4, MD 4 stated patients presenting with chest pain need to have serial troponins before they can be declared stable for discharge. This includes in the emergency department. MD 4 stated the initial troponin often does not show much, it is the second and third troponin where you would see the best diagnostic information. During an interview on 9/18/25 at 2:50 p.m. with Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), CNO stated patients presenting with chest pain should receive serial troponins. CEO agreed this is the expectation. Both CEO and CNO stated it was not appropriate to assign an ESI of 3 for patients presenting with chest pain. During a review of the facility’s policy and procedure titled, “Care of the patient in the Emergency Department: Triage to Discharge”, revised date 2/2025, indicated on their excel table that, “active chest pain patients” have an acuity of, “high-risk situation” and the assigned ESI level is a, “Level 2”. Patients should be, “roomed immediately and reassessed with continuous monitoring of vital signs hourly or more if condition warrants it with documentation”. During a review of the facility’s order set titled, Chest pain Order Set (undated), the Chest Pain Order Set indicated under the, “Standard Lab Order” section that, “All lab orders will be STAT” including, “Troponin - repeat Q3 hours until stable or down trending”. During a review of professional reference titled, “Emergency Severity Index (ESI) Handbook: A triage tool for emergency department care”, dated 2023, the handbook indicated,”... the importance of correct assignment of the ESI is to ensure critically ill patients receive immediate attention. Mis-classification can delay life-saving care. Whereas accurate ESI helps in triaging and streamlines patient flow.””

“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: 37529 Based on interview and record review the hospital failed to provide stabilizing treatment in the Emergency department for three of 20 sampled patients (Pt 1, Pt 2, and Pt 3), when: 1. Pt 1 came to the emergency department (ED) by ambulance on 6/13/25 at 11:50 a.m. with complaints of a two-week history of shortness of breath, cough, and increasing weakness, which resulted in Pt 1’s inability to stand on her own. Pt 1’s medical history included hypertension (high blood pressure) and chronic kidney disease (CKD). Pt 1’s electrocardiogram (EKG/ECG) in the ambulance indicated,”Device interpretation: Large anterolateral infarct, age undetermined. Tachycardia, right and left atrial enlargement, right bundle branch block”, she was hypotensive (low blood pressure) in the ambulance and was given intravenous fluids. On arrival to the ED, Pt 1’s heart rate was 108 beats per minute (bpm, normal 60-100 bpm), respiratory rate was 50 respirations per minute (rpm, normal 12-20 rpm), she was hypoglycemic (low blood sugar) and the medical screening exam (MSE) was initiated by the ED physician shortly after Pt 1’s arrival. Pt 1 was placed on BiPAP for respiratory support, initial lab tests and vital signs suggested severe sepsis (an emergency medical condition), and one dose of antibiotics was given. When additional lab tests and imaging studies were completed, the results indicated Pt 1 had acute right heart failure (also an emergency medical condition). Despite having two identified Emergency Medical Conditions (EMCs), after the transfer process was initiated at 5:43 p.m., no stabilizing measures were implemented, no intake and output was documented for the entire stay, interpretation of cardiac rhythm was not recorded, vital signs were not recorded for five hours, administration of medication ordered for low blood pressure and heart failure was delayed, and when Pt 1’s blood pressure was not being picked up by the monitor it was not immediately acted upon. No calls to initiate transfer requests were made for a three hour period from 6:29 p.m. until 9:37 p.m., the nursing staff and the physician did not recognize the seriousness of Pt 1’s condition, the physician did not request the on-call cardiologist come into the hospital to consult on Pt 1’s care, and did not consider accessing the resources of the hospital’s intensive care unit for hemodynamic monitoring and specialty care in order to stabilize Pt 1 while the transfer was being arranged. 2. Pt 2 came into the Emergency Department (ED) on 7/28/25 for chest pain 10/10, status post pacemaker/Automatic Implantable Cardiovert Defibrillator (PM- provides timed electrical impulses for slow heartbeats/AICD both implanted in the chest monitors heart rhythm and delivers electrical pulses or shock to correct a dangerously fast or irregular heartbeat to prevent cardiac arrest) placement 1 week prior, was assessed and discharged with diagnosis of rib contusion. Pt 2 came back by ambulance less than three hours later and was diagnosed with severe sepsis (a life-threatening stage of a serious infection where the body’s immune response causes organ damage, leading to symptoms like low blood pressure, confusion, difficulty breathing, and reduced urine output) and MI (myocardial infarction- heart attack). Because of the actual serious harm to patient 1 (death) and the potential for serious harm to patient 2 related to the hospital’s inability to provide appropriate stabilizing treatment that was within their capability an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2407 42 CFR 482.24(d)(3) on 9/16/25 at 2:50 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), the Chief Operations Officer (COO), the Chief Medical Officer (CMO), Director of Quality (IP/DQ), and Risk Manager (RM). The IJ (immediate Jeopardy) template was provided to the facility. The hospital submitted an IJ Plan of Removal (Version One) on 9/17/25 at 10:01 a.m. and it was unacceptable. The hospital submitted an IJ Plan of Removal (Version Two) on 9/17/25 at 4:54 p.m. which was reviewed and was unacceptable. The hospital submitted an IJ Plan of Removal (Version Three) on 9/18/25 at 1:15 p.m. After consultation with CMS, the Plan of Removal was accepted on 9/18/25 at 1:56 p.m. with the CEO, CNO, and RM. On 9/18/25 the survey team validated all staff currently working were being educated on the IJ for A2407 Stabilizing Treatment, posters were placed in appropriate areas for staff education in the ED, badge buddies were being distributed to all ED staff, testing to confirm material was understood and the hospital had a plan for all staff that work in the ED to be educated before coming back to work. The IJ was removed onsite with the CEO, CNO, and RM in attendance on 9/18/25 at 3:19 p.m. EMTALA violations remained following removal of the IJ 3. Pt 3 was brought in by ambulance on 7/1/25 after being in a motor vehicle accident (MVA) with a chief complaint of 10/10 chest pain and an open bleeding wound on his left hand. Pt 3 was assigned an ESI of 2, triage started 45 minutes after arrival and MSE started 1.5 hours after arrival to ED. Pt 3’s pain was not treated until almost six hours after arrival to the ED and his hand was not treated for four hours after arrival. These failures resulted in not stabilizing the emergency medical condition and led to Pt 1 suffering a cardiac arrest and died less than 12 hours after arriving in the ED and Pt 2 and 3 