Northside Hospital Cherokee

“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: 42305 Based on review of facility Medical Staff Bylaws, policy and procedures, medical records and staff interviews, it was determined that Emergency Department (ED) staff failed to provide an appropriate Medical Screening Exam (MSE) for one (P) (Patient #1) of 20 patients reviewed when she presented on 11/12/25 accompanied by a service animal requesting treatment for knee pain and swelling. Facility staff refused to allow the service animal in the ED patient care area and P#1 left after three hours without being seen. Cross Refer to A-2406 as it relates to the facility’s failure to provide a medical screening examination.”

“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: 42305 Based on review of facility Medical Staff Bylaws, policy and procedures, medical records, and staff interviews, it was determined that the Emergency Department (ED) failed to provide an appropriate Medical Screening Examination (MSE) to one patient (Patient #1) out of 20 patients reviewed who came to the ED seeking treatment. Specifically, P#1 presented to the ED on 11/12/25 at 5:05 p.m. with a complaint of knee pain and swelling. Facility staff refused to allow P#1’s service animal accompany her to the ED patient care area and P#1 left without receiving a MSE. Findings included: A review of the Medical Staff Bylaws, approved by the Board on 11/6/2023, and Rules and Regulations of the Medical Staff, approved 11/7/2024, Article 5, Emergency Services, Section C, Medical Screening Examinations (MSE), revealed that an MSE must be provided to any person who came to the facility’s Emergency Department or the Labor and Delivery Department and requested examination or treatment. Review of the facility’s policy titled, “Access to Emergency Medical Treatment”, 11355, revised 1/30/20, revealed that it was the policy of the facility to provide an appropriate medical screening examination to any person who came to the ED and requested examination or treatment. Review of the facility’s policy titled “Service Animals” 10143, revised 5/3/23, revealed that the facility recognized the right of individuals with disabilities who were accompanied by service animals to independently access facilities and services. A person using a service animal had the same access to facilities as a person who did not have a service animal. Service animals were individually trained to do work or perform tasks directly related to an individual’s disability. If the role of an animal brought into the facility was not immediately apparent, staff may have asked two questions: was the animal required because of a disability, and what work or task was the animal trained to perform? An individual with a service animal was not asked about the nature or extent of the disability. If the presence of a service animal raised an issue that was not described in the policy and staff were considering limiting the service animal’s access to the facility, the issue would be referred to Risk Management for disposition. If a decision was made to exclude a patient’s service animal, the reason for the exclusion would be documented in the medical record. A review of the “ED Clinic Summary” for P#1 revealed that P#1 arrived in the ED on 11/12/25 at 5:05 p.m. “ED Triage Part 1” by the Registered Nurse (RN) II at 5:36 p.m. revealed that P#1 was complaining of worsening severe knee pain and swelling. P#1 had a service dog with her that was calm and well-controlled. Review of Discharge Information revealed that P#1 left without being seen on 11/12/25 at 8:50 p.m. Review of the End of Shift Report by the ED Supervisor (EDS) AA, no date/time, revealed that the a patient had an emotional support animal. After following the policy, and the matter was escalated to administration and, security was made aware that the dog could not stay. The patient left without being seen. During a telephone interview with the complainant on 11/24/25 at 10:54 a.m., the complainant stated that after being told the animal was a service dog, the ED supervisor (EDS AA) asked what tasks the dog performed. EDS AA was not satisfied with the answers given and said the dog was an emotional support animal. P#1 felt obligated to disclose medical and psychiatric conditions in front of a crowded waiting room to convince EDS AA that the dog was a service animal. P#1 offered to show the dog’s registration information, but EDS AA refused to see it. EDS AA told P#1 she would not be seen in the ED because of the emotional support animal. P#1 was placed in a wheelchair and backed into a storage area where wheelchairs were normally stored in the Emergency Department (ED). The triage nurse told P#1 to wait in that place until things could be sorted