Intermountain Health Lutheran Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient Rights, was out of compliance. A-0154 (e) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Based on interviews and documents reviewed, the facility failed to ensure physical restraints were discontinued at the earliest possible time in two of three restraint patients’ medical records reviewed. (Patient #16 and #20)”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 44751 Based on interviews and documents reviewed, the facility failed to ensure physical restraints were discontinued at the earliest possible time in two of three restraint patients’ medical records reviewed. (Patient #16 and #20) Findings include: Facility policy: The Patient Restraints and Seclusion policy read, use restraints only to protect the immediate physical safety of the patient, caregiver, or others. Restraints are not to be used as a means of coercion, discipline, convenience, or staff retaliation. Discontinue restraints at the earliest possible time, once the patient’s behavior is no longer a threat to self, caregiver or others, regardless of the scheduled expiration of the order. All restraint applications are continued pursuant to an order by the physician or Advanced Practice Provider (APP) primarily responsible for the ongoing care of the individual served. References: The Restraint Seclusion Violent/Self-Destructive Procedure, defined Violent or Self-destructive Behavior as unpredictable, physically threatening or assaultive behavior, behavior that is dangerous to the patient or others, patient exhibiting poor or absent impulse or behavioral controls. 1. The facility failed to ensure physical restraints were discontinued at the earliest possible time. A. Document Review i. Review of Patient #16’s medical record, revealed on 1/24/26 was transported by ambulance to the emergency department (ED) and at 5:21 a.m., the patient arrived in the ED. Further review revealed Patient #16 became combative with EMS staff and was mechanically restrained (4-point locking restraints attached to the body used to restrict movement) and administered 2.5 mg of droperidol (sedative medication). Review of the violent restraint order for Patient #16 revealed the patient was a danger to themselves and others. The release criteria on the order required the patient to no longer pose a danger to themselves or others. Further review of the restraint documentation revealed at 5:45 a.m., 24 minutes after the patient was restrained staff documented the patient was calm and sleeping. However, despite the patient being calm and sleeping, Patient #16 remained restrained until 7:45 a.m., a total of two hours and 24 minutes. ii. Review of the medical record for Patient #20 revealed EMS transported the patient to the ED on 1/26/26 at 12:02 p.m., after local law enforcement conducted a welfare check and found the patient manic and non-redirectable. At 1:00 p.m., staff placed the patient in 4-point locking restraints after the patient became undirectable and began yelling at staff. Review of the violent restraint documentation revealed at 2:00 p.m., one hour after the patient was placed in 4-point locking restraints, staff documented Patient # 20 was sleeping. Despite being asleep, Patient #20 remained restrained until 4:09 p.m., a total of three hours and nine minutes. The restraint events for Patient #16 and Patient #20 contrasted with the Patient Restraints and Seclusion policy. According to the policy staff were required to discontinue restraints at the earliest possible time once the patient’s behavior no longer posed a threat to the patient, caregiver, or others. B. Interviews i. On 3/3/26 at 2:14 p.m., an interview was conducted with ED provider (Provider) #3. Provider #3 stated staff used locking restraints when patients posed a danger to themselves or others and discontinued them once the patient no longer posed a threat. Provider #3 further stated a sleeping patient met the criteria for release from restraints and locking restraints should be discontinued. ii. On 3/5/26 at 2:43 p.m., an interview was conducted with ED registered nurse (RN) #1. RN #1 stated the patient had to meet the indicated release criteria before locking restraints were discontinued. RN #1 stated patients who were sedated or asleep did not exhibit harmful or threatening behaviors and no longer posed a threat to self or others.”

“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: 44751 Based on interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: A-2407: Stabilizing Treatment. (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. Based on interviews and documents reviewed, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient was stabilized before discharge in one of one emergency department (ED) acute respiratory failure (when not enough oxygen passes from the lungs to the blood) patient medical records reviewed.”

“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: 44751 Based on interviews and documents reviewed, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient was stabilized before discharge in one of one emergency department (ED) acute respiratory failure (when not enough oxygen passes from the lungs to the blood) patient medical records reviewed. (Patient #16) Findings include: Facility policy: The EMTALA policy read, if the medical screening exam (MSE) indicates the individual has an emergent medical condition (EMC), the facility shall provide the necessary stabilizing treatment within the capabilities of the staff and facilities routinely available at the facility prior to discharge or transfer. If the person is stabilized, the hospital may discharge or transfer the person as appropriate. The person’s stabilized condition shall be documented in the medical records. If the individual is not stabilized, the hospital will not discharge or transfer the person unless the following conditions are met and documented on the Patient Facility Transfer Form: the person requests in writing a discharge or transfer to another facility, a physician certifies in writing that the benefits of discharge or transfer outweigh the risks. Additionally, the EMTALA policy defined stabilizing treatment as medical treatment of a patient’s condition necessary to assure, within reasonable medical probability, that no material deterioration of the patient’s condition is likely to result. 1. The facility failed to ensure a patient’s oxygen (O2) saturation (amount of oxygen in the blood) was stabilized without supplemental oxygen (extra oxygen) before discharge. A. Document Review i. Review of the medical record revealed Patient #16 was transported by ambulance to the ED on 1/24/26. According to the emergency medical services (EMS) patient care record, at 4:43 a.m., Patient #16 became combative and was placed in mechanical restraints (devices attached to the body used to restrict movement). Further review of the EMS patient care record revealed, at 4:50 a.m., 2.5 mg of droperidol (sedative medication) was administered, and Patient #16 was placed on 2L supplemental oxygen. At 5:12 a.m., Patient #16 arrived in the ED. Additionally, review of Patient #16’s medical record revealed, at 1:00 p.m., Patient #16’s oxygen was increased to 4L via nasal cannula, and at 3:00 p.m., Patient #16’s supplemental oxygen was increased to 5L. Review of Provider #3’s ED note, entered at 4:36 p.m., revealed Patient #16 had a history of sleep apnea (repeated stops and starts in breathing during sleep), and had periods of apnea while receiving 5-6L of supplemental oxygen. At 4:38 p.m., bilevel positive airway pressure (BiPAP - non-invasive ventilation which delivers pressurized air to support breathing) was initiated for the patient. According to respiratory therapist (RT) #2’s note, entered at 5:14 p.m., RT #2 attempted to place Patient #16 on continuous positive airway pressure (CPAP - delivers a steady, gentle stream of pressurized air through a mask into the airway). However, while on CPAP, Patient #16’s respiratory rate dropped to seven breaths per minute (normal is 12 to 12), and the patient showed distress with abdominal breathing. RT #2 then placed Patient #16 on BiPAP. At 7:53 p.m., Patient #16 was taken off of BiPAP and placed on CPAP, and at 8:51 p.m., Patient #16 was taken off of CPAP and placed on 5L of supplemental oxygen via nasal cannula. Review of a provider’s note, entered on 10:14 p.m., revealed admission was attempted, however, the hospitalist declined to admit Patient #16 because they were newly on BiPAP for respiratory failure, which was believed to be secondary to alcohol intoxication and phenobarbital (medication used for alcohol withdrawal to prevent tremors and seizures) administration. The provider note also revealed Patient #16 had been taken off of oxygen support and would be discharged with a course of Tranxene (medication used for alcohol withdrawal), with caution to monitor respiratory status. However, review of the Patient #16’s vital signs revealed, on 1/25/26 at 2:00 a.m., Patient #16’s oxygen saturation was 97% while on 5L of supplemental oxygen. At 2:25 a.m., nursing staff documented the Tranxene pack was given to Patient #16’s roommate. Patient #16 was discharged from the ED on 1/25/26 at 2:26 a.m. The review of Patient #16’s discharge instructions failed to reveal why or how often the patient was supposed to take Tranxene, or how Patient #16 was to monitor their respiratory status. Upon request, the facility was unable to provide evidence Patient #16 was determined to not require supplemental oxygen at discharge. Additionally, the facility was unable to provide evidence supplemental oxygen had been arranged for the patient prior to discharge. This was in contrast to the EMTALA policy, which read necessary stabilizing treatment would be provided within the capabilities of the staff and facilities routinely available at the facility prior to discharge or transfer. Additionally, the patient’s stabilized condition would be documented in the medical records, and the patient would not be discharged if they were not stabilized. B. Interviews i. Interviews with staff revealed patients who received supplemental oxygen during their ED admission should have had a room air challenge prior to discharge to determine whether oxygen needs had stabilized, and if the patient could safely discharge home without oxygen. a. On 3/5/26 at 11:06 a.m., an interview was conducted with ED Provider #1. Provider #1 stated patients who required supplemental oxygen in the ED had their oxygen needs assessed prior to discharge. Provider #1 stated nursing and respiratory staff assessed oxygen needs by titrating and attempting to remove supplemental oxygen. Provider #1 stated the provider was notified when a patient was unable to maintain an oxygen saturation above 90%. Provider #1 stated once notified the provider entered an order to have home oxygen service established for the patient. Provider #1 stated patients who were discharged without oxygen and oxygen services were at risk for respiratory distress, loss of consciousness and heart failure. b. On 3/3/25 at 1:43 p.m., an interview was conducted with RT #4. RT #4 stated RT staff, ED nurses, and ED technicians were trained to perform room air challenges for patients. RT #4 stated during a room air challenge, the supplemental oxygen was stopped and the patient’s oxygen saturation was monitored on room air. RT #4 stated patients unable to maintain an oxygen saturation of 90% or more on room air were discharged with supplemental oxygen, and had home oxygen services established before they were discharged. RT #4 stated when room air challenges were performed, staff documented the results of the challenge in the medical record. RT #4 stated patients who were unable to maintain their oxygen saturation were at risk of respiratory failure, hypoxia (the body does not get enough oxygen), and organ failure. c. On 3/5/26 at 3:01 p.m. An interview was conducted with ED registered nurse (RN) #5. RN #5 stated patients placed on supplemental oxygen while in the ED required assessment on room air prior to discharge. RN #5 stated the room air challenge ensured the patient could breathe independently without supplemental oxygen. RN #5 stated a provider order was not needed to perform a room air challenge, and all clinical staff in the ED could perform a room air challenge. RN #5 stated when patients failed the room air challenge, staff informed the ED provider and documented the results in the medical record. Additionally, RN #5 stated patients requiring supplemental oxygen had a home oxygen evaluation performed to establish supplemental oxygen services prior to the patient being discharged. Upon request, the facility was unable to provide evidence Patient #16 had a room air challenge performed, and did not require supplemental oxygen to maintain their oxygen saturation at or above 90%. Additionally, the facility was unable to provide evidence the ED provider had been notified Patient #16 required 5L supplemental oxygen before they were discharged. Lastly, the facility was unable to provide evidence a home oxygen evaluation was conducted for Patient #16. These interviews were in contrast with Patient #16’s medical record, which revealed the patient’s oxygen needs had not been evaluated to determine whether their oxygen needs had stabilized, and if the patient was safe to discharge without oxygen.”