not receiving the care needed to stabilize their emergency medical conditions. Findings: 1. During a concurrent interview and record review on 9/15/25 at 10 a.m. with the Informatics Nurse (IN 2), Patient 1’s medical record was reviewed. IN 2 stated he worked in the ED before he was hired as an informatics nurse. Review of the Patient Care Record (PCR- Record of prehospital care provided by Emergency Medical Services [EMS] personnel), dated 6/13/25, indicated Pt 1 was a 58 year old with a medical history of high blood pressure, chronic kidney disease and hyperlipidemia (too much cholesterol in your blood) who complained of severe weakness and shortness of breath and cough for two weeks, and was hypotensive (low blood pressure- less than 90/60 millimeters of mercury [mmHg]) with a blood pressure (BP) of 86/52 mmHg when EMS arrived at her house. Pt 1 received intravenous (IV-into a vein) fluids in the ambulance on the way to the hospital. The electrocardiogram (ECG/EKG) obtained in the ambulance indicated, “Device interpretation: Large anterolateral infarct, age undetermined. Tachycardia, right and left atrial enlargement, right bundle branch block.” Pt 1 arrived in the ED at 11:50 a.m. and was triaged at 11:55 a.m. Pt 1 was alert and oriented and initial vital signs were temperature 37.8 degrees Celsius (100 degrees Fahrenheit), heart rate 108 beats per minute (bpm, range 60-100 bpm), BP 108/70 mmHg, respiratory rate was 50 respirations per minute (rpm, range 12-20 rpm), oxygen saturation 98 % on five liters of oxygen. IN 2 stated he was not able to find documentation of an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient’s condition and the resources needed, ESI 1 is the most serious, in order to prioritize care) level assigned at triage. At 12:05 p.m. an EKG was obtained. EKG Machine interpretation: sinus tachycardia. Right and left atrial enlargement, incomplete right bundle branch block, right ventricular hypertrophy, probable septal myocardial infarction of indeterminate age, lateral myocardial infarction of indeterminate age, moderate t-wave abnormality, consider anterior and inferior ischemia. MD 1 initialed the EKG at 12:05 p.m. There was no indication in the record whether or not a cardiologist ever interpreted the EKG. Review of the “Emergency Department Order Set,” dated 6/13/25 at 12:03 p.m., indicated orders were placed by the ED Physician (MD 1) for, “Continuous ECG [EKG] monitoring, Blood pressure, Pulse, Respiratory Rate, Oxygen Saturation, and Temperature. Oxygen to maintain Oxygen Saturation greater than 93%. EKG ...Chest x-ray ...” lab tests, and intravenous (IV-into a vein) dextrose (sugar) 50% (D50). The sepsis order set was not initiated for Pt 1. Pt 1’s blood glucose (sugar) was 61 milligrams per deciliter (mg/dL, range 70-100mg/dL) and Pt 1 was given one amp (50 milliliters [mL]) of IV dextrose (sugar) 50% (D50). A foley catheter was placed. The respiratory therapist attempted to put Pt 1 on Bilevel positive airway pressure (BiPAP- a non-invasive ventilation therapy that delivers higher air pressure when breathing in, and lower when breathing out), however at first Pt 1 did not tolerate it and had what was initially thought to be a seizure (abnormal electrical activity in the brain causing changes in awareness and muscle control) and Pt 1 was given 10 mg of IV diazepam (a medication to control seizures). Pt 1 was placed on BiPAP at 1:15 p.m. Lab results from blood samples collected at 12:05 p.m. indicated white blood cells were elevated, (12.7; range 4.6-10) and liver function tests (LFT) were elevated. Troponin (proteins that are released when the heart muscle has been damaged) drawn at 12:17 p.m. was 46.3 picograms/milliliter (pg/mL- range 10-20). Lactic Acid (elevated in patients with sepsis or conditions such as liver failure) drawn at 12:18 p.m. was elevated at 5.6 millimoles per liter (mmol/L- range 0.5-2.0 mmol/L), at 1:08 p.m. it was 6.53 mmol/L. Results of the chest x-ray completed at 12:45 p.m. indicated, “Cardiomegaly [an enlarged heart] with pulmonary vascular congestion [a buildup of fluid in the lungs].” Brain natriuretic peptide (BNP-a hormone released by the heart when it is under stress, elevated in heart failure) drawn at 1:45 p.m. was elevated at 1596 picograms per milliliter (pg/mL, normal range 0-100 pg/mL). The record did not indicate blood cultures were ordered, and no blood cultures were done. Review of the medication administration record (MAR) indicated Rocephin (an antibiotic, used to treat bacterial infections) 1 gram IV was given at 2:05 p.m. The MAR also indicated an IV infusion of Lactated Ringers (LR, an intravenous fluid) was started at 1 p.m., however the amount of fluid infused and the time the infusion ended were not documented anywhere in the record. The intake and output record where staff document all oral or intravenous fluids administered to the patient and all urine collected from the foley catheter, was blank for Pt 1’s entire ED stay. A computerized tomography scan, (CT scan- uses X-rays and a computer to create detailed cross-sectional images of the body) of the chest, abdomen and pelvis for shortness of breath (SOB) and sepsis (the body’s overwhelming and life-threatening response to infection) and CT angiography (CTA- medical imaging that combines a CT scanner and an injection of dye to produce detailed images of both blood vessels and tissues in various parts of the body) of the chest, abdomen, pelvis were completed at 3:15 p.m. Results indicated, “Marked dilation of the right atrium and ventricle with compression of the left atrium and ventricle. Main pulmonary artery is dilated suggesting pulmonary hypertension. Cardiology evaluation is recommended. Diffuse centrilobular micronodularity throughout both lungs suggesting an infectious/inflammatory process.” Lactic acid was rechecked at 4:40 p.m. and had decreased to 1.8 mmol/L. 5:57 p.m. EKG Machine interpretation: Sinus rhythm, right and left atrial enlargement, right ventricular hypertrophy, minimal ST depression, Abnormal ECG [EKG]. MD 1 initialed the EKG at 6:01 p.m. There was no indication in the record whether or not a cardiologist ever interpreted the EKG. Troponin was rechecked at 6:54 p.m. and had increased to 95.9 pg/mL (normal 10-20 pg/mL). Critical result called to physician at 7:28 p.m. Review of Pt 1’s “Outer Facility Transfer Log,” dated 6/13/25, indicated Pt 1’s diagnosis was “Right heart failure, pulmonary distress, respiratory failure, seizures,” and Pt 1 needed to be transferred to another hospital for “cardiology (cath lab)” services. The log listed the names and contact information for 27 hospitals for the staff to use when initiating transfer requests, spaces to write the date and time of the call, the name of the hospital contacted, the name of the person contacted, whether the transfer was accepted or declined, and the reason (if declined), and any additional comments. The log indicated on 6/13/25 at 5:43 p.m., the first call was made to a hospital (Hospital B) in an attempt to transfer Pt 1, and the reason declined was “does meet requirements,” with no explanation of what this meant. At 6:19 p.m. the second hospital (Hospital C) was contacted, and the reason declined was “no cath lab,” however Hospital C does