out. P#1 waited three hours to be seen in the ED and was never taken to an exam room. Security was called multiple times to report that an emotional support animal was in the ED. Patient Relations also came to talk to P#1 twice. P#1 left the ED after the person who was taking the blood pressures told P#1 that she was not going to be seen and after P#1 overheard EDS AA tell staff to call security again. A telephone interview was conducted with the ED Supervisor (EDS AA) on 11/25/25 at 10:07 a.m. EDS AA said that he was called to the triage area because Patient #1 (P#1) had a dog. EDS AA reviewed the hospital’s service animal policy and began asking P#1 the required service animal questions. P#1 stated the dog helped her stay calm. EDS AA said this answer fell under “emotional support,” and emotional support animals were not permitted under hospital policy. EDS AA told P#1 the dog would need to leave, but P#1 would be allowed to stay. P#1 requested to speak with a supervisor. EDS AA contacted the House Coordinator. Security was also contacted after the discussion escalated. According to EDS AA, the decision was made that the patient could stay but the dog could not remain in the ED. EDS AA confirmed that P#1 remained in the ED for approximately three hours and was seated in the alcove area behind triage. A telephone interview was conducted with the House Coordinator (HC BB) on 11/25/25 at 10:36 a.m. HC BB responded after receiving a call from the ED Supervisor regarding a patient with a dog. HC BB located P#1 in the lobby with a small dog in her lap. P#1 told HC BB that the ED staff said P#1 could not be seen with the dog. HC BB said the dog was calm and not disruptive. An interview was conducted with the Supervisor of Security (SS CC) on 11/25/25 at 11:04 a.m. in the Boardroom. SS CC said security received a call regarding a patient in the ED with a dog. SS CC asked P#1 the two permitted ADA questions, and P#1 said the dog performed a task related to PTSD. SS CC said the dog appeared well-controlled and that P#1 answered both questions appropriately. SS CC said there was no reason to doubt the dog was a legitimate service animal. SS CC said removing a patient with a service animal from the ED would be an EMTALA violation and that there was no basis to tell P#1 or the dog to leave. An interview was conducted with Security Corporal (SC DD) on 11/25/25 at 11:11 a.m. SS DD said security received a call about a patient with a dog. SS DD spoke with P#1, asked the two ADA service animal questions, and P#1 answered appropriately. SS DD notified the charge nurse that the dog was allowed to remain with the patient. SS DD told P#1 that no one should interfere with her regarding the dog. A telephone interview was conducted with House Coordinator (HC EE) on 11/25/25. HC EE arrived in the ED at 7:00 p.m. HC EE had been informed that P#1 was concerned about whether she would be permitted to have a service animal in the ED. HC EE observed P#1 in the alcove area and noted the dog was calm. HC EE said the ED staff continued trying to determine whether the dog was permitted to remain under policy. An interview was conducted with the Clinical Supervisor (CS FF) on 11/25/25 at 11:44 a.m. CS FF received a call indicating there was a dog in the ED and the situation was being handled by EDS AA. CS FF was later told by the House Coordinator that the dog needed to leave, and CS FF passed that message to EDS AA. CS FF said P#1 was approached multiple times about the dog. CS FF contacted security because staff had been questioning the patient repeatedly. CS FF said she was told P#1 would be seen, but the dog could not remain unless the service animal criteria were met. CS FF confirmed the patient had been spoken to multiple times regarding the dog. A telephone interview was conducted with Clinical Supervisor (CS GG) on 11/26/25 at 10:11 a.m. CS GG said P#1 was in the alcove and reported being asked multiple times about the service animal. CS GG said several staff members, including ES AA, CS FF, and PR HH, had asked questions about the dog. CS GG said staff continued reviewing the policy because they were unsure if the dog qualified as a service animal. CS GG said P#1 told her the repeated questioning made her believe she would not be seen with the dog. CS GG said security confirmed the patient answered both ADA questions correctly, but staff continued reviewing policy and discussing whether the dog could stay. A telephone interview was conducted with the Patient Relations representative (PR HH) on 11/26/25 at 10:17 a.m. PR HH was approached by the house coordinator concerning a patient who was upset about a dog. PR HH spoke to security and SS CC went with PR HH to see the patient. PR HH asked P#1 what task the dog performed. P#1 said it