“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: 52761 Based on interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. 1. The facility failed to meet the following requirements under the EMTALA regulations: A-2406: Appropriate Medical Screening Examination. (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. Based on interviews and documents reviewed, the facility failed to comply with the EMTALA. Specifically, the facility failed to provide a medical screening examination (MSE) for patients who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) according to facility policy. This failure was identified in four of four patients reviewed who did not receive an MSE. (Patients #5, #8, #9, and #14) (Cross-reference A-2407) A-2407: Stabilizing Treatment. (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. Based on interviews and documents reviewed, the facility failed to comply with the EMTALA. Specifically, the facility failed to ensure a patient who presented to the facility for the management of alcohol withdrawal received stabilizing treatment. This failure was identified in one of four patients reviewed who presented to the Emergency Department (ED) with concerns related to alcohol abuse. (Patient #9) (Cross-reference A-2406)”

“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: 52761 Based on interviews and documents reviewed, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening examination (MSE) for patients who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) according to facility policy. This failure was identified in four of four patients reviewed who did not receive an MSE. (Patients #5, #8, #9, and #14) (Cross-reference A-2407) Findings include: Facility policies: According to the EMTALA policy, the facility shall comply with the emergency care obligations imposed by EMTALA. The facility shall provide an appropriate MSE (the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an EMC exists) to any individual who comes to the emergency department. Screening is to be conducted to the extent necessary, by physicians and/or other qualified medical personnel (QMP) (practitioners acting within the scope of their privileges) to determine whether an EMC exists. If the MSE indicates the individual has an EMC, the facility will provide the necessary stabilizing treatment within the capabilities of the staff and facilities routinely available at the facility prior to discharge or transfer. The Emergency Department Clinical Documentation policy read, all patients will be assessed for pain at triage, with vital signs per care site standards/policy and procedure and following any pain relieving interventions. Refer to care-site specific policy/procedure as appropriate. All patients receiving pain analgesics will have reassessment of pain and vital signs per policy. Refer to care-site specific policy/procedure as appropriate. A full set of vital signs is blood pressure, pulse, respirations, and pulse oximetry. Repeat vital signs based on ESI level. Patients with an ESI of two should have vital signs assessed every 15-30 minutes until stable, and then every two hours. Reference: The COVID 19: Lorazepam Severity of Ethanol Withdrawal Scale (SEWS) Alcohol Withdrawal Protocol read, SEWS is a clinical tool used to measure the severity of alcohol withdrawal symptoms. SEWS assesses anxiety, nausea, dry heaves or vomiting, sweating, tremor, agitation, orientation, hallucinations, and vital signs to calculate a score out of 22 possible points. A score of 1-6 indicates mild withdrawal, 7-12 indicates moderate withdrawal, and 13-22 indicates severe withdrawal. The Richmond Agitation Sedation Scale (RASS) is a clinical tool used to assess a patient’s level of agitation and sedation. A score of zero indicates the patient is alert and calm, +1 indicates they are restless, and -1 indicates they are not fully alert but have sustained awakening to voice. 1. The facility failed to ensure patients who presented to the facility with an EMC received an MSE according to facility policies. A. Document Review i. Review of Patient #8’s medical record revealed Patient #8 presented to the ED on 7/14/25 at 12:14 p.m. for a fall secondary to alcohol intoxication. At 12:20 p.m., the registered nurse (RN) documented a triage assessment for Patient #8, which revealed Patient #8 was agitated, confused, and delirious (a change in thinking and awareness), and had slurred speech secondary to alcohol intoxication. An ED provider’s note from 12:20 p.m. revealed Patient #8 had a history of alcoholism and appeared moderately intoxicated upon arrival to the ED; an addendum to this note later revealed the patient was clinically sober at 3:30 p.m. At 4:42 p.m., a different ED provider’s note revealed concerns Patient #8 was going into alcohol withdrawal and noted symptoms of the patient’s withdrawal to include tongue fasciculations (involuntary, uncontrolled, and constant movements of the tongue), tremors (involuntary shaking), and tachycardia (rapid heart rate). At 10:55 p.m., Patient #8 received phenobarbital (barbiturate medication used to prevent or treat seizures and reduce symptoms of alcohol withdrawal). On 7/15/25 at 1:01 a.m., Patient #8 received lorazepam (benzodiazepine medication used to prevent seizures during alcohol withdrawal). At 1:57 a.m., an ED provider’s note revealed Patient #8’s heart rate had improved, however, failed to reveal an assessment of Patient #8’s tongue fasciculations or tremors after phenobarbital and lorazepam were administered. Additionally, there was no evidence of SEWS assessments performed for Patient #8 during their stay. ii. Review of Patient #5’s medical record revealed Patient #5 presented to the ED on 7/16/25 at 10:03 p.m. for a fall secondary to alcohol intoxication. At 10:10 p.m., the RN documented a triage assessment for Patient #5, which revealed Patient #5 was intoxicated. An ED provider’s note from 10:37 p.m. revealed Patient #5 smelled of alcohol and had dysarthric (slurred) speech consistent with alcohol use. An addendum to this note later revealed Patient #5’s family stated the patient had a history of alcohol abuse. At 11:18 p.m., the ED provider documented Patient #5’s RASS score was zero (alert and calm), and placed orders for SEWS assessments to be performed by nursing staff every six hours for 48 hours, or if the patient displayed signs of alcohol withdrawal. RASS assessments were to be performed by nursing staff with each SEWS assessment. There was no evidence of a SEWS assessment completed by nursing staff until 7/17/25 at 9:22 a.m., 10 hours and four minutes after the orders were placed. Patient #5’s medical record also failed to reveal a RASS assessment performed with the SEWS assessment, or a provider’s reassessment of the patient’s withdrawal symptoms. iii. Review of Patient #9’s medical record revealed Patient #9 presented to the ED on 7/28/25 at 8:51 p.m. for alcohol withdrawal. At 8:52 p.m., the triage RN documented a SEWS assessment for Patient #9, which revealed Patient #9’s SEWS score was 14 (severe withdrawal). The medical record failed to reveal follow-up SEWS assessments. An ED provider’s note from 9:12 p.m. revealed Patient #9 was vomiting, tachycardic, and tremulous (shaking or quivering); a later addendum revealed Patient #9’s symptoms improved following treatment with Zofran (medication for nausea) and phenobarbital (barbiturate medication used to treat alcohol withdrawal symptoms and prevent seizures), both had been administered at 9:44 p.m. Patient #9 received phenobarbital again on 7/29/25 at 12:14 a.m. and diazepam (benzodiazepine medication used to treat alcohol withdrawal symptoms and prevent seizures) at 1:12 a.m. The medical record failed to reveal reassessments of the Patient #9’s withdrawal symptoms following the second administration of phenobarbital and diazepam. Patient #9 was discharged to a social detoxification facility (offers short term, nonmedical treatment services for individuals with substance use disorders) on 7/29/25 at 3:05 a.m. Additional medical record review for Patient #9 revealed they returned to the ED on 7/29/25 at 5:12 a.m. for alcohol withdrawal, two hours and seven minutes after they had been discharged. At 5:22 a.m., the triage RN documented an assessment, which revealed Patient #9 was anxious, tachycardic, nauseous, and vomiting. An ED provider’s note from 5:32 a.m. revealed Patient #9 was hypertensive (elevated blood pressure), tachycardic, tremulous, and restless. The medical record revealed Patient #9 received phenobarbital at 6:10 a.m. At 7:31 a.m., an RN documented a SEWS assessment which revealed Patient #9’s SEWS score was 3 (mild withdrawal). At 7:59 a.m., a different ED provider’s note revealed Patient #9’s heart rate had improved and the patient would return to the social detoxification facility. There was no evidence of a reassessment for the anxiety, restlessness, nausea, vomiting, or tremors Patient #9 had initially presented with. iv. Review of an additional medical record for Patient #9 revealed Patient #9 presented to the ED on 8/19/25 at 7:03 p.m. for alcohol intoxication. At 7:07 p.m., an ED provider placed orders for SEWS assessments to be performed by nursing staff every six hours for 48 hours, or if the patient displayed signs of alcohol withdrawal and RASS assessments were to be performed by nursing staff with each SEWS assessment. There was no evidence of a SEWS assessment completed by nursing staff until 11:36 p.m., four hours and 29 minutes after the orders were placed. Patient #9’s medical record also failed to reveal a RASS assessment performed with the SEWS assessment. The ED provider’s note from 7:29 p.m. revealed Patient #9 was tachycardic and had slurred speech consistent with alcohol intoxication. At 10:02 p.m., a reassessment by the ED provider revealed Patient #9 endorsed the onset of withdrawal symptoms, however, did not reveal what those symptoms were. At 11:57 p.m., the ED provider’s note, again, revealed Patient #9 continued to endorse withdrawal symptoms, however, did not reveal what those symptoms were. The note also revealed Patient #9 would be discharged home once their HR was stable. Patient #9’s medical record failed to reveal a provider’s reassessment of the patient’s withdrawal symptoms prior to discharge. On 8/20/25 at 12:18 a.m., Patient #9 received diazepam. The medical record failed to reveal reassessment of the Patient #9’s withdrawal symptoms following the administration of diazepam. Patient #9 was discharged to a social detoxification facility at 12:55 a.m. Further medical record review for Patient #9 revealed they returned to the ED on 8/20/25 at 6:57 a.m. for alcohol withdrawal, six hours and two minutes after they had been discharged. At 7:09 a.m., the triage RN documented a SEWS assessment which revealed Patient #9’s SEWS score was 8 (moderate withdrawal) and RASS score was +1 (restless). The ED provider’s note from 7:26 a.m. revealed Patient #9 was anxious, tachycardic, and tremulous. At 7:52 a.m., the RN administered diazepam. At 7:56 a.m., the RN documented Patient #9’s SEWS score was 13 (severe withdrawal). At 8:15 a.m., the RN administered phenobarbital. At 10:00 a.m., the RN documented Patient #9’s SEWS score was 7 (moderate withdrawal). At 12:00 p.m., the RN documented Patient #9’s RASS score at -1 (drowsy). At 2:00 p.m., the RN documented Patient #9’s SEWS score was 8 (moderate withdrawal), and a RASS score of +1 (restless). An ED provider’s note at 2:35 p.m. revealed Patient #9 was experiencing severe alcohol withdrawal. At 4:39 p.m., the RN documented a SEWS assessment which revealed Patient #9’s SEWS score was 9 (moderate withdrawal). An ED provider’s note at 5:15 p.m. revealed Patient #9 was tachycardic upon standing despite any significant withdrawal symptoms. The record failed to reveal reassessment of Patient #12’s SEWS score by the RN. v. Review of Patient #14’s medical record revealed Patient #14 presented to the ED on 9/6/25 at 6:39 a.m. for an exacerbation of chronic pain. At 6:44 a.m., the triage RN documented an assessment which revealed Patient #14 had rated their pain 10/10 (0 is no pain, 10 is the worst pain). The medical record revealed Patient #14’s blood pressure (BP) was 140/90 (normal 120/80) and heart rate (HR) was 110 (normal 60-100) at that time. Patient #14 was then assigned an Emergency Severity Index (ESI) (a five-level triage algorithm that helps healthcare professionals prioritize patient care based on their acuity) of two. At 8:00 a.m., one hour and 16 minutes later, Patient #14’s vital signs were assessed. Patient #14’s BP was 192/132 and their HR was 124. The next assessment of Patient #14’s vital signs was conducted at 9:47 a.m., one hour and 47 minutes later, at which time their BP was 207/162 and their HR was 118. This was in contrast to the Emergency Department Clinical Documentation