have a cath lab, and no further explanation was documented. At 6:23 p.m. the third hospital (Hospital D) was contacted, did not accept or decline, and the comments were, “Needs to talk to cardiologist.” At 6:29 p.m. the fourth hospital (Hospital E) was contacted and the reason declined was “no higher level of care,” however Hospital E was a higher level of care, and there was nothing else documented to explain the comment. The log indicated no other calls to hospitals to initiate Pt 1’s transfer were made for three hours until 9:37 p.m. when Hospital F was contacted and “Cancel Transfer” was the only documentation regarding the call, with no explanation as to why the transfer request was cancelled. There were no additional calls to other hospitals to initiate a transfer request, and no information was documented to explain why. There was an untimed note written at the top of the log which indicated, “Per [ED Physician’s name], will try to get acceptance to [Hospital D] but no acceptance then will be accepted to [Hospital G].” There was no additional information regarding when Hospital G was contacted, if and when Hospital D declined and why, or any other transfer information. Review of the Emergency Department Chart- Provider note, undated and untimed, indicated, “Pt came as a stat. general weakness. Has been for a couple of weeks. Has history of hypertension [HTN]. Has been having cough for a couple of weeks. Uses a cane. Also had nausea, runny nose. Review of Systems [ROS]: Weakness. Resp: Shortness of Breath [SOB], Cough. GI: Nausea ...Physical Exam: Lungs clear. Tachypneic [breathing fast]. Ekg: Rate 104. Normal Sinus Rhythm [NSR]. Diagnosis: 1. Severe Sepsis 2. Acute Respiratory Failure 3. Right-sided heart failure 4. Pulmonary Hypertension.” Review of the “ED Provider Progress Record,” undated, untimed and unsigned, indicated, “ ...Initially tachycardic, tachypneic, febrile, meeting severe sepsis criteria, initial lactate 7. Started antibiotics [one gram of Rocephin given at 2:08 p.m.] and some fluid. Chest x-ray showed vascular congestion; fluids stopped. Placed on BiPAP for respiratory support. Pt doing better lactate down to 1.8 [drawn 4:40 p.m., resulted at 5:14 p.m.]. Troponin 40 to 90. LFTs [liver function tests] elevated ...CTA chest negative for pulmonary embolus, but showing likely right-sided acute heart failure and pulmonary hypertension. Discussed case with [name of cardiologist] who recommended transfer. Hospital B cardiologist declined. Discussed case with [name of intensivist (physician specializing in critical care of patients in the intensive care unit-ICU)] who also recommended transfer. Hospital B ICU declined. [Name of intensivist] recommended central line and dobutamine [a medication given for heart failure (when the heart muscle doesn’t pump blood as well as it should) and shock]. Right internal jugular [IJ] placed and confirmed on x-ray and dobutamine started [at 9:10 p.m.] ...Discussed care with hospitalist and [name of oncoming ED physician] who will assume care of patient and continue transfer attempt and admit here if unable to transfer ...” Review of the physician’s orders for Pt 1’s ED stay did not indicate an order to transfer Pt 1 to another hospital, or to admit Pt 1 to Hospital A. Review of the vital signs (VS) record indicated vital signs were obtained at 1:30 p.m., 2:30 p.m., 3:37 p.m. and not again until 8 p.m. At 8 p.m. Pt 1’s BP was 95/65 mmHg, heart rate 112 bpm, respiratory rate 33 rpm, oxygen saturation 94% on BiPAP. A dobutamine IV drip was ordered at 8 p.m. and was started at 9:10 p.m. The record indicated at 10 p.m. Pt 1’s BP was “not reading,” heart rate 110 bpm, respiratory rate 31 rpm, temperature 99.7 degrees Fahrenheit (F), and oxygen saturation 95% on BiPAP. There was no documentation of another attempt to obtain Pt 1’s blood pressure either with another blood pressure monitor or with a manual blood pressure cuff, or by palpation and no notification to the physician until after 11 p.m. Review of the nurses notes indicated at 10 p.m., “Patient accepted at [Hospital G]. Paperwork is underway. MD indicated patient will be transferred to Hospital G in the morning.” There was no further information in the record regarding transfer plans to Hospital G, the name of the MD who indicated the patient would be transferred in the morning, or why the transfer was delayed. Review of the “ICU Consult Note,” dated 6/13/25 at 10:56 p.m., indicated, “Pt seen and examined. Labs and meds reviewed. Pt on BiPAP, alert but diaphoretic [sweating excessively]. Heart rate 115-120 bpm. Blood Pressure: Not recordable. [Oxygen] Saturation 95%. Lung base crackles. Tachycardia. Extremities: Cold, clammy ... Impression: Acute hypoxic respiratory failure. Shock ...? Sepsis. Likely cardiogenic. Acute right ventricular failure. Acute renal failure ...Recommendations: Start Antibiotics: Ceftriaxone/Azithromycin. Nothing by mouth [NPO]. IV Pressors: Levo [Norepinephrine- medication used to treat life threatening low blood pressure] and Dobutamine [a medication given for heart failure (when the heart muscle doesn’t pump blood as well as it should) and shock]. Seen by cardiology at [Name of hospital]. Please transfer patient to a higher level of care for cardiology services. May need intubation if deteriorates ...” Review of the nurses notes dated 6/13/25 at 11p.m. indicated, “ ...Pt is becoming agitated, heart rate is 110 [bpm] and BP is being checked manually. Not getting BP readings and MD notified. MD ordered Levophed to be administered. 11:10 p.m.- Levophed is pulled, RT in the room ...Pt became unresponsive, code blue is called ...” Review of respiratory therapist notes dated 6/13/25, indicated at 11:15 p.m., “I [Respiratory Therapist (RT)] was checking patient on BiPAP and Pt was not responding to stimuli. I called the RN over and we told the doctor in ER, and we started CPR. Code blue was called ...” Review of the Code Blue Flow Sheet documentation indicated at 11:11 p.m. Pt 1 did not have a pulse, a code blue was called at 11:12 p.m. and CPR was started. At 11:15 p.m. the EKG monitor indicated Pulseless Electrical Activity (PEA- the heart has detectable electrical activity but is unable to generate a palpable pulse). The record indicated the code continued until 11:43 p.m. when Pt 1 was pronounced dead. During an interview on 9/15/25 at 4:40 p.m. with the CEO, concerns identified during the review of Pt 1’s record were discussed. The CEO stated she was not aware of this patient prior to this survey and would review this record. During an interview on 9/16/25 at 10:15 a.m. with the Chief Medical Officer (CMO) and the CEO, the CMO stated the medical director of the ED left around a month ago and he (the CMO) was the acting medical director of the ED until the hospital was able to find a replacement. The CMO stated he had reviewed Pt 1’s record, and the CEO stated that she had as well. The CMO stated he reviewed the ED physician’s narrative note and it was not dated or timed and should have been. The CMO stated the ED physician consulted with the on-call cardiologist and the intensivist after the results of the CT scans showed heart failure, and the on call physicians recommended transfer. The CMO stated the CT scans were completed at 3:15 