was for PTSD. PR HH asked for a rabies tag, because the tag was not visible. P#1 was trying to show PR HH something on her phone, but PR HH said the physical rabies tag was required. PR HH did not look at the phone. P#1 was in a wheelchair by herself, and PR HH asked if there was someone who would help with the puppy. P#1 said that if she was admitted, she would call a family member to care for the dog. PR HH told P#1 the dog could not go for testing. P#1 got upset and began to scream that nobody was going to separate her from the dog. A telephone interview was conducted with ED Tech (EDT JJ) on 11/26/25 at 10:27 a.m. EDT JJ said he took P#1’s vital signs and noticed a dog. EDT JJ did not think anything of the dog because patients could have service animals. It was clear that leadership was aware of the dog. EDT JJ said P#1 verbalized that she was unhappy about waiting in alcove and mentioned that ES AA had been watching her. The dog was very well-behaved. EDT JJ was not sure why P#1 left the ED. It had been a very busy night and not uncommon for patients to be frustrated with waiting times. P#1 told EDT JJ that she did not think she was going to get a room. A telephone interview was conducted with the ED Medical Director (MD MM) on 11/25/25 at 12:11 p.m. MD MM said that when a patient arrives with an animal, staff would ask whether the animal was a service animal or a pet. If the animal was a service animal, the patient would be allowed to remain and would not be treated differently than other patients. MD MM said the first step would be to contact Risk Management for directions, and in general the ED would err on the side of accommodating the situation. Staff were expected to take care of the patient. An interview was conducted with the ED Nurse (RN) Manager (NM NN) on 11/25/25 at 1:42 p.m. in the Boardroom. NM NN learned the next morning that a patient had presented to the ED after 5 p.m. with what staff believed was an emotional support animal. The situation had been escalated to the house coordinator, patient relations, and security. The patient left without being seen. An interview was conducted with the ED Tech (EDT JJ) on 11/26/25 at 10:27 a.m. EDT took P#1’s vital signs in the alcove. EDT JJ noted that P#1 had a dog but did not question it. EDT JJ said P#1 was upset and frustrated about waiting and about staff repeatedly questioning her about the dog. The dog was well behaved. P#1 later left the ED. A telephone interview was conducted with Risk Management (RM OO) on 11/26/25 at 10:35 a.m. RM OO said she was called after hours by ED staff. RM OO said a patient presented to the ED with what they believed was an emotional support animal. RM OO said staff were trying to arrange for someone to come get the dog. The patient told staff that a family member could come pick up the dog. ED staff asked whether they could call the family member to retrieve the dog. RM OO told the staff that it was acceptable to call. An interview took place with ED Tech (EDT RR) on 11/26/25 at 11:02 a.m. in the Boardroom. EDT RR said P#1 came to the ED and was registered at the front desk. EDT RR brought P#1 to Station A and did vitals. The dog was well-behaved. Someone at registration let the supervisor know there was a dog. The supervisor came to discuss the dog and what services the dog provided. P#1 was upset.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 52769 Based on review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one patient (P) P#1 of four sampled patients (P#1, P#2, P#3, and P#4), received pain medication in a timely manner per physician’s orders. Specifically, nursing staff were unable to view electronic physician orders for P#1 due to an IT error which resulted in a delay in medication administration. Findings include: A review of the facility’s Complaint and Grievance log revealed that P#1 submitted a complaint on 9/18/25 related to courtesy, respect, and promptness to needs and requests. A second complaint was submitted on 9/18/25 related to coordination of care. A review of medical records for P#1 revealed that she was admitted to the facility on 9/17/25 for a cervical revision of C6-C7 ACDF & C5-C6 revision ACDF (a surgical procedure that involves joining two or more vertebrae in the neck to stabilize the cervical spine and alleviate pain). The nurse practitioner (NP) entered orders on 9/17/25 at 7:19 p.m. for P#1 to receive 1000 mg of acetaminophen (analgesic) intravenously (medicine administered through a catheter directly into a vein) (IV) every six hours for 24 hours. A review of P#1’s ‘Medication Administration Record’ (MAR) revealed that P#1 received the first dose of acetaminophen 1000 mg IV at 1:22 a.m. on 9/18/25. An “Occupational Therapy Form” revealed that P#1 participated in therapy