policy which read, a full set of vital signs included blood pressure, pulse, respirations, and pulse oximetry, and was assessed every 15-30 minutes until stable and then every two hours for patients with an ESI of two. At 8:57 a.m., the RN documented a pain assessment, which revealed Patient #14 was in 10/10 pain, and oxycodone (narcotic pain medication) was administered. At 9:20 a.m., the RN administered dilaudid (narcotic pain medication). There was no evidence of a pain reassessment following the administration of oxycodone, prior to the administration of dilaudid, or following the administration of dilaudid. This was in contrast to the Emergency Department Clinical Documentation policy which read, all patients who received pain analgesics would have had reassessment of pain and vital signs per policy. Upon request, the facility was unable to provide the policy referenced in the Emergency Department Clinical Documentation policy, and was also unable to provide clarification regarding reassessment guidelines. Patient #14 was discharged home at 10:04 a.m. Additional medical record review for Patient #14 revealed they returned to the ED on 9/6/25 at 5:07 p.m., seven hours and three minutes after they had been discharged, for an exacerbation of chronic pain and suicidal ideation. At 5:11 p.m., the triage RN documented an assessment which revealed Patient #14 had rated their pain as 10/10. The medical record revealed Patient #14’s BP was 156/120 and their HR was 125 at that time. Patient #14 was then assigned an ESI of two. At 8:00 p.m., two hours and 49 minutes after the previous pain assessment, Patient #14 received dilaudid. At 8:51 p.m., the RN documented Patient #14’s pain score was 4/10 and administered ketorolac (pain medication) and acetaminophen (pain medication). The medical record failed to reveal a reassessment of Patient #14’s pain. At 1:42 a.m., Patient #14 received dilaudid. The medical record failed to reveal an assessment of Patient #14’s pain prior to the administration of pain medication. These pain medication administrations were in contrast to the Emergency Department Clinical Documentation policy which read, all patients who received pain analgesics would have reassessment of pain per policy. At 8:51 p.m., three hours and 40 minutes after the first assessment of vital signs, the RN documented Patient #14’s BP was 142/88, and their HR was 102. The next assessment of vital signs was performed at 9:32 p.m., 41 minutes later, at which time Patient #14’s BP was 176/138 and their HR was 111. At 11:33 p.m., two hours and one minute later, Patient #14’s BP was 160/100, and their HR was 110. Clonidine (medication used to treat high blood pressure) was administered by the RN. Patient #14’s vital signs were assessed again on 9/7/25 at 12:56 a.m., one hour and 23 minutes later, at which time their BP was 190/110 and their HR was 116. At 2:00 a.m., one hour and four minutes later, Patient #14’s HR was 111; there was no evidence of an assessment for Patient #14’s blood pressure at this time. This was in contrast to the Emergency Department Clinical Documentation policy which read, a full set of vital signs included blood pressure, pulse, respirations, and pulse oximetry, and would be assessed every 15-30 minutes until stable, and then every two hours for patients with an ESI of two. These medical records were in contrast to the EMTALA policy which read, the facility should have provided an appropriate MSE to any individual who came to the ED to determine if an EMC existed. B. Interviews i. On 9/10/25 at 3:04 p.m., an interview was conducted with RN #1. RN #1 stated it was important to monitor patients withdrawing from alcohol due to the risk for seizures. RN #1 stated SEWS assessments should be performed by the RN if the patient displayed symptoms consistent with alcohol withdrawal, such as tremors, agitation, and nausea. This was in contrast with medical record review for Patient #8, which failed to reveal documentation of a SEWS assessment. RN #1 stated it was important to assess SEWS and RASS scores 15 minutes before and 15 minutes after the administration of diazepam or lorazepam to evaluate whether or not the medication was effective in reducing alcohol withdrawal symptoms. This was in contrast to medical record review for Patient #8, which failed to reveal a SEWS assessment prior to or following the administration of lorazepam. This was also in contrast to Patient #9’s medical record review, which failed to reveal a SEWS or RASS assessment prior to or following the administration of diazepam. Additionally, this was in contrast to the medical record review for Patient #9, which revealed SEWS and RASS assessments were performed 43 minutes prior to the administration of diazepam, with SEWS reassessed two hours and 18 minutes after, and RASS reassessed four hours and 18 minutes after. RN #1 stated pain was assessed prior to and following the administration of pain medication to determine whether or not the treatment was effective. RN #1 stated it was important to assess the patient 15 minutes following the administration of dilaudid, or 30 minutes following the administration of oxycodone, to monitor for oversedation and respiratory depression (breathing that is too slow or shallow). RN #1 stated it was important to assess pain prior to and following the administration of pain medication to determine whether or not the treatment was effective. This was in contrast with medical record review for Patient #14, which failed to reveal pain assessments prior to the administration of oxycodone at 8:57 a.m., prior to and following the administration of dilaudid at 9:20 a.m., prior to the administration of dilaudid at 8:00 p.m., and following the administration of ketorolac and acetaminophen at 8:51 p.m. ii. On 9/10/25 at 3:49 p.m., an interview was conducted with RN #2. RN #2 stated SEWS assessments could be ordered by the provider or were nurse-driven (initiated by the RN) if the patient displayed symptoms consistent with alcohol withdrawal, or if they had a history of alcoholism. RN #2 stated it was important to conduct ongoing assessments of patients withdrawing from alcohol to monitor for and treat complications related to withdrawal, including seizures, nausea and vomiting, tremors, confusion, and delirium (severe confusion). RN #2 stated treatment for alcohol withdrawal often included the administration of diazepam or lorazepam, and it was important to reassess SEWS and RASS following diazepam or lorazepam administration to determine whether or not the medication was effective in treating withdrawal symptoms. RN #2 stated elevated heart rate and blood pressure might indicate a patient was in severe pain. RN #2 stated hypertension could put patients at risk for stroke or aneurysm (a bulge in a blood vessel in or around the brain). RN #2 stated clonidine was a medication used to treat high blood pressure. RN #2 stated it was important to assess blood pressure and heart rate before and after the administration of clonidine to ensure the patient’s blood pressure did not become too low. This was in contrast to medical record review for Patient #14, which failed to reveal a blood pressure reassessment until one hour and 23 minutes after the administration of clonidine RN #2 stated vital signs were assessed based on ESI score protocols. RN #2 stated it was important to frequently assess vital signs to evaluate the patient’s stability and to monitor for changes in condition. This was in contrast to medical record review for Patient #14, which revealed Patient #14’s ESI was two, and there was a one hour and 16 minute gap, a one hour and 47 minute gap, a three hour and 40 minute gap, a two hour and one minute gap, a one hour and 23 minute gap, and a one hour and four minute gap between assessments of blood pressures. iii. On 9/10/25 at 1:57 p.m., an interview was conducted with charge RN (RN) #3. RN #3 stated patients withdrawing from alcohol were assessed by the provider and the RN. RN #3 stated SEWS assessments could be nurse-driven or ordered by the provider; orders included instructions for SEWS assessment frequency, which would be followed by the RN. This was in contrast to medical record review for Patient #5, which revealed orders to assess SEWS every six hours or if the patient displayed signs of alcohol withdrawal, however, failed to reveal documentation of a SEWS assessment until 10 hours and four minutes after the order was placed. This was also in contrast to medical record review for Patient #9, which revealed orders to assess SEWS every six hours or if the patient displayed signs of alcohol withdrawal, however, failed to reveal documentation of a SEWS assessment until four hours and 29 minutes after the order was placed. RN #3 stated diazepam and lorazepam were medications used to treat alcohol withdrawal symptoms and prevented life-threatening seizures; both medications had the risk for respiratory depression. RN #3 stated it was important to conduct a SEWS assessment prior to and following the administration of diazepam or lorazepam to monitor for respiratory depression and evaluate the patient’s response to treatment. iv. On 9/10/25 at 3:42 p.m., an interview was conducted with RN manager (Manager) #4. Manager #4 stated pain was assessed before and after the administration of pain medication to evaluate the effectiveness of treatment. Manager #4 stated a normal blood pressure in an adult was 120/80. Manager #4 stated elevated blood pressures should have been reevaluated because it could put patients at risk for stroke or aneurysm (a bulge in a blood vessel in or around the brain). v. On 9/11/25 at 11:09, an interview was conducted with Provider #5. Provider #5 stated nursing assessments and provider assessments were used to medically screen patients. Provider #5 stated the primary tools used to monitor alcohol withdrawal symptoms were SEWS assessments, which were performed by nursing staff, or provider assessments of the patient’s withdrawal symptoms, which were documented in the provider’s note upon presentation to the ED and at the time of discharge. vi. On 9/10/25 at 4:10 p.m., an interview was conducted with Provider #6. Provider #6 stated assessments of alcohol withdrawal were performed by nursing staff and providers upon initial presentation to the ED, and then until discharge or transfer. This was in contrast to medical record reviews for Patient #8, #5, and #9, which failed to reveal ongoing nursing or provider assessments of alcohol withdrawal symptoms. Provider #6 stated reassessment of alcohol withdrawal symptoms should be performed following the administration of medications used to treat withdrawal in order to determine whether or not the medication was effective. This was in contrast to medical record review for Patient #8, which failed to reveal a reassessment of withdrawal symptoms following the administration of phenobarbital and lorazepam, and Patient #9, which failed to reveal a reassessment of withdrawal symptoms following the administration of phenobarbital and diazepam. vii. On 9/10/25 at 3:23 p.m., an interview was conducted with Provider #7. Provider #7 stated vital signs assessments, SEWS assessments, and a physical examination were all used to medically screen patients withdrawing from alcohol. Provider #7 stated all patients withdrawing from alcohol should be assessed using the SEWS scale because it helped drive medication management. Provider #7 explained low SEWS scores indicated mild withdrawal, whereas high SEWS scores indicated severe withdrawal; mild withdrawal was treated with different medications than severe withdrawal. Provider #7 stated SEWS assessments should be performed by RNs, so the appropriate medications could be ordered by the provider. Provider #7 stated it was important to assess and reassess SEWS scores to track the progression of withdrawal and to monitor for life-threatening complications related to alcohol withdrawal, such as seizures and delirium tremens (DTs) (sudden and severe mental or nervous system changes). Provider #7 stated SEWS assessments should be performed within 15 minutes of the order being placed. This was in contrast to medical record review for Patient #5, which failed to reveal a SEWS assessment until 10 hours and four minutes after the order was placed. This was also in contrast to medical record review for Patient #9, which failed to reveal a SEWS assessment until four hours and 29 minutes after the order was placed. viii. On 9/10/25 at 10:41 a.m., an interview was conducted with director (Director) #9. Director #9 stated pain assessments should be conducted before and after the administration of pain medication. This was in contrast to the medical record review for Patient #14, which failed to reveal pain assessments conducted before and after the administration of pain medications.”