p.m., but he does not know when those physicians were contacted or what information they were provided, because the ED physician did not document that, and there is no consult note from the cardiologist, and the intensivist’s consult note was from 10:56 p.m. when the intensivist examined Pt 1. The CMO stated the intensivist’s note indicated Pt 1 had been seen by the cardiologist while in the ED, however that was not accurate. The CMO stated the ED physician spoke to the cardiologist on the phone. The CMO stated it appeared the hospital tried to transfer the patient but was unable to do so prior to Pt 1 coding. The CMO stated he did not know how many hospitals were called or when, to request the transfer or if the staff escalated the transfer request up through the chain of command if there was a delay. The CMO stated he reviewed the RN’s note that indicated Pt 1 had been accepted for admission to Hospital G but not until the following morning (6/14/25), but the CMO stated there is nothing in the record or transfer log to confirm or explain that. The CMO was asked about admitting or moving Pt 1 to the intensive care unit (ICU) for close observation and monitoring and initiation of ongoing stabilization measures while the transfer was being arranged, given the ED physician note indicated admission at Hospital A if not transferred to another hospital for a higher level of care. The CMO stated the hospital could not admit Patient 2 to the hospital because they could not provide the care needed, referring to cardiology services with a cath lab. Pt 1’s RNs and the ED physician (MD 1) were not available for interview during the survey. During an interview on 9/16/25 at 1:35 p.m. with the ED Clinical Coordinator (EDCC 1), and the hospital’s clinical educator (CE), EDCC 1 stated part of the clinical coordinator role is to coordinate patient transfers out of the ED to other hospitals. EDCC 1 stated the ED physician will let him know when a patient is to be transferred and what specialty is needed. There is a transfer out form that is completed with the patient’s name, diagnosis and the specialty need that they (Hospital A) cannot provide, for example neurosurgery. EDCC 1 stated they can usually find a hospital to accept the patient, but if they are having difficulty finding a hospital to accept the patient or if the process is taking longer than usual, EDCC 1 stated he would escalate the request using their chain of command. EDCC 1 stated the CC and/or the unit clerk keep the physician informed concerning the transfer process. The EDCC stated he was not involved in the transfer request for Pt 1 and did not have any information as to why additional hospitals were not contacted or why there was a three hour lapse between the calls to other hospitals to request Pt 1’s transfer. EDCC 1 stated the form has a list of many hospitals with the contact telephone number, and calls are made until the patient has a place to go. EDCC 1 and CE were asked about the continuous cardiac monitors in the ED rooms and whether or not during a electronic health record (EHR) downtime situation affected the ability to monitor a patient and whether audible alarms would be functional. The CE stated the cardiac monitors were not affected by the downtime, they were not part of the same system as the EHR. The CE stated the monitor techs in the intensive care unit also observe the cardiac monitor activity of the patients in the ED and contact the ED if they see something concerning. The CE stated documenting on paper instead of in the EHR did not change the function of the monitor, the alarms, the appearance of the tracing, or the requirement for nurses to document what they observe on the monitor. EDCC 1 stated for the ED patients on continuous cardiac monitoring, there are computers at the ED nurses station next to where the CC sits that display the cardiac monitor activity for each ED patient. The CE stated the monitors in the ED can be easily disconnected to be able to function as a transport monitor when a patient is leaving the department in order to have a CT scan done. EDCC 1 and the CE stated they were not working the day Pt 1 died (6/13/25) so they did not have any information as to why there was no documentation of the alarms sounding before or during the time when the respiratory therapist checked on Pt 1’s BiPAP and found Pt 1 to be unresponsive and without a pulse. EDCC 1 stated the alarms would have been heard by the staff and seen on the monitor at the nurses station. The CE and EDCC 1 did not know why there were no printed paper monitor strips scanned into the medical record from the ED stay or the code blue. During an interview on 9/18/25 at 3:20 p.m. with the CNO and CEO, the CNO stated it was important to follow the sepsis protocol to recognize signs and symptoms, and all follow the same process. The CEO stated the sepsis protocol, screening tool, and order set all need to align. The CEO stated Pt 1’s record did not have evidence of a sepsis screening form completed or the sepsis order set initiated. During an interview on 9/18/25 at 3:30 p.m. with the CEO (also an RN), the CEO stated if a patient’s blood pressure is not able to be obtained by a blood pressure monitor, it is her expectation that the nurse assess the patient, check the patient’s blood pressure with a manual blood pressure cuff, and notify the physician. The CEO stated the nurse should verify the monitor was functioning properly also. As far as measurement and documentation of fluids given and urine output, the CEO stated accurate I&O is important particularly for patients whose condition may be affected by taking in too much fluid. During a review of the hospital’s policy and procedure (P&P) titled, “Emergency Medical Treatment & Active Labor Act (EMTALA) and Transfer Policy,” dated 2/25, the P&P indicated, “It is the mission of [Name of Hospital (Hospital A)] to provide a MSE and stabilizing treatment to all patients in a timely manner ...If staff determines that an individual has an emergency medical condition, then [Hospital A] shall: 1) Provide treatment to stabilize the medical condition within the capabilities of the staff and the facilities available at Hospital A; or 2) Provide for an appropriate transfer of the individual to another facility, after the emergency screening exam and stabilization. Stabilization of an Emergency Medical Condition means: Providing such medical treatment of the condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during the transfer or discharge of the individual from a facility ... Emergency Medical Screening Exam - Each person who presents to the facility for emergency must be examined and evaluated in enough depth and detail to determine whether an emergency medical condition exists Such screening must be done within the facility’s capabilities and available personnel, including on-call physicians. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient’s needs and continue until the patient is either stabilized or appropriately transferred. Consultations: When necessary, the screening examination and evaluation shall include consultation with specialty physicians qualified to give an opinion or to render treatment necessary to stabilize the individual. Such consultation may be obtained by telephone. However, when the emergency and specialty physicians jointly determine it medically necessary, the consultation shall include review of the individual’s medical record and examination and treatment of the individual in person by the specialty physician ...” During a review of the hospital’s P&P titled, “Care of the Patient in the Emergency Department: Triage to Discharge,” dated 9/25, the P&P indicated, “ ...Purpose: To provide nursing care guidelines in evaluating patients on arrival to the Emergency Department (ED), providing ongoing high quality care and assessment of the patient during their ED stay and providing a safe discharge that meets the needs of the patient ...Reassessment and care of the patient: 1. All patients will have an initial nursing assessment completed by an RN during their stay in the Emergency Department. Ongoing reassessment will be based on their ESI level and or a change in their condition or on discharge. Ongoing reassessment includes vital signs, physical assessment and evaluation of the treatments given to the patient. 2. Nursing staff will deliver care/ treatments ordered by the ED provider who is assigned to the patient. They will document the care/treatments given in the patients’ medical record and report back to the provider the patient’s response to the treatment/care ...” During a review of the hospital’s P&P titled, “STANDARDS OF EMERGENCY NURSING PRACTICE,” dated 4/25, the P&P indicated, “ ...The clinical assessment and documentation is to include vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation and pain assessment) and shall be based on the initial documented patient triage acuity using the ESI classification system ...Level 2: no less than every hour for the first four hours, then every 2 hours if clinically stable ...” During a review of the hospital’s document titled, “Sepsis Alert Checklist/Handoff Tool,” undated, the document indicated, “ ...2 SIRS criteria (Systemic Inflammatory Response Syndrome criteria- set of four clinical indicators for widespread inflammation: temperature greater than 100.4 degrees Fahrenheit [F], or less than 96.8 F, heart rate greater than 90 bpm, respiratory rate greater than 20/min, or white blood cell count greater than 12,000) and Suspected Infection= Code Sepsis ...” During a review of the hospital’s P&P titled “Sepsis Assessment and Treatment,” dated 8/24, the P&P indicated, “ ...Sepsis screening will be performed for all patients in the Emergency Department [ED] at triage ...If the screen is positive for sepsis the RN will notify the physician, and the physician will order the Sepsis Order Set ...” During a review of the document titled, “Sepsis Order Set,” undated, the document indicated, “ ...Nursing Orders: Continuous ECG monitoring, Blood Pressure, Pulse, Respiratory Rate, Oxygen Saturation, and Temperature. Oxygen as needed to maintain oxygen saturation greater than 93%. Insert two large bore IV lines or central access if needed. Blood Cultures: Obtain two sets of blood cultures from different sites before administering antibiotics ...” During a review of the P&P titled, “Sepsis Identification and Management Policy,” dated 9/25, the P&P indicated, “PURPOSE: To provide a standardized approach for the early identification, timely treatment, and monitoring of patients with suspected or confirmed sepsis ...SCOPE: ED Physician: Assess patient for sepsis, order and oversee sepsis order set. Escalate care for patients requiring ICU inpatient admission or transferring for a higher level of care. Roles and Responsibilities: Physicians: Assess patient, determine medical necessity, identifies transfer need, initiates process, and completes physician to physician acceptance at accepting facility. Clinical Coordinator: ...Prepare patients, coordinate transport, oversee process, escalates with difficult acceptance, ensures documentation completeness. Registered Nurse: Perform sepsis screening at triage and admission ...Monitor and document vital signs, urine output and reassessments. Notify provider of abnormal findings or deterioration ...” During a review of the professional reference titled, “Nursing care of the patient hospitalized with heart failure: A scientific statement from the American Association of Heart Failure Nurses,” dated 2/13/24, retrieved from https://doi.org/10.1016/j.hrtlng.2024.01.007, the reference indicated, “ ...Clinical nurses: Clinical assessment, care plan development, and patient education are paramount nursing roles in the overall management of patients with HF, irrespective of acuity. Vigilant monitoring of patient symptoms, vital signs, fluid intake and output, and daily weight are crucial assessments, particularly during phases of active diuresis. The medical care teams depend on nurse assessments to formulate comprehensive treatment plans to guide safe, effective care, and manage symptoms. Nurses also provide support for patients with activities of daily living (ADLs) and serve as liaisons between medical care teams and caregivers and families. Emergency care: The goal of HF management in the emergency department (ED) is to stabilize hemodynamics and improve symptoms. The role of the ED clinical nurse is to triage, monitor, and evaluate patients who present with signs and symptoms of HF. The focus of treatment is decongestion (typically with intravenous [IV] diuretics), assessment and monitoring of end-organ perfusion and oxygenation, optimization of cardiac output with administration of inotropes when appropriate, and management of arrhythmias. Additionally, the ED clinical nurse coordinates with the multidisciplinary team and facilitates the disposition to discharge, continued observation, or admission to the inpatient setting. Laboratory: Nurses review laboratory results and are accountable for timely noti?cation to the medical team of critical results. During diuresis, nurses are responsible for recording intake and output volumes and daily weights ...” 2. During a concurrent interview and record review on 9/15/25, at 11:07 a.m., with the ED Manager (EDM), Pt 2’s ED Visit electronic health records (EHR) dated 7/28/25 was reviewed. Pt 2’s EHR indicated Pt 2 arrived at 7:36 p.m. with a chief complaint of 10/10 (verbal pain scale 1-10, 10 worst pain) chest pain, describing its location as the left upper quadrant abdomen located just under the heart. Pt 2 had a recent history of PM/AICD placed approximately one week prior (no mention in Triage charting what the PM/AICD site looked s like). At 7:39 p.m. vital signs done all within normal limits. At 7:47 p.m. EKG (electrocardiogram- print out of electrical activity of the heart) completed, MD 2 (medical doctor) read no stemi (meaning no ST elevation heart attack seen). MD 2 ordered chest pain protocol and labs to include Troponin (cardiac enzyme if elevated indicates heart damage), CBC (complete blood count), CMP (complete metabolic panel), BNP (Brain Natriuretic Peptide - hormone released by heart can indicate heart failure), Lipase (breakdown dietary fat), PT and INR (prothrombin time and International Normalized Ratio - assess blood clotting ability) and UA (urinalysis). At 8:07 p.m. MD 2 orders Toradol (powerful nonsteroidal anti-inflammatory drug (NSAID) used for the