on 9/18/25 at 9:56 a.m. P#1’s head pain score was a level 3 (pain scale measures the level of pain per the patient with 0 being ‘no pain’ and 10 being the worst pain imaginable). The Occupational Therapist (OT) reassessed P#1’s pain at the end of the session and notified the nurse that the pain score was a level 3 and that P#1 requested pain medication. A review of the facility’s policy titled “Pain Management -System,” number 11342, last revised 10/4/23 revealed that the purpose of this policy was to outline the facility’s guidelines for the safe and effective management of pain, documentation of pain, staff education, and performance improvement efforts related to pain. The facility was committed to ensuring that patients received optimal comfort & pain control through a proactive pain management plan that was developed through patient, family, significant other and healthcare team member collaboration. Appropriate pain assessment, effective pain management, utilization of non-pharmacologic interventions and medications, and safe opioid prescribing practices were a priority. The facility’s approach to pain management was based on the following principles: 1.The experience of pain was subjective and may have been affected by age, gender, and/or culture. 2. Clinicians accepted and respected a patient and family’s report of pain. 3. Regular pain assessments were essential elements in successful pain management. 4. A pain management plan was individualized. 5. Timely interventions were critical to managing pain. 6. Patients were allowed choice and input in their pain management plan. 7. The treatment of pain should have been effective while minimizing any risks associated with the pain treatment plan. Procedures included Initial pain assessment: 1. Staff should have screened patients for the presence of pain on admission: To any inpatient setting 2. The pain interventions should have evaluated and updated to reach an effective level determined by the patient when possible and as appropriate to the patient’s clinical condition. Patient Pain Relief Effectiveness 1. Assisted patients to identify an acceptable level of pain that should have allowed them to perform activities related to recovery. 2. Evaluated relief in terms of the patient’s acceptable level of pain whenever assessing pain. 3. Implemented pain interventions when patients’ pain intensity exceeded their acceptable level. 4. Patients should have changed the level of pain that was acceptable for them at any time. Pain Assessment/Reassessment Elements Pain assessment/reassessment elements included: 1. Pain intensity: measured using an appropriate pain scale based on the patient’s age, clinical condition and ability to understand. Use a pain scale that supported patient condition and considered patient’s ability to understand and communicate. 2. Description of pain 3. Onset / duration 4. Aggravating factors 5. Location of pain and assessment of site 6. Treatment history (past and current), which included -Effectiveness of previous relief measures -Effect on activities of daily living (ADL’s) A review of the facility’s policy titled “Medication Administration,” number 36027, last reviewed 11/5/24 revealed the purpose of the policy: 1. Provided guidelines for safe and timely administration of medications to patients. 2. Provided guidelines for documentation of medications. 3. Provided guidelines for consistent scheduling of medications and define medication categories in which timing was critical. During an interview with Registered Nurse (RN) BB in the boardroom at 1:25 p.m., on 10/01/25, RN BB stated that he worked at the facility for four years as an RN. RN BB’s duties included working in the Post Anesthetic Care Unit (PACU) assessing patients for pain and making sure that their airway was protected. RN BB reported that he assessed patients for pain by asking them their pain level on the pain scale if they were able to talk. For patients that were unable to communicate, RN BB assessed patients by observing grimacing, and elevated heart rate and blood pressure. RN BB explained that post operative medications were entered into the patient’s electronic chart by the surgeon and that the orders followed the patient to the hospital floor when transferred from the recovery room. RN BB recalled that P#1’s surgery was postponed the previous day, 9/16/25, due to a sterile tray contamination. He further recalled that P#1 was not happy that her surgery was postponed to 9/17/25. RN BB acknowledged that if he had a patient whose medication was not in the patient’s chart, he would call the anesthesiologist and ask them to put it in. If that did not work, RN BB reported that he would then contact the charge nurse to report it. RN BB further acknowledged that he