“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: 52761 Based on interviews and documents reviewed, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient who presented to the facility for the management of alcohol withdrawal received stabilizing treatment. This failure was identified in one of four patients reviewed who presented to the Emergency Department (ED) with concerns related to alcohol abuse. (Patient #9) (Cross-reference A-2406) Findings include: Facility policy: The EMTALA policy read, the facility shall comply with the emergency care obligations imposed by EMTALA. The facility shall provide an appropriate medical screening exam (MSE) (the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition (EMC) exists) to any individual who comes to the emergency department. If the MSE indicates the individual has an EMC, the facility shall provide the necessary stabilizing treatment within the capabilities of the staff and facilities routinely available at the facility prior to discharge or transfer. If the person is stabilized, the hospital may discharge or transfer the person as appropriate. The person’s stabilized condition shall be documented in the medical records. An individual is deemed stabilized for discharge if they do not require continued care or no material deterioration is likely to result if they receive continued care as an outpatient or later as an inpatient and the patient is given a plan for appropriate follow-up care. In some situations, inpatient admission may be required to stabilize an EMC. If the individual is not stabilized, the hospital will not discharge or transfer the person unless the following conditions are met and documented on the Patient Facility Transfer Form: The person requests in writing a discharge or transfer to another facility after being informed of the hospital’s EMTALA obligations and risks of transfer; or a physician certifies in writing that the benefits of discharge or transfer outweigh the risks. Reference: The COVID 19: Lorazepam Severity of Ethanol Withdrawal Scale (SEWS) Alcohol Withdrawal Protocol read, SEWS is a clinical tool used to measure the severity of alcohol withdrawal symptoms. SEWS assesses anxiety, nausea, dry heaves or vomiting, sweating, tremor, agitation, orientation, hallucinations, and vital signs to calculate a score out of 22 possible points. A score of 1-6 indicates mild withdrawal, 7-12 indicates moderate withdrawal, and 13-22 indicates severe withdrawal. 1. The facility failed to provide stabilizing treatment to a patient who presented to the facility for management of alcohol withdrawal. A. Document Review i. Review of Patient #9’s medical record revealed Patient #9 presented to the ED on 7/28/25 at 8:51 p.m. for alcohol withdrawal. At 8:52 p.m., the triage RN documented a SEWS assessment for Patient #9, which revealed Patient #9’s SEWS score was 14 (severe withdrawal) based on the presence of nausea, dry heaves or vomiting, tremor, agitation, and a heart rate (HR) greater than 110 (normal 60-100). At 9:44 p.m., Patient #9 received Zofran (medication for nausea) and phenobarbital (medication used to treat alcohol withdrawal symptoms and prevent seizures). A provider’s note following the administration of these medications revealed Patient #9’s symptoms improved. Patient #9 received phenobarbital again on 7/29/25 at 12:14 a.m. and diazepam (medication used to treat alcohol withdrawal symptoms and prevent seizures) at 1:12 a.m. The medical record failed to reveal evidence Patient #9’s withdrawal symptoms had been stabilized following the administration of diazepam and the second dose of phenobarbital. At 8:52 p.m., Patient #9’s HR was 140. From 10:00 p.m. until 1:30 a.m., Patient #9’s HR ranged from 103 to 127. At 1:10 a.m., the provider documented Patient #9 was in stable condition with stable vital signs at the time of discharge. At 2:34 a.m., Patient #9’s HR was 97. At 3:00 a.m., five minutes prior to Patient #9’s discharge, the RN documented an assessment which revealed Patient #9’s cardiac rhythm (sequence of heart beats) was sinus tachycardia (heart rate greater than 100). No heart rate was documented at this time. There was no evidence the provider was made aware of Patient #9’s tachycardia before they were discharged. At 9:30 p.m., the RN documented an assessment which revealed Patient #9 was anxious, nauseous, retching, and tachycardic. On 7/29/25 at 1:10 a.m., the provider’s note revealed Patient #9’s symptoms had improved after the Zofran and first dose of phenobarbital were administered. According to the provider’s note, Patient #9 was in stable condition. However, at 3:00 am, the RN documented an assessment which revealed Patient #9 remained anxious, nauseous, retching, and tachycardic, which were unchanged from Patient #9’s initial assessment. There was no evidence the provider was made aware of Patient #9’s symptoms before they were discharged. At 3:05 a.m., Patient #9 was discharged to a social detoxification facility (offers short term, nonmedical treatment services for individuals with substance use disorders). ii. Additional medical record review for Patient #9 revealed they returned to the ED on 7/29/25 at 5:12 a.m. for alcohol withdrawal, two hours and seven minutes after they had been discharged. At 5:15 a.m., Patient #9’s HR was 145. From 5:17 a.m. until 7:33 a.m., Patient #9’s HR ranged from 110 to 132. At 5:22 a.m., the triage RN assessment revealed Patient #9 was anxious, tachycardic, nauseous, and vomiting, which was similar to Patient #9’s initial assessment upon presentation to the ED on 7/28/25 and their final assessment upon discharge. iii. Medical record for Patient #9 revealed Patient #9 presented to the ED on 8/19/25 at 7:03 p.m. for alcohol intoxication. The provider’s note from 7:29 p.m. revealed Patient #9 was tachycardic and had slurred speech consistent with alcohol intoxication. At 10:02 p.m., a reassessment by the provider revealed Patient #9 endorsed the onset of withdrawal symptoms, however, did not reveal what those symptoms were. At 11:36 p.m., the RN documented a SEWS assessment which revealed Patient #9’s SEWS score was 10 (moderate withdrawal). At 11:57 p.m., the provider’s note, again, revealed Patient #9 continued to endorse withdrawal symptoms, however, did not reveal what those symptoms were. On 8/20/25 at 12:18 a.m., Patient #9 received diazepam. The medical record failed to reveal reassessment of Patient #9’s SEWS score or a provider’s reassessment of Patient #9’s withdrawal symptoms following the administration of diazepam. Patient #9 was discharged to a social detoxification facility at 12:55 a.m. iv. Additional medical record review for Patient #9 revealed they returned to the ED on 8/20/25 at 6:57 a.m. for alcohol withdrawal, six hours and two minutes after they had been discharged. At 7:09 a.m., the RN documented Patient #9’s SEWS score was 8 (moderate withdrawal). At 7:42 a.m., the RN administered Zofran and an intravenous (IV) infusion of 1,000 ml Lactated Ringer’s (IV fluids used for hydration). At 7:52 a.m., the RN administered diazepam. At 7:56 a.m., the RN documented Patient #9’s SEWS score was 13 (severe withdrawal). At 8:15 a.m., the RN administered phenobarbital. At 9:34 a.m., the RN administered a second IV infusion of 1,000 ml Lactated Ringer’s. At 10:00 a.m., the RN documented Patient #9’s SEWS score was 7 (moderate withdrawal). At 11:49 a.m., the RN administered promethazine (medication used for nausea). At 2:00 p.m., the RN documented Patient #9’s SEWS score was 8 (moderate withdrawal). An ED provider’s note at 2:35 p.m. revealed Patient #9 was experiencing severe alcohol withdrawal. At 4:39 p.m., the RN documented a SEWS assessment, which revealed Patient #9’s SEWS score was 9 (moderate withdrawal). At 8:02 p.m., the provider ordered for Patient #9 to be admitted to the facility. At 8:43 p.m., Patient #9 was transferred out of the ED. From 11:49 a.m. to 8:43 p.m., the medical record failed to reveal evidence of interventions provided to stabilize Patient #9’s moderate to severe withdrawal. These medical record reviews were in contrast to the EMTALA policy which read, if the MSE indicated the individual had an EMC, the facility would provide the necessary stabilizing treatment within the capabilities of the staff and facilities routinely available at the facility prior to discharge or transfer. A person’s stabilized condition would be documented in the medical records. An individual was deemed stabilized for discharge if they did not require continued care or no material deterioration was likely to result if they received continued care as an outpatient or later as an inpatient and the patient was given a plan for appropriate follow-up care. B. Interviews i. On 9/10/25 at 1:10 p.m., an interview was conducted with licensed clinical social worker (Social Worker) #11. Social Worker #11 stated patients withdrawing from alcohol could be discharged to social detoxification facilities or medical detoxification facilities. Social Worker #11 explained social detoxification facilities could not manage medical conditions, and therefore patients who were experiencing medical complications secondary to alcohol withdrawal should be referred to medical detoxification facilities. This was in contrast to medical record review for Patient #9, which revealed Patient #9 was anxious, nauseous, retching, and tachycardic upon discharge to a social detoxification facility on 7/29/25 at 3:05 a.m. Patient #9 returned to the ED two hours and seven minutes later with persistent tachycardia and similar medical symptoms. ii. On 9/11/25 at 11:09 a.m., an interview was conducted with Provider #5. Provider #5 stated providers documented their assessments of a patient’s alcohol withdrawal symptoms upon initial presentation and discharge. The provider’s assessments and the RN’s assessments were evaluated to ensure the patient had been stabilized and was appropriate for discharge. This was in contrast to medical record review for Patient #9 from 7/28/25, which revealed the RNs assessed Patient #9’s symptoms as unchanged at admission and discharge, yet the patient was discharged. iii. On 9/10/25 at 4:10 p.m., an interview was conducted with Provider #6. Provider #6 stated a patient would be deemed unstable for discharge if they had abnormal vital signs. Provider #6 stated abnormal vital signs could indicate underlying medical conditions which required intervention. This was in contrast to medical record review for Patient #9, which revealed Patient #9 was tachycardic upon discharge on 7/29/25 at 3:05 a.m. iv. On 9/10/25 at 3:23 p.m., an interview was conducted with Provider #7. Provider #7 stated it was important for nursing staff to conduct ongoing SEWS assessments because they helped providers evaluate how patients responded to treatment. This was in contrast to medical record review for Patient #9 on 7/28/25, which failed to reveal ongoing SEWS assessments performed by nursing staff. This was also in contrast to medical record review for Patient #9 on 8/19/25, which failed to reveal a SEWS reassessment following the administration of diazepam. v. On 9/10/25 at 2:21 p.m., an interview was conducted with Provider #8. Provider #8 stated complications related to alcohol withdrawal included anxiety, tremors, hypertension, tachycardia, DTs, hallucinations, seizures, and death. Provider #8 stated patients withdrawing from alcohol were continually assessed by the RN to monitor for complications and to evaluate severity of withdrawal. Provider #8 stated assessments of withdrawal symptoms guided medication management, which was necessary to stabilize the patient’s condition. This was in contrast to medical record review for Patient #9 on 8/20/25, which failed to reveal interventions provided from 11:49 a.m. to 8:43 p.m., despite SEWS scores which ranged from 8 to 9 (moderate withdrawal). This was also in contrast to medical record review for Patient #9 which failed to reveal interventions provided on 8/20/25, following the provider’s reassessment at 2:35 p.m., which revealed Patient #9 was in severe withdrawal. vi. On 9/10/25 at 12:23 p.m., an interview was conducted with Provider #10. Provider #10 stated a patient who was withdrawing from alcohol would be deemed stable for discharge if their assessments were consistent with mild withdrawal and they were hemodynamically stable (had stable vital signs). This was in contrast to medical record review for Patient #9, which failed to reveal evidence Patient #9 was in mild withdrawal and hemodynamically stable upon discharge on 7/29/25 at 3:05 a.m. This was also in contrast to additional medical record review for Patient #9, which failed to reveal Patient #9 was in mild withdrawal upon discharge on 8/20/25 at 12:55 a.m.”