short-term treatment of moderately severe, acute pain), Morphine (powerful and highly addictive opioid medication used to treat severe pain), Zofran (an anti-nausea medication used to prevent vomiting), and chest x-ray (imaging test that uses a small amount of radiation to create pictures of the lungs, heart, blood vessels, ribs, and diaphragm to help diagnose conditions) two view and these were given and completed. Results for Pt 2’s labs and x-ray include, wbc (white blood cells) 11.7 (normal 4.6-10), Percentage of Neutrophils 7.8 (normal 1.7-7.6), troponin 7.7 (normal 10-20), small left pleural effusion (fluid accumulation in the space between the left lung and chest wall, which may cause symptoms like a cough, chest pain, or shortness of breath). At 9:46 p.m. Pt 2’s pain was reassessed by the nurse and patients stated it was much better and now 2/10. At 11:42 p.m. MD 2 put disposition time with diagnosis of Rib Contusion, patient in stable condition, labs within normal limits and can be discharged home. On 7/29/25 at 12:25 a.m. During a review of Pt 2 “Emergency Department’s After Care Sheet,” dated 7/29/25, at 12:23 a.m., the sheets discharge instructions given indicated patient should back if symptoms get worse, pain level 2/10, condition stable, depart time 12:26 a.m., and patient able to walk at time of discharge. During a concurrent interview and record review on 9/15/25 at 11:30 a.m., with the EDM, Pt 2’s ED Visit EHR’s dated 7/29/25 were reviewed. Pt 2’s EHR for 7/29/25 indicated he was brought in by ambulance (BIBA) to the ED at 3:44 a.m., with a stated complaint of (C/O) severe sepsis, elevated troponin and chief complaint hypotension (low blood pressure). At 3:53 a.m. triage nurse assesses Pt 2 “Pt arrives via EMS [Emergency Medical Services] with C/O hypotension and syncope (dizziness or fainting). Pt was here prior for the same complaint. Denies Pain.” Vital Signs (vs) respiratory rate (RR) 19, heart rate (HR) 89, 0/10 pain. Pt 2 has a history of falls and currently has weak gait. At 4 a.m. wbc 16.7 high. At 4:42 a.m. HR 108, RR 23, 97 percent on 2 liters (L- oxygen) nasal cannula (nc-a thin, flexible tube that wraps around your head, typically hooking around your ears to deliver oxygen to the patient), blood pressure (BP) 108/83. At 4:59 a.m. Pt 2 reports 9/10 chest aching, cramping pain. MD 2 discussed the case with on call cardiologist who recommended repeat troponin and EKG. At 5:20 a.m. vs HR 102, RR 23, 94 percent on 2 Ll nc, BP 83/58. At 5:44 a.m. Troponin critical lab 131.7 and Lactic Acid (lab used to diagnose lactic acidosis, a dangerous condition where lactic acid levels in the blood become too high, indicating that cells are not receiving enough oxygen or the liver is unable to process the acid) 4.7 reported to MD 2. 6:42 a.m. EKG done MD aware - ischemic (a less-than-normal amount of blood flow to part of your body) changes compared to prior EKG on 7/28/25 at 7:40 p.m. At 8:05 a.m. Troponin critical lab 435.1 reported to MD 3. At 9:18 a.m. Echo (echocardiogram- An ultrasound test that provides information about a person’s heart structure and function) at bedside no results seen. The Hospital attempted to do a CTA (Computed Tomographic Angiography- A non-invasive medical imaging test that uses X-rays and a special dye to create detailed 3D images of blood vessels, often to check for blockages in the heart arteries or other parts of the body.) of Pt 2’s chest, patient became anxious and said he could not breathe pulling off everything and was not able to get CTA done. On 7/30/25 Pt 2 received 1 unit of blood. Pt was transferred to a higher level of care, via helicopter, for cardiothoracic surgical consultation. During a concurrent interview and record review on 9/17/25, at 10:16 a.m., with MD 2, Pt 2’s ED visit for 7/28/25 was reviewed. MD 2 stated on 7/28/25 she was working at this hospital for the first time, she was being orientated to the hospital’s system and did not know she would be doing paper charting, her shift was from 7 p.m. to 7:30 a.m. the next morning on 7/29/25. MD 2 stated she did not remember Pt 2 until after he was described as a 50-year-old male had an PM/AICD placed one week prior, came in for Chest pain 10/10, history of cardiac stents, and a heart attack in 2022. MD 2 stated Pt 2 had an extensive cardiac history. MD 2 stated “yes” she vaguely remembered Pt 2 and believed the pain was more associated at the time with his surgical site because he had been doing some lifting. Review of MD 2’s ED Provider note dated 7/28/25 indicated she had a differential diagnosis (most likely condition causing a patient’s symptoms) of Acute Coronary Syndrome (ACS- a medical emergency that includes unstable chest pain and heart attack), pneumothorax (a condition where air leaks into the space between the lung and the chest wall), costochondritis (inflammation of cartilage in your rib cage that connects your ribs to your breastbone), rib fracture (break), and/or rib contusion (bruising) and “labs all WNL (within normal limits) Trop (troponin x 1) neg (negative)”. MD 2 stated Pt 2 mentioned that he had seen his cardiologist earlier that day and that his PM/AICD was working properly. MD 2 stated to rule out ACS a patient with chest pain the standard of practice is to do serial (series of three done 3-6 hrs apart) troponins for all patients to rule out ACS. MD 2 stated she looked at Pt 2’s EKG to rule out that he was not having a heart attack but did not notice the pacer spikes (electrical signals generated by an artificial pacemaker that appear on an electrocardiogram) were not in appropriate places, if she had noticed she stated she would have called the cardiologist and had his PM/AICD interrogated (looked at to make sure it was working appropriately). MD 2 stated, “It was so chaotic. I knew I shouldn’t have taken the shift, but they were desperate, [there were] no electronic medical records and I was being trained at the same time.” MD 2 stated she was present when Pt 2 came back by ambulance for hypotension and syncope but did not recall that his troponin was elevated on his return. During an interview on 9/16/25, at 8:36 a.m., with Pt 2, Pt 2 stated, “I started having pain the day after my surgery ... the pain was right below my heart ... on Monday and Tuesday I had a little attack and on Thursday, Friday and Saturday I was having pain. I saw my Cardiologist on Monday and told him I was having the pain, and he said it was normal.” Pt 2 stated, “When I went to the ED, they didn’t do what they should have done. They sent me home like I was just having a stomach pain or something. They didn’t listen to me, the MD that was on wouldn’t listen to me. My wife is a registered nurse, and the MD just kept writing us off like it was no big deal.” Pt 2 stated he was discharged home and within one hour of being home he passed out in the hallway and his wife had to help him to the bathroom where he passed out again and fell off the toilet and was wedged between the toilet and the wall. Pt 2 stated my wife had to call emergency services to come help me up and they brought me back into the hospital. Pt 2 stated that the surgeon that had put in his PM/AICD had nicked his heart, and it was causing it to bleed into his chest, they ended up putting