“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: 48269 Based on interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2411: §489.24(f) A participating hospital that has specialized capabilities or facilities may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. Based on document reviews and interviews, the facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED).”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 48269 Based on document reviews and interviews, the facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED). Findings include: Facility policy: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, the facility shall comply with the emergency care obligations imposed by EMTALA. The facility shall accept appropriate transfers of individuals with emergency medical conditions if the facility has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals. 1. The facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED). a. Review of the audio file of the provider-to-provider call which occurred on 2/11/25 revealed Provider #2 stated multiple times they did not see a need for a patient in an outlying facility to be transferred across state lines during the night. The referring ED provider explained they were concerned about the patient’s necrotic (death of skin cells) operative site and had attempted several other referral centers, which had not had a specialist or the capacity to receive the patient. The referring ED provider stated they could not refuse the patient transfer based on EMTALA regulations. Provider #2 declined to accept the patient transfer. This was in contrast to the EMTALA policy which read, the facility should have accepted the patient with an emergency medical condition if the facility could treat the patient and had the specialized capabilities which were not available at the transferring hospital. b. The facility’s on-call list was reviewed and confirmed Provider #2 had been the hand specialist on-call the night of 2/11/25. c. Review of information sent to Provider #2 after an internal review of the event was conducted, encouraged Provider #2 to review the education sent by Officer #4 with details about the EMTALA obligation to accept transfers. d. A document from the facility’s public relations firm was reviewed. The document read it had distributed EMTALA education on behalf of Provider #5 to all facility providers with an active email address in their database. Additionally, as of 6/9/25, the document read, 870 physicians had received the email and 298 providers had opened the email, which was an open rate of 34%. Review of the document did not reveal a date by which the email was expected to be opened, or the expectation for follow-up with providers who had not opened the email. e. On 6/10/25 at 12:14 p.m., an interview was conducted with ED provider (Provider) #1. Provider #1 stated they were only able to refuse transfers to the ED if the facility did not have the capacity to care for the patient. Provider #1 stated they were aware of EMTALA regulations and received annual compliance training on EMTALA. Provider #1 stated their physician group occasionally discussed EMTALA topics, such as form revisions or changes in the electronic health record (EHR). Provider #1 stated they were not aware of recent communications from the facility related to EMTALA. f. On 6/12/25 at 7:00 a.m., an interview was conducted with hand specialist (Provider) #2. Provider #2 stated on the night of 2/11/25, they received a call from the transfer center and spoke with an ED provider from a smaller facility in a bordering state. Provider #2 stated the patient had a right radial (large artery in the wrist) heart catheterization (procedure where a tube was inserted through a blood vessel to the heart) the month before. Provider #2 stated the patient had developed a blockage of blood circulation to the hand and developed necrotic tissue after the procedure. Provider #2 stated the patient had required amputation of fingers two through four, which had been completed by an orthopedic surgeon at a sister facility four days before they had received the call. Provider #2 stated the patient had returned to the ED in another state on 2/11/25, and the referring ED provider had been concerned for additional necrosis. Provider #2 stated the referring ED provider had contacted the orthopedic specialist who had performed the amputation, and the orthopedic specialist stated the patient needed a hand specialist. Provider #2 stated after they spoke with the referring ED provider, their opinion had been there was no urgent need to transfer the patient across state lines at night. Provider #2 stated necrosis along incision lines was common after amputation, and there had been no sign of infection or new concerns. Provider #2 stated the patient had outpatient care scheduled. Provider #2 stated the ED provider had called several other referral centers without a hand specialist or the capacity to care for the patient. Provider #2 stated at the end of the call, the referring ED provider told them to refuse the transfer would have been an EMTALA violation. Additionally, Provider #2 stated they had not received EMTALA education and training during their 10 years of residency training. Provider #2 stated they had not heard of EMTALA before coming to practice in this state four years ago. Provider #2 stated they had not received formalized training about EMTALA until this situation occurred. Provider #2 stated after this occurrence, multiple emails were sent system-wide about rules for transfers and EMTALA information. Provider #2 stated the EMTALA law was an important safety mechanism to ensure all patients treated in EDs received the care they needed, whether at the facility they were in or another facility that could have provided the services. Provider #2 stated patients were at risk for poor outcomes and not receiving the correct standard of care if EMTALA regulations were not followed. g. On 6/10/25 at 3:17 p.m., an interview was conducted with compliance officer (Officer) #3. Officer #3 stated they had listened to the audio recording of the provider-to-provider phone call. Officer #3 stated they concluded it had not been appropriate for Provider #2 to decline the transfer of the patient. Officer #3 stated provider actions or inactions could cause an EMTALA violation, and it was important for them to understand the EMTALA law. Officer #3 stated after this event occurred, an opportunity was identified for education to all providers about EMTALA regulations and the obligation to accept transfers. This was in contrast to the facility’s public relations firm documentation, which revealed only 34% of providers had opened the facility’s EMTALA education email. h. On 6/12/25 at 7:31 a.m., an interview was conducted with chief medical officer (Provider) #4. Provider #4 stated Provider #2 had called them to discuss the provider-to-provider call soon after the call had occurred. Provider #4 stated they also received a notification from the transfer center with an audio recording of the call. Provider #4 stated the facility had the capacity and capability to care for the patient, and the referring ED provider had needed the patient to be transferred for specialty care. Additionally, Provider #4 stated they had attempted to send EMTALA education to their providers on an every-other-year basis. Provider #4 stated education had been disseminated to providers through emails, newsletters, and committee meetings. Provider #4 stated the facility used to facilitate sessions where legal would educate the providers. Also, Provider #4 stated the facility used to have an EMTALA playbook for reference. Provider #4 stated there was no formal online EMTALA education module for the providers. Further, Provider #4 stated every patient deserved equal care. Provider #4 stated EMTALA rules were written to ensure every patient received the same level of care at every facility. Provider #4 also stated if the facility had specialized care and the ability to provide the care, the facility should have accepted the patient, just like any other patient who walked through the door of the ED. Finally, Provider #4 stated patients could experience delays in care and diagnoses or complications if EMTALA regulations were not followed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance. A-0154 STANDARD: USE OF RESTRAINT OR SECLUSION Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Based on interviews and document review, the facility failed to ensure patients remained free from restraints except when the patient posed a risk of injury or harm to themselves or others. Furthermore, staff did not ensure mechanical restraints were discontinued once they were no longer necessary. The facility also failed to evaluate restraint episodes for appropriate use, assess and monitor chemically restrained patients, and ensure providers entered orders for chemical restraints. These failures had the potential to affect all patients at the facility.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 44751 Based on interviews and document review, the facility failed to ensure patients remained free from restraints except when the patient posed a risk of injury or harm to themselves or others. Furthermore, staff did not ensure mechanical restraints were discontinued once they were no longer necessary. The facility also failed to evaluate restraint episodes for appropriate use, assess and monitor chemically restrained patients, and ensure providers entered orders for chemical restraints. These failures had the potential to affect all patients at the facility. Findings include: The Patient Restraints and Seclusion policy read, all patients have the right to be free from restraint and seclusion, of any form imposed as a means of coercion, discipline, convenience, or retaliation by associates. Restraint and/or Seclusion may only be imposed to ensure the immediate physical safety of the patient, an associate, or others, may only be used for the time necessary to accomplish their purpose, and must be discontinued at the earliest possible time when criteria for release have been met. Restraint and/or Seclusion use is defined by intent rather than diagnosis or the type of device or mechanism employed and is specific to the patient’s behavior. Restraint and/or Seclusion use within the hospital is limited to situations only after the least restrictive interventions and alternatives have been considered and are deemed ineffective. The policy defined chemical restraint as a drug or medication used as an involuntary restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. The order for a chemical restraint must be obtained from the responsible caregiver in order to administer the chemical restraint. If mechanical/physical restraint and chemical restraint are to be used at the same time, a separate order is required for each type of restraint. The elements required as part of a restraint order include the patient’s name, the date and time of the order, the name of the responsible caregiver, the reason for restraint, and the type of restraint must also be indicated. The Assessment, Monitoring, and Documentation of Restraints section read, assessment and monitoring of restrained patients, including taking vital signs and interpreting the relevance to the physical safety of the patient in restraint. For patients administered a Chemical Restraint, monitoring includes monitoring of pulse oximetry and/or ETCO2 capnography (end-tidal carbon dioxide, the amount of carbon dioxide in exhaled breath) along with assessment using a sedation score (RASS score) to monitor for over-sedation, and changes in the patient’s condition, such as improved mental status and capacity to adhere to expected behaviors. 