in a chest tube and almost got three liters out of blood and he ended up being flown to a different hospital that had a cardiothoracic surgeon. During an interview on 9/16/25, at 3:45 p.m. with the Chief Executive Officer (CEO) and the Chief Medical Officer (CMO), they were requesting clarification on the issues that were found during review of Pt 2’s EHR ED visit 7/28/25, CMO stated he did not feel Pt 2 required serial troponins to be done (Of note the CMO is not a cardiologist). The CEO stated that the chest pain protocol/order set indicates that serial troponins are being ordered and this is the standard of practice for patients presenting with chest pain. During review of Pt 2’s ED visit on 7/28/25, there was no mention of what his surgical site looked like for his PM/AICD in either of the nursing assessments nor the MD 2’s assessment. During review of Pt 2’s EKG dated 7/28/25 indicated the pacemaker spikes were not pacing appropriately (meaning the pacemaker was not working appropriately). CMO stated the EKG should have been addressed during Pt 2’s first visit to the ED on 7/28/25. During an interview on 9/17/25, at 12:35 p.m., with Cardiologist (MD 4), MD 4 stated he has worked at this hospital a long time and he is currently working with them on the chest pain protocol and order set. MD 4 stated if a patient presents to the ED with chest pain that is cardiac related then he would expect staff to order serial troponins. MD 4 stated Pt 2 should have had serial troponins done on his first ED visit on 7/28/25. During an interview on 9/18/25, at 3:15 p.m., with the Chief Nursing Officer (CNO), the CNO stated it is important to follow the chest pain protocol to ensure quality of care and the safety of patients. The CNO stated it is important for the triage nurse to look at surgical incisions when patients come in with recent surgery. The CNO stated Pt 2’s first ED visit on 7/28/25 should have gone differently meaning Pt 2 should have had serial troponins done and either been placed on observation or admitted. The CNO stated ED nurses are required to have ACLS (Advanced Cardiac Life Support- refers to a set of advanced guidelines and skills developed by the American Heart Association (AHA) for healthcare professionals to treat life-threatening cardiovascular emergencies like cardiac arrest, stroke, and acute coronary syndromes), PALS (Pediatric Advanced Life Support- a specialized medical training program for healthcare providers designed to improve the care of critically ill infants and children) and they are working on getting their NRP (Neonatal Resuscitation Program, a course offered by the American Academy of Pediatrics (AAP) that trains healthcare professionals in the basic skills needed to resuscitate a newborn) certifications. The CNO stated the ED Nurses and telemetry monitor (monitoring the electrical activity of the heart) technicians should be able to read EKGs and tell if a pacemaker is not pacing appropriately. The CNO stated if this is found then they should report it to the ED providers immediately so they can decide if a cardiac consult is needed. The CNO stated staff should listen to their patients especially because they know their bodies and their health better than we do. Review of the Hospital’s “Chest Pain Order Set” not dated, the order set indicated, “Standardized Procedures: Continuous ECG monitoring, Blood Pressure, Pulse, Respiratory Rate, Oxygen Saturation, and temperature. Oxygen PRN to maintain O2. 93%. EKG. Standard Lab Orders: CBC and CMP. Troponin (repeat Q 3 hours until stable or down trending). BNP. PT, INR, aPTT. Lipase ...” Review of the Hospital’s policy and procedure titled, “Standardized Procedures,” dated 2/2025, indicated, “ ... Standardized Procedures shall be implemented on patients presenting in the Emergency Department. The RN will consult with the ED provider anytime questions or concerns regarding the patient’s care arise. PURPOSE: The immediate treatment of an acutely ill or injured patient is the primary goal of the Emergency Department ... To facilitate the timely treatment of Emergency Department patients with acute conditions, it is also recognized that trained Emergency Department RNs may have the responsibility to institute Standardized Procedures ... there may be situations in the Emergency Department when the provider is not immediately available for 15-30 minutes. At these times, the Standardized Procedures may be applied, and notification of the provider may occur when the provider becomes available ... 2. The following Standardized Procedures have been approved for Implementation by ED RNs: a. Abdominal pain b. Altered mental status without history of head trauma c. Chest pain, acute suspected to be cardiac in origin d. Chest pain, not suspected to be cardiac in origin ... m. Patients meeting sepsis criteria Standardized Procedures Implemented by an Emergency Department RN will follow [name of hospital] policies and procedures and the American Heart Association Guidelines for ACLS, BLS and PALS ... Procedures: ... C. Chest Pain, Acute - Suspected to be Cardiac in Origin a. Vital Signs: Blood Pressure, Heart Rate, Temperature, Oxygen Saturation, Respirations. b. Cardiac monitor. c. O2 to keep O2 sats greater than 92 %. d. Continuous Pulse Oximetry. e. Complete 12-Lead EKG within 10 minutes of arrival, (EKG to be shown to ED attending physician immediately). f. Saline lock IV (intravenous- in a vein). g. Draw blood for laboratory tests: CBC, Chem 14, troponin. h. Portable CXR (chest x-ray) i. Obtain urine specimen for U/A (urinalysis) for all, and urine HCG (for females Human Chorionic Gonadotropin- to detect pregnancy) of reproductive age ... M. Patients Meeting Sepsis criteria at triage [same as above but no troponin instead Blood cultures and Lactic acid].” 3. During an interview on 9/15/25, at 7:48 a.m., with Pt 3’s spouse, Pt 3’s care on 7/1/25 at this hospital’s ED was discussed. Pt 3’s spouse stated she is a retired nurse and the care they received at this hospital was not appropriate. Pt 3’s spouse stated she her and her husband were in a motor vehicle accident on the freeway and were hit in the rear by a semitruck, while they were at a dead stop, which forced them into the vehicle in front of them. Pt 3’s spouse stated that the airbags deployed and both of them suffered from the impact causing chest pain. Pt 3’s spouse stated they were bought to the ED by EMS and when they arrived her husband’s’ hand had a cut and was actively bleeding, both of them were in pain and only her husband was on a gurney. Pt 3’s spouse stated she did not feel staff knew what they were doing, and she had to ask them to treat her husband first since he was actively bleeding. Pt 3’s spouse stated both she her and her husband were placed in the same room due to how busy the hospital was and at times it felt like they were not treated like separate patients. Pt 3’s Spouse stated it took the hospital over four hours to address Pt 3’s bleeding hand and took them six hours to get him pain medication when he was having 10/10 chest pain. During a concurrent interview and record review on 9/15/25, at 10:12 a.m., with the EDM, Pt 3’s EHR for his ED visit on 7/1/25 was reviewed. Pt 3’s “RN’s History & Progress Form Emergency Department,” dated 7/1/25 at 4:49 p.m., the form indicated Triage started at 4:49 p.m. “ ... chief complaint BIB EMS (brought in by emergency medical services), MVA (motor vehicle accident), pt reports back of neck sore, chest is painful, SOB (shortness of breath), GCS 15 (Glasgow Coma Scale- scoring system ranges from 3-15 the better the score the better level of consciousness a patient has), cut on L (left) hand ...” Vital signs BP 157/88, HR 89, RR 18, temp 37.2 Celsius, 94 percent on room air (referring to patients oxygen levels), 10/10 pain. Chest Pain: Moderate, tightness, oriented x 3, speech normal. 