1. The facility failed to ensure staff did not restrain patients for the purposes of coercion, discipline, convenience, or behavior management. Additionally, the facility failed to ensure staff removed mechanical restraints when they were no longer necessary. A. Document review revealed staff restrained Patient #2 when the patient did not actively pose a risk of harm to themselves or others. Medical record review also revealed 4-point locking restraints (restraints applied to both arms and legs) were used to manage the patient’s behavior and as a form of discipline. i. Medical record review revealed Patient #2, a 12-year-old, had remained in the emergency department (ED) from 10/12/24 to 12/30/24 while residential placement was coordinated. ii. On 11/11/24 and 12/6/24, restraint safety events revealed Patient #2 was restrained when the patient did not actively pose a risk of harm to themselves or others. a. A review of the restraint safety event entered on 11/11/24 at 10:04 p.m. revealed Patient #2 was mechanically and chemically restrained. According to the report, at 10:04 p.m., Patient #2 left their ED room and went to the lobby. In the lobby, Patient #2 loudly expressed feeling disrespected and unheard by the ED staff. Security officer (Officer) #2 and ED charge nurse (Charge RN) #1 spoke with Patient #2 and instructed them to return to their ED room, but Patient #2 refused. After Patient #2 refused to return to their ED room, RN #10 brought an ED trauma gurney to the lobby. Charge RN #1 informed Patient #2 they would be physically assisted onto the gurney and placed in 4-point locking restraints if the patient did not comply. When Patient #2 refused again, Charge RN #1 directed staff to assist Patient #2 to the gurney, mechanically restrain the patient, and transport Patient #2 back to their ED room. Once the patient was back in their ED room, staff held Patient #2 down while RN #4 administered 5 milligrams (mg) of Zyprexa (medication administered for its sedative effects when patients display aggression or severe behavioral disturbance) in the patient’s left thigh. b. A review of the safety event report entered on 12/6/24 at 10:05 p.m. revealed Patient #2 went to the lobby and refused to return to their ED room. When ED staff arrived in the lobby, Patient #2 stated they did not want to return to their room and felt trapped there. Charge RN #5 instructed Patient #2 to return to their room. Patient #2 refused and insisted they be allowed to sit on the bench in the lobby. Charge RN #5 repeatedly told Patient #2 to return to their room. In response, Patient #2 made derogatory statements toward the ED staff. After Patient #2 refused to return to their room, Officer #2 recommended to Charge RN #5 that Patient #2 be placed in 4-point locking restraints due to their non-compliance. Charge RN #5 left the lobby and returned with a trauma gurney and 4-point locking restraints. Charge RN #5 instructed Patient #2 to return to their ED room. When Patient #2 refused, Charge RN #5 directed staff to physically restrain the patient, who became combative and shouted loudly. Once security and medical staff transported Patient #2 back to their ED room, nursing staff administered 5 mg of Zyprexa as a chemical restraint to Patient #2’s left arm while security staff held the patient down. iii. Further medical record review revealed Patient #2 remained in 4-point locking restraints after they no longer posed a risk of harm to themselves or others. a. The restraint documentation in Patient #2’s medical record revealed that staff placed Patient #2 in 4-point locking restraints at 10:30 p.m. on 12/6/24. By 11:15 p.m., 45 minutes after staff restrained Patient #2, the patient’s agitation subsided, and Patient #2 was calm due to the sedative effects of Zyprexa. Despite Patient #2 being calm and asleep, staff kept Patient #2 restrained for an additional hour and 10 minutes until 12:25 a.m. on 12/7/24. These events contrasted with the patient restraint and seclusion policy. According to the policy, staff should have used restraints only to ensure the immediate physical safety of the patient or others and apply them only for the time necessary to accomplish their purpose. Staff were required to discontinue restraints as soon as the patient met the criteria for release. Furthermore, the policy read that all patients had the right to be free from restraint or any form of restraint imposed as a means of coercion, discipline, or convenience. B. Interviews with staff revealed staff restrained Patient #2 despite the patient posing no risk of harm to themselves or others. Staff also kept the patient in 4-point locking restraints after the patient no longer posed a risk to themselves or others. i. On 12/30/24 at 1:45 p.m., RN #10 stated staff informed Patient #2 they would apply 4-point locking restraints if the patient refused to return to their ED room. RN #10 stated Patient #2 had a history of becoming aggressive and combative, which led staff to apply the locking restraints when Patient #2 did not comply with instructions. However, RN #10 stated staff restrained Patient #2 even when the patient was not actively aggressive to ensure the patient returned to their ED room. ii. On 1/8/25 at 3:33 p.m., an interview was conducted with ED Manager #3. ED Manager #3 stated staff should only restrain patients when they pose a danger to themselves or others. ED Manager #3 explained if the patient was not endangering themselves, other patients, or staff, staff should not have used restraints. After reviewing Patient #2’s medical record with surveyors, ED Manager #3 identified the restraint episodes on 11/14/24 and 12/6/24 as situations where staff should not have restrained Patient #2. ED Manager #3 stated patients who were sedated or sleeping no longer posed a threat to themselves or others and did not display behaviors requiring restraint use. ED Manager #3 further stated staff kept Patient #2 in locking restraints longer than needed on 12/6/24. ED Manager #3 stated staff should have released the locking restraints once Patient #2 no longer met the criteria for restraint. 2. Providers failed to enter a chemical restraint order for medications used to chemically restrain patients. Additionally, staff failed to monitor and assess chemically restrained patients per facility policy. A. Medical record review revealed staff chemically restrained patients without providers placing orders for chemical restraint, and nursing staff failed to monitor or assess the oxygen level, sedation level, and breathing of these patients. i. A review of Patient #2’s medication and restraint orders from 11/11/24 to 12/29/24 revealed an order for chemical restraint was not entered even though Zyprexa was administered to Patient #2 as a chemical restraint. Additionally, after the patient was administered Zyprexa as a chemical restraint, nursing staff did not monitor Patient #2’s oxygen level, sedation level, and breathing after the patient was administered Zyprexa as a chemical restraint. Examples include: a. On 11/11/24, at 10:12 p.m., Patient #2 was placed in 4-point locking restraints and administered 5 mg of Zyprexa. b. On 11/14/24, at 8:17 p.m., Patient #2 was placed in 4-point locking restraints and administered 5 mg of Zyprexa. c. On 12/6/24 at 10:30 p.m., Patient #2 was placed in 4-point locking restraints and administered 5 mg of Zyprexa at 10:43 p.m. d. On 12/22/24 at 4:50 p.m., Patient #2 was placed in 4-point locking restraints and administered 5 mg of Zyprexa. e. On 12/24/24, Patient #2 was in 4-point locking restraints from 12:30 p.m. to 4:49 p.m. At 1:53 p.m., staff administered 10 mg of Zyprexa, and at 4:49 p.m., they administered an additional 5 mg. f. On 12/29/24 at 1:45 p.m., Patient #2 was placed in 4-point locking restraints and administered 5 mg of Zyprexa. ii. A review of Patient #3’s medical record revealed at 8:18 a.m. on 12/6/24, 11-year-old Patient #3 was transported by ambulance to the hospital after attempting to physically assault their grandmother. a. At 9:12 a.m., staff placed Patient #3 in 4-point locking restraints and administered 5 mg of Zyprexa as a chemical restraint after Patient #3 became agitated and attempted to strike a security officer. Further review of Patient #3’s medical record revealed Provider #7 ordered 4-point locking restraints for violent behavior and ordered Zyprexa to be given to the patient. However, Provider #7 did not order Zyprexa as a chemical restraint, even though Zyprexa was administered as a chemical restraint. Additionally, nursing staff failed to assess and monitor Patient #3’s oxygen level, sedation level, and breathing after Patient #3 was administered Zyprexa as a chemical restraint. The medical record reviews of Patients #2 and #3 contrasted with the Patient Restraints and Seclusion policy, which read that restraint orders should have included the reason for restraint and specified the type of restraint to be used. Additionally, the policy read that medication administered to involuntarily manage the patient’s behavior or restrict the patient’s freedom of movement was a chemical restraint. Additionally, the patient’s oxygen level, sedation level, and breathing were to be monitored when a chemical restraint was administered. B. Interviews with staff revealed a chemical restraint order was required when patients were administered medications to manage violent or aggressive behavior. Additionally, interviews revealed the oxygen level, sedation level, and patient breathing should have been monitored for chemically restrained patients. i. On 1/14/25 at 1:07 p.m., an interview was conducted with Medical Director (Director) #8. Director #8 stated medications administered to manage a patient’s violent behavior and prevent the patient from harming themselves or others were considered a chemical restraint. Director #8 stated a chemical restraint was the administration of medications with sedative effects to manage violent or aggressive behaviors. Director #8 further stated patients who were mechanically restrained and administered a chemical restraint should have had an order for both the chemical and mechanical restraints entered by the provider. Additionally, Director #8 stated the medical provider needed to specify the reason for administering a chemical restraint and the signs and symptoms justifying its administration. Director #8 further stated Zyprexa was used as a chemical restraint when administered to Patient #2 and Patient #3, and an order for chemical restraint should have been entered by the medical provider. Director #8 stated excessive sedation and respiratory depression could occur when patients were chemically restrained, and patients were at risk of not being properly monitored and assessed by nursing staff when providers did not enter orders for chemical restraint correctly. ii. On 1/14/25 at 11:06 a.m., an interview was conducted with RN #9. RN #9 stated chemical restraints were medications administered to stop aggressive or violent behavior and caused a sedative effect. RN #9 further stated an order for the use of chemical restraint was required by the patient’s medical provider. RN #9 stated the patient’s oxygen level, sedation level, and breathing needed to be monitored when patients were chemically restrained. RN #9 stated the oxygen level, sedation level, and breathing were monitored for chemically restrained patients to ensure the patient did not experience life-threatening respiratory depression due to oversedation. 3. The facility failed to audit all patient restraint episodes in accordance with the facility’s expectations. A. Document review i. A review of the quarterly Regulatory Readiness meeting minutes between 10/2023 and 1/2025 revealed the emergency department failed to meet its target restraint audit rate of 100 percent (%). a. In February of 2024, the restraint audit rate was 0%. b. In June of 2024, the restraint audit rate was 23%. c. In January of 2025, the restraint audit rate was 35%. This contrasted with the Tracer Observation Form provided by the facility on 1/13/25, which stated all restraint episodes were to be audited. Additionally, upon request, the facility could not provide evidence of preventive measures, process improvement evaluations, or actionable measures implemented to address the lack of restraint audits performed. B. Interviews i. Interviews with leadership revealed a lack of quality oversight, as well as the facility’s failure to perform patient restraint audits and implement interventions to prevent recurrence a. On 1/8/25 at 3:33 p.m., an interview was conducted with ED Manager #3. ED Manager #3 stated they had not ensured all patient restraint episodes in the ED were reviewed. ED Manager #3 stated restraint use was supposed to be audited to ensure the use of restraints was required, patients were released when they were no longer a threat to themselves or others, and the patient was assessed according to the type of restraint implemented. Additionally, ED Manager #3 stated restraint should be used only when necessary, as the use of restraints could cause physical injuries, psychological harm, increased agitation, and even death when used. b. On 1/13/25 at 12:50 p.m., Quality Director (Director) #6 was interviewed. Director #6 stated restraint episodes were audited to ensure the correct order for restraint was entered, the use of restraint was appropriate, and patient monitoring and assessment were performed according to the type of restraint used. Director #6 stated the quality department had identified patient care units had failed to audit 100% of the restraint episodes since 10/2023. Director #6 further stated during the regulatory readiness meetings, patient care units, including the ED, were informed staff needed to audit all restraint episodes and received resources to ensure they performed the audits. However, Director #6 stated a corrective action plan had not formally been developed to address the issue.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition §482.13 Patient Rights, was out of compliance. A-0143 The patient has the right to personal privacy. Based on observation, document review, and interviews, the facility failed to ensure the personal privacy of five of five patients reviewed who received care while placed in hall beds located in the emergency department (ED)(Patients #1, #4, #5, #6, and #8). A-0144 The patient has the right to receive care in a safe setting. Based on observations, document reviews, and interviews, the facility failed to ensure the safety of hall bed patients in the emergency department (ED) by neglecting to provide a call system in five of five patient observations (Patients #1, #4, #5, #6, and #8). Furthermore, the facility failed to ensure the minimal usage of hallway beds, and when used, the facility failed to ensure the safety of hall bed patients by its lack of policy, procedure, and guidance to the staff on the care of hall bed patients. (Cross reference A-0143)”