79-year-old male with health history of Asthma (chronic lung condition), DM (Diabetes Mellitus- a chronic condition that affects blood glucose levels), PTSD (Post Traumatic Stress Disorder- a mental health condition that’s caused by an extremely stressful or terrifying event), HTN (hypertension- high blood pressure), mild anemia (condition where the body does not have enough red blood cells to carry oxygen effectively), sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep), ab (abdominal) sx (surgery) with mesh (provides structural support to strengthen weak or damaged tissue) placement, knee replacement (a surgical procedure that replaces the damaged cartilage and bone in the knee joint with artificial implants). MSE started at 5:36 p.m., MD ordered EKG, CBC, CMP, Troponin x 1, CT abdomen/pelvis, head, c-spine, and chest without contrast. EDM stated the expectation is for the triage nurse to see patients quickly after they arrive and to have the MSE started within the first 30 minutes of the ED visit. During a concurrent interview and record review on 9/15/25, at 10:25 a.m., with the EDM, Pt 3’s ED “Nurse Notes,” dated 7/1/25, were reviewed, the notes indicated at 7:30 p.m. “pt is still 9/10 (pain) reviewed with MD.” At 8:20 p.m. note indicated, “wound to L (left) knuckle - washed, dressing done and covered w/ (with) kerlix ...” At 9 p.m. note indicated, “Pt is requesting pain med (medication) for mid chest pain.” At 11:10 p.m. note indicated, “notified of same w/ medical order. [MD name] notified of pts wound L knuckle - bleeding continuing - bleeding controlled.” 7/2/25 at 3:50 a.m. note indicated, “Pt is ready for DC but Pt’s wife is not comfortable to go home/stay in Pt hotel as they are still in pain. [MD name] notified of unsafe DC and will be referred to case management for consultation in AM ... offered to transfer pt to a gurney but pt refused and stated he is more comfortable in recliner ...” Additional Notes dated 7/1/25 for Pt 3 reviewed, indicated, “Reassessment: ... 2118 [9:18 p.m.] sternum pain, aching 10/10. 2150 [9:50 p.m.] mid sternum c (chest) pain 10/10. 2220 [10:20 p.m.] mid sternum c pain 9/10. 0445 [4:45 a.m.] mid sternum c pain 9/10. 0530 [5:30 a.m.] mid sternum chest pain 3/10. 0800 [8 a.m.] slight chest pain 3/10.” Pt 3’s E.R. “Medication Administration Record (MAR),” dated 7/1/25 was reviewed, the MAR indicated, “2155 [9:55 p.m.] Morphine 4 mg (pain medication given).” 7/2/25 at 3:54 a.m. “Keflex (antibiotic) 500 mg (given).” At 3:37 a.m. “Lidocaine w/ epinephrine (numbing medication with medication used for allergic reactions)” administer prior to suturing. At 4:20 a.m. “Bacitracin (antibiotic used to prevent or treat minor skin infections) 1 app (application).” At 4:25 a.m. “Booster”. At 4:56 a.m. “morphine 4 mg (given).” EDM stated Pt 3 should not have had to wait six hours to get pain relief but also stated a patient with 10/10 pain may not want pain medication or need it based on how they are visually presenting to the nurse. Review of Pt 3’s “Physician’s Orders,” dated 7/1/25, the orders indicate Pt 3 had the following orders: 1. 7/1/25 at 5:50 p.m. CT Chest/Abdomen/Pelvis with IV contrast; 2. 7/1/25 at 9:44 p.m. Morphine 4 mg (milligrams- unit of measurement); 3. 7/2/25 at 2:34 a.m. Lidocaine, Booster tetanus (a vaccine that helps protect against tetanus, a serious bacterial infection that can cause muscle stiffness and paralysis) IM (intermuscular), and repeat CBC; 4. Keflex 500 mg PO (by mouth); 5. 7/2/25 at 4:16 a.m. Bacitracin, Morphine 4 mg IV; 6. 7/2/25 (no time) D/C (discharge) Pt. During a review of Pt 3’s “ED Provider Progress Record,” dated 7/2/25, at 3:37 a.m., indicated, “left hand laceration Lido c epi (lidocaine with epinephrine) wound irrigation site prepped c (with) betadine close 5-0 Nylon interrupted sutures Keflex (antibiotic) booster ... CT scan shows sternal fx (fracture) c Hematoma (bruise). He is > 12 hours since accident and is stable will obtain repeat CBC ... 3:48 a.m. HGB stable ... from trauma Not a safe D/C will consult with case management ... (no time) D/C patient per [name of doctor] Order. Per patient him and his wife got a hotel at [name of hotel] tonight c family member [name] will be coming to meet them and help back to Arizona tomorrow morning at 12:40 pt understood d/c instructions had no questions or concerns ... LAC, walked patient to taxi steady and stable gait. GCS 15.” During review of Pt 3’s “E.D. Discharge Nurse’s Notes,” dated 7/2/25 at 10:20 a.m., the note indicateds Pt 3’s disposition was is to hotel, verbal instructions, written instructions, and verbalized understanding, “driver: taxi driver RX given to: Patient” pain level 3/10, condition improved “Depart Time: 10:40 (a.m.).” During review of Pt 3’s “Emergency Department Aftercare Sheet,” dated 7/2/25, the sheet indicated “Prescription: ... Norco ... Lidocaine ... Keflex ... Discharge Instructions: MVA-muscle strains suture care Additional Instructions: Sternal fx Return for increased pain/ SOB or any concern sutures out in 7 days Follow-Up: Your Doctor/Clinic in sutures out 7 days ...” During an interview on 9/18/25, at 3:15 p.m., with the Chief Nursing Officer (CNO), the CNO stated when a patient reports a 10/10 pain score that the patient is saying they are in pain, and it should be treated. The CNO stated waiting six hours to treat a 10/10 pain for Pt 3 was not acceptable. The CNO stated patients should be triaged and a [medical] provider should see them within 30 minutes of arrival. The CNO stated that typically when a patient comes in by ambulance the triage nurse will see the patient and the provider will go over and see the patient right away. During a review of the hospital’s policy titled, “Emergency Medical Treatment & Active Labor Act (EMTALA) and Transfer Policy,” dated 2/2025, the policy indicated, “ ... PURPOSE: To ensure: 1. All patients seeking emergency care receive an emergency medical screening exam and stabilizing treatment ... G. [Hospital Name] shall provide care for all patients presenting themselves for emergency medical care. 2. Medical Screening Examination A. [Hospital Name] shall provide an appropriate emergency Medical Screening Exam (MSE) within the capabilities of the hospital, including ancillary services routinely available to the Emergency Department, for each individual who requests an emergency screening examination or treatment to determine if an emergency medical condition exists. The MSE shall be the same appropriate screening examination the hospital would perform on any individual coming to the hospital with those signs and symptoms, regardless of the individual’s ability to pay.”