“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: 48269 Based on observations, document review, and interviews, the facility failed to ensure the personal privacy of five of five patients reviewed who received care while placed in hall beds located in the emergency department (ED)(Patients #1, #4, #5, #6, and #8). Findings include: Facility policy: The facility Patient Rights and Responsibilities policy read, its purpose is to communicate and provide patient rights and responsibilities to all patients with recognition of the patient’s personal values and beliefs as long as they do not interfere with the well-being of others or the patient’s medical treatment. The policy is to provide care and treatment in a safe setting that is respectful, recognizes a person’s dignity, cultural values, and religious beliefs and preferences, and provides for personal privacy to the extent possible during the course of treatment. 1. The facility failed to have a process in place to ensure the personal privacy of patients who received care while placed in hall beds. A. Observations i. On 12/26/23 at 8:55 a.m., a tour of the ED was conducted with clinical nurse manager (Manager) #4. According to Manager #4, the ED was divided into 4 areas: main ED, senior ED, behavioral health, and fast-track and triage area. In total, the ED had 52 beds which included the triage area. Hall beds #24, #28, #32, #37, and #40 were designated in the main area of the ED. Two additional hall beds #48 and #54 were designated in the senior area of the ED. The hall beds were positioned in the open corridors of the ED. Hall bed patients, patients admitted to ED rooms, and ED visitors had access to and were observed walking through the open corridors. This left patients admitted to hall beds visible to other patients and visitors in the ED. During the tour, hall bed stretchers were observed with clean sheets and supplies and appeared ready to receive patients. Manager #4 stated the beds were prepared in case they were needed for lower acuity patients when the rooms were all full. Additionally, Manager #4 described the ED track board and pointed out the location of hall beds on the track board. ii. On 12/26/23 at 2:47 p.m., an additional ED observation was conducted. Observations revealed Patient #4 was in hall bed #37 next to the nurse’s station, however, there was nothing in place to protect the patient’s privacy while receiving care in the hallway. a. A review of Patient #4’s medical record revealed they were admitted to the ED for syncope (fainting) and were triaged as an ESI-3 (stable and less acute patient whose condition required two or more resources for a disposition to be made). Patient #4 moved from ED room #35 to ED hall bed #37 at 1:13 p.m., and discharged from hall bed #37 by ambulance transport to home on 12/26/23 at 4:20 p.m. Patient #4 spent a total of three hours in a hall bed with no means in place to protect their privacy. iii. On 12/28/23 at 3:05 p.m., an additional ED observation was conducted. The director of emergency services (Director) #6 was present at the time of the observation. Observations revealed all five hall beds were in use during the observation period. During this time, approximately half of the rooms in the senior ED section of the ED were empty. Director #6 said there had been multiple staff call-outs that day and they were actively recruiting staff to come in so they could open the rest of the beds in the senior ED section. a. Further observations during this time revealed the patient and visitor located in hall bed #32 were able to observe staff providing care to a female patient, Patient #7, who was not fully clothed, in trauma room #32. The privacy curtains were not pulled to protect Patient #7’s privacy. Patient #7’s care was in direct line of sight of the patient and visitor in hall bed #32. b. Further observations during this time revealed Patient #5 was located in hall bed #37 and received a 12-lead electrocardiogram (EKG), lab draw, ultra-sound guided intravenous (IV) catheter placement, and a care management consult in the corridor with nothing in place to protect their privacy. Staff, patients, and visitors were observed walking past Patient #5 while they were receiving patient care services. A review of Patient #5’s medical record revealed they were brought to the ED by ambulance after having several falls at their nursing facility that day. The nursing facility also reported the patient had been having increased agitation and aggressive behaviors. Patient #37 had a history of cognitive impairment and a behavioral disorder. Patient #5 was triaged as an ESI-3. Patient #5 was placed in hall bed #37 on 12/28/23 at 2:52 p.m., and moved to room SR49 on 12/28/23 at 8:23 p.m. Patient #5 spent a total of five and a half hours in a hall bed without a way to protect their privacy. c. Further observations during this time revealed Patient #6 was located in hall bed #32 and received a nasal swab while in the hallway to collect a specimen for a respiratory panel that could detect a respiratory infection such as COVID or influenza with no way to protect their privacy. A review of Patient #6’s medical record revealed they were brought to the ED by ambulance from their home with shortness of breath. They were triaged a level ESI-2 (urgent level two patient, very ill and should be seen as soon as possible) and placed in ED hall bed #32 on 12/28/23 at 4:39 p.m. Patient #6 was moved to ED room 34 at 5:58 p.m. Patient #6 spent a total of one hour and ten minutes in a hall bed without a way to protect their privacy. iv. Observations were conducted of video camera footage from 12/7/23 from 2:45 p.m. to 8:15 p.m. in the main ED. Observations revealed two patients were located on stretchers in the hallway by the nursing station. There was nothing in place to protect their privacy while receiving care in the hallway. a. Further observations from the video camera footage revealed Patient #1 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher with nothing in place to protect their privacy. The patient received triage assessment (the process of sorting patients based on their need for immediate medical treatment), lab draw, IV catheter insertion, 12-lead EKG, a care management consult, and a physical therapy evaluation in the hallway. A review of Patient #1’s medical record revealed they were brought to the ED by ambulance from urgent care where they had been evaluated for recent falls and weakness. A head CT had been conducted at the urgent care. Patient #1 was triaged at a level ESI-3 and placed in ED hall bed #37 at 2:54 p.m. Documentation revealed at 7:07 p.m. the nurse could not find an available wheelchair to transport the patient to the bathroom so a urinal was provided to the patient in the hallway under a sheet for modesty. Patient #37 was moved to ED room 23 at 7:56 p.m. Patient #5 spent a total of five hours in a hall bed without a way to protect their privacy. b. Further observations from the video camera footage revealed Patient #8 was in hall bed #32 across from ED room #32 wearing street clothes and lying on a stretcher without a way to protect their privacy. The patient received triage assessment, vital signs, lab draw, IV catheter insertion, and 12-lead EKG in the hallway. During the observation of the 12-lead EKG, the patient’s abdomen was visible throughout the procedure. A review of Patient #8’s medical record revealed they were brought to the ED by ambulance for weakness and respiratory distress. Patient #8 was triaged level ESI-2 and placed in ED hall bed #32 at 12:56 p.m. They were moved to ED room #32 at 4:32 p.m. Patient #8 spent a total of three and a half hours in a hall bed without anything in place to protect their privacy. This was in contrast to the Patient Rights and Responsibilities policy which read, staff were to provide care and treatment in a safe and respectful setting, that recognized a person’s dignity, cultural values and religious beliefs, and preferences, and provided for personal privacy to the extent possible during treatment. B. Interviews i. On 12/28/23 at 8:10 a.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated when they assessed patients they needed to ask private questions and it was a challenge when the patient was located in the hall bed. RN#7 stated they tried hard to protect patient privacy, for example, if there was a patient in a room nearby they would close the door to that room, or if a visitor was in the hallway they would ask the visitor to step into the room; or if someone was walking by they would wait until they walked by and then continue talking to the patient. RN #7 stated as far as physical privacy, they attempted to find a room or space for privacy and moved the patient there to conduct an exam or to provide personal care. They said a lot of patient care was done in the hallway which included IV catheter insertions, medication administrations, and the majority of the physical exam. Further, they said a patient would have their test results spoken in the hallway. They explained this sometimes caused delays in talking to patients in the main ED because, for example, if a brain tumor was seen on imaging, they would need to find a private area to give the test results to the patient. ii. On 12/26/23 at 8:55 a.m., an interview was conducted with clinical nurse manager (Manager) #4 while touring the ED. Manager #4 confirmed the use of hall beds in the ED. They said patients who were low acuity, were ready for discharge, or who had tests pending would be placed in a hall bed. Manager #4 stated patients should have been moved to a private treatment room for care that required privacy. Further, they said there was no formal written policy or process to determine which patient was assigned a hall bed. Additionally, they said the ED utilized hall beds when it was at capacity for patients or when there was not enough staff to assign a patient to a private room. Manager #4 confirmed that hall beds had a designation on the patient tracking system. iii. On 1/2/24 at 12:32 p.m., an interview was conducted with the director of emergency services (Director) #6. Director #6 stated patients had the right to privacy. They said hall bed patients were given privacy to the best of their ability. They also said hall bed patients received the same care as a patient in a private treatment room. Director #6 stated they were not sure if ED staff had received training on hall bed care. iv. On 12/28/23 at 1:51 p.m., an interview was conducted with ED physician (MD) #8. MD #8 stated they had cared for hall bed patients when the ED was full. They said they did a full exam, to a certain degree, in the hallway and protected the privacy of the patient as much as possible. MD #8 stated they minimized personal medical information discussed in the hallway. They said they were limited because they could not discuss confidential information when patient history was discussed in the hallway to protect the personal health information of the patient. Further, they stated the biggest limitation was the lack of privacy in the hallway to remove clothing for physical assessment. MD #8 said if it was physically important and the patient needed a more private exam, they found a space to make that happen. Additionally, they said this often meant they needed to switch rooms with another patient. v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated they would speak quietly with hall bed patients to protect their privacy. Also, they sometimes found a private place for conversation. They stated for the physical exam they did what they could privately in the hallway. Director #1 stated they would swap patients temporarily or permanently if privacy was needed. Director #1 stated hall beds were used as a “pop-off valve” when space was not adequate to meet patient needs or volume. They said there was no policy for hall bed care. Further, they said hall beds were used as a last resort and that no one wanted to be in a hall bed. This was in contrast to the Patient Rights and Responsibilities policy which read, staff were to provide care and treatment in a safe and respectful setting, that recognized a person’s dignity, cultural values and religious beliefs, and preferences, and provided for personal privacy to the extent possible during treatment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48269 Based on observations, document reviews, and interviews, the facility failed to ensure the safety of hall bed patients in the emergency department (ED) by neglecting to provide a call system in five of five patient observations (Patients #1, #4, #5, #6, and #8). Furthermore, the facility failed to ensure the minimal usage of hallway beds, and when used, the facility failed to ensure the safety of hall bed patients by its lack of policy, procedure, and guidance to the staff on the care of hall bed patients. (Cross reference A-0143) Findings include: Facility policies: The facility Patient Rights and Responsibilities policy read, its purpose is to communicate and provide patient rights and responsibilities to all patients with recognition of the patient’s personal values and beliefs as long as they do not interfere with the well-being of others or the patient’s medical treatment. The policy is to provide care and treatment in a safe setting that is respectful, recognizes a person’s dignity, cultural values, and religious beliefs and preferences, and provides for personal privacy to the extent possible during the course of treatment. The facility ED Triage policy read, its purpose is to prioritize patient needs to the available resources of the Emergency Department, a 5-level evidence-based standardized triage process will be followed. The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment. Definitions: Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel (QMP). ESI 1 - Resuscitative/ Emergent Level 1 patients are critically ill and require immediate physician evaluation and interventions. ESI 2 - Urgent Level 2 patients are very ill and should be seen as soon as possible. Emergency care can be initiated through protocols without a physician at the bedside. The patient needs interventions, but their clinical condition will not deteriorate. Included but not limited to: High-Risk Situations, New onset confusion, lethargy, or disorientation, and severe pain or distress. ESI 3 - Stable Less acute patients whose condition requires 2 or more resources for a disposition to be made. ESI 4 - Non-urgent Less acute patients whose condition requires a single resource for a disposition to be made. ESI 5 - Non-urgent Less acute patients whose conditions require no resources for a disposition to be made. 1. The facility failed to provide a nurse call system for all patients who received care in an ED hall bed. A. Observations and Medical Record Reviews i. On 12/26/23 at 2:47 p.m., an observation was conducted of the main ED. One patient (Patient #4) was located on a stretcher alone in the hallway. The patient did not have access to a nurse call system. Observations further revealed Patient #4 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher without a call system. Review of Patient #4’s medical record revealed they were admitted to the ED for syncope (fainting). They received a CT of the head and cervical spine during their evaluation in the ED. After they were evaluated, Patient #4 was prepared to be discharged and was moved from ED room #35 to ED hall bed #37 at 1:13 p.m. to wait for ambulance transport. They were discharged from hall bed #37 on 12/26/23 at 4:20 p.m. Patient #4 spent a total of three hours in a hall bed without access to a nurse call light. ii. On 12/28/23 at 3:05 p.m., an additional observation was conducted of the main ED. Five patients were located on stretchers in the hallway. The patients did not have access to a nurse call system. The director of emergency services (Director) #6 was present at the time of the observation. Observations confirmed that five hall beds were in use during the observation period. During this time, approximately half of the rooms in the senior ED section of the ED were empty. Director #6 said there had been multiple staff call-outs that day and they were actively recruiting staff to come in so they could open the rest of the beds in the senior ED section. a. Observations further revealed Patient #6 was in ED hall bed #32 across from ED room 32 wearing street clothes, and lying on a stretcher without a call system. A review of Patient #6’s medical record revealed they were brought to the ED by ambulance from their home with shortness of breath. They were triaged a level ESI-2 and placed in ED hall bed #32 at 4:39 p.m. Patient #6 received a nasal swab while in the hallway to collect a specimen for a respiratory panel that could detect a respiratory infection such as COVID or influenza. At 5:58 p.m. they were moved to ED room 34. Patient #6 spent a total of one hour and ten minutes in a hall bed without access to a nurse call light. b. Observations further revealed Patient #5 was in hall bed #37 across from ED room #37 wearing street clothes and lying on a stretcher without a call system. A review of Patient #5’s medical record revealed they were brought to the ED by ambulance after having several falls at their nursing facility that day. The nursing facility also reported they had been having increased agitation and aggressive behaviors. Patient #37 had a history of cognitive impairment and a behavioral disorder. Patient #5 was triaged as an ESI-3 and placed in ED hall bed #37 at 2:52 p.m. At 8:23 p.m. they were moved to ED room SR49. Patient #5 spent a total of three and a half hours in a hall bed without access to a nurse call light. iii. Observations were conducted of video camera footage from 12/7/23 at 2:45 p.m. to 8:15 p.m. in the main ED. Two patients were located on stretchers in the hallway. The patients did not have access to a nurse call system. a. Observations further revealed Patient #1 was in hall bed #37 across from ED room #37 wearing street clothes, lying on a stretcher alone and without a call system. A visitor was observed arriving at their hall bed approximately ten minutes after the patient arrived. A review of Patient #1’s medical record revealed they were brought to the ED by ambulance from urgent care where they had been evaluated for recent falls and weakness. A head CT had been conducted at the urgent care. Patient #1 was triaged a level ESI-3 and placed in ED hall bed #37 at 2:54 p.m. At 7:56 p.m. they were moved to ED room 23. Patient #5 spent a total of five hours in a hall bed without access to a nurse call light. b. Observations further revealed Patient #8 was in hall bed #32 across from ED room #32 wearing street clothes and lying on a stretcher alone and without a call system. A review of Patient #8’s medical record revealed they were brought to the ED by ambulance for weakness and respiratory distress. They were triaged a level ESI-2 and placed in ED hall bed #32 at 12:56 p.m. At 4:32 p.m. they were moved to ED room 32. Patient #8 spent a total of three and a half hours in a hall bed without access to a nurse call light. These observations and medical record reviews were in contrast to the Patient Rights and Responsibilities policy which read, patients were to receive care and treatment in a safe setting. B. Interviews i. On 12/26/23 at 9:46 a.m., an interview was conducted with emergency department technician (EDT) #2. EDT #2 stated patients placed in ED hall beds did not have access to a nurse call light. Also, EDT #2 said they were not sure if a staff member was always present at the nursing station to observe hall bed patients who did not have access to a call light. ii. On 12/26/23 at 9:25 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated a risk of caring for patients in a hall bed was that these patients did not have access to a call light. Further, they said hall beds were used in the past and the practice went away after a visit from the state health department; then during the COVID pandemic hall beds were put back in use and had been used ever since. iii. On 1/2/24 at 11:46 a.m., an interview was conducted with charge nurse (RN) #5. RN #5 stated patients in hall beds did not have access to a nurse call light. They also said a risk to patients who received their care in a hall bed was the lack of access to a nurse call system to call for assistance when the patient needed to get up to prevent a fall. Further, they said access to a call light should have been available to all ED patients. iv. On 12/27/23 at 9:17 a.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated there were risks associated with caring for patients in hall beds without access to a call light. Specifically, they said patients could have vital signs or mental status changes, could fall, and could need assistance with personal care, toileting, or medications. Manager #4 stated ED staff wanted to ensure patients were kept safe. v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated hall bed patients received the same standard of care as ED patients who had been cared for in a private ED room. They said hall bed patients had access to a nurse call light. Further, they said staff would never put a patient in a hallway if there was a room available for patient care. This was in contrast to the observations and interviews conducted that revealed patients receiving care in the hall did not have access to a nurse call system. This was also in contrast to the observation that revealed patients received care in hall beds when there were open rooms in the senior section of the ED. 2. The ED staff provided care to patients in hall beds in the absence of facility policies, procedures, and education to guide the staff in the care of the hall bed patient. A. Document review i. A facility policy or procedure for the care of hall bed patients in the ED was requested. An email from the manager of regulatory affairs (Manager) #9 stated the facility did not have a policy for hall beds. ii. Facility tracking and trending on the use of hall beds in the ED was requested. An email from Manager #9 stated the facility was not currently tracking and trending the use of hall beds. iii. A review of the medical record for Patient #6 revealed on 12/28/23 the patient arrived at the ED with a chief complaint of shortness of breath. They were placed in hall bed 32 at 4:39 p.m. At 4:51 p.m. triage was completed and the patient was assigned a triage level of ESI-2. According to the policy, ESI-2 patients were defined as Urgent Level 2 patients who were very ill and should have been seen as soon as possible. iv. A review of the medical record for patient #8 revealed on 12/7/23 the patient arrived by ambulance at the ED with a chief complaint of weakness and respiratory distress. They were placed in hall bed 32 at 12:56 p.m. At 1:14 p.m. triage was completed and the patient was assigned a triage level of ESI-2. B. Interviews i. On 12/28/23 at 8:10 a.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated the decision to put a patient in the hall bed was made by the charge nurse. They said patients with low acuity who were not as sick as other patients should have been the patients placed in hall beds because the nurses were not able to monitor the hall beds as closely. They also said there was no written policy for guidance on patients receiving care in hall beds. Furthermore, RN #7 said the current process for when the ED rooms were full was that patients were put in hall beds because they were next in line. RN #7 stated staff did not want to put patients in hall beds, but if there was nowhere else to place a patient a higher acuity patient, such as a patient with chest pain, could have been placed in a hall bed. RN #7 stated hall bed patients were at risk of delays in care because staff were looking for a place to provide care privately. (Cross reference A-0143) They said it was hard to conduct an accurate physical exam in the hallway because there was a lot of noise and they could not hear with the stethoscope. RN #7 stated the equipment required for attending to a patient in a hallway bed was not readily accessible, specifically citing the absence of immediate access to suction equipment, a resource typically available in dedicated patient rooms. Furthermore, they said the staff did their best for patients but the hall beds made it difficult to provide the best care to patients. ii. On 1/2/24 at 11:46 a.m., an interview was conducted with ED charge nurse (RN) #5. They stated ideally staff would never use hall beds. RN #5 stated they did not know if there was a written policy for hall bed use. RN #5 also stated no special training was provided to nurses for the process of patients receiving care in hall beds. RN #5 stated the charge nurse decided which patients went to the hall beds and those patients were lower acuity patients with an ESI-3 (stable, less acute patients whose condition required two or more resources for a disposition to be made). She said more acute ESI-1 (resuscitative/ emergent level one patients who were critically ill and required immediate physician evaluation and interventions) and ESI-2 (urgent level two patients who were very ill and should have been seen as soon as possible with concerns included but not limited to high-risk situations, new onset confusion, lethargy, or disorientation, and severe pain or distress) level patients should not have been put in a hall bed. This was in contrast with the medical record reviews conducted that revealed ESI-2 level patients received care in hall beds. iii. On 1/2/24 at 12:32 p.m., an interview was conducted with the director of emergency services (Director) #6. Director #6 stated they weren’t sure how often hall beds were used. They said the ED staff pulled patients out of their rooms frequently to accommodate for incoming ambulance patients. However, they said there was no tracking and trending data collected related to hall bed use. Further, they said they would need to ask if there was an ED policy on hall bed use. Director #6 stated staff caring for hall bed patients would have the same guidelines as patients located in an ED room. They said they would need to ask the ED educator if there was any special training for staff on the care of hall bed patients. Furthermore, they stated patients in hall beds got the same care as patients in a room. This was in contrast to the interview with RN #7 who stated it was difficult to conduct assessments in the hallway due to the traffic and excessive noise. iv. On 12/28/23 at 1:51 p.m., an interview was conducted with physician (MD) #8. MD #8 stated they would occasionally care for a patient in a hall bed when the ED was busy and full. They stated that sometimes it was the only option. MD #8 said the biggest limitation was not being able to remove a patient’s clothing to do a thorough exam in the hallway. Additionally, they said history-taking interviews were somewhat limited due to a lack of privacy in the hallway. v. On 12/28/23 at 7:40 a.m., an interview was conducted with medical director (Director) #1. Director #1 stated the use of hall beds was not regular or standard. They explained it was a “pop-off valve” used whenever space was not adequate to meet patient needs or volume. They said the charge nurse would decide if a patient needed to be placed in a hall bed. Director #1 stated they did not think there was a policy about the use of hall beds. They said the criteria for placing a patient in a hall bed would have been a stable patient who would not need immediate intervention. They said the staff would not put a high-acuity patient in a hall bed. This was in contrast to the review of medical records for patients #6 and #8 who were triaged as an ESI-2 and assigned to a hall bed location.”