would also reach out to registration to see if there were two accounts and ask them to merge them. During a telephone interview with Nurse Practitioner (NP) EE on 10/1/25 at 1:38 p.m., NP EE reported she prescribed P#1’s pain medication which included: intravenous Tylenol, Percocet, and Dilaudid (pain medications) to be administered PRN (as needed) every 6 hours for 24 hours. NP EE further reported that she received several phone calls from the unit staff reporting that they could not see the orders for P#1. NP EE reported that she put the orders in several times and did not know why the unit staff could not see the orders. NP EE requested that the charge nurse get in touch with (Information Technology) IT or bed control to assist with the problem. NP EE did not understand how P#1 was able to get her post operation orders for x-ray but not her orders for medication. NP EE reported that she thought the problem was solved once she stopped receiving phone calls. NP EE recalls the nurse saying that she called IT but they were not available at night. NP EE acknowledged that it was “unbelievable,” that P#1 did not receive her medication as prescribed. NP EE reported that there was a system called Omni Cell that could have been utilized. It was a global list where all orders could be accessed. During a telephone interview with Registered Nurse (RN) AA 10/1/25 at 4:44 p.m., she reported that she worked night shifts and that her duties included direct patient care. RN AA recalled that P#1 came up to her unit on the eighth floor right after shift change. RN AA recalled that P#1 did not complain about having pain. RN AA further recalled that taking P#1 to the bathroom two to three times during the night without complaining about pain. RN AA explained that she was able to access P#1’s pain medication, especially intravenous Tylenol with some difficulties but it did not affect P#1’s care. RN AA further explained that P#1 had two financial information numbers (FIN’s). RN AA explained that she could access more pain medication if it was needed. RN AA recalled in that in the morning between 5:30 a.m. and 6:30 a.m., P#1 expressed her wishes to go home to the NP EE.”

“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: 47718 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that one (P#2) out of five sampled patients received safe care by ensuring a laboratory order/blood draw was stopped after several normal values as per the facility’s policy. Findings: A review of Patient (P) #2 medical record revealed that P#2 was admitted to the facility on 11/5/23 at 1:22 p.m. via the Emergency Department (ED) with the diagnosis of Sepsis (a life-threatening complication of an infection). A review of the order comments under the Activities and Interventions documentation recorded on 11/5/23 at 1:06 p.m. revealed documentation of: Sepsis ED (emergency department); Bedside POC (Plan of care); Lactate; Repeat POC lactate in two hours or before patient leaves the ED. Up to two times (no more than two repeats). A review of the History and Physical (H&P) notes by MD HH on 11/5/23 at 2:05 p.m. revealed that P#2 had an elevated lactic acid (a chemical the body produces when the body cells break down carbohydrates for energy) level on admission with a value of 3.8. Normal lactic range as per documentation was 0.50 - 2.20. A review of the medical record revealed that P#2’s Assessment/Plan included: - Repeat lactic every four hours (q4) until cleared? difficult to clear in setting of chronic kidney disease. Documentation failed to reveal a stop order for the repeat lactic acid q4. A review of MD FF’s progress notes on 11/6/23 at 9:27 a.m. revealed documentation that P#2’s lactic acid was initially elevated, but subsequently normal. Laboratory values on 11/6/23 at 6:06 a.m. was 1.07. Documentation failed to reveal a discontinuation of the lactic acid checks/blood draws. An electronic review of P#2’s medical record was done at the facility on 1/2/24 at 3:00 p.m., which revealed the following times at which the lactic acid check was done with the values documented: On 11/5/23, at 3:01 p.m., the lactic acid level was 1.97. The normal range indicated on the laboratory test values was (0.50 - 2.20). On 11/5/23 at 5:59 p.m., the level was 2.08. On 11/5/23 at 10:31 p.m., the level was 1.78. On 11/6/23, at 2:13 a.m., the level was 1.60. On 11/6/23, at 6:06 a.m., the level was 1.07. On 11/6/23, at 9:59 a.m., the level was 1.82. On 11/6/23, at 2:06 p.m., the level was 1.89. On 11/6/23, at 6:13 p.m., the level was 1.26. On 11/6/23, at 11:57 p.m., the level was 1.66. On 11/7/23, at 2:17 a.m., the level was 1.41. On 11/7/23, at 4:46 a.m., the level was 1.67. The order was discontinued on 11/7/23 at 12:15 p.m. P#2 was discharged home on 11/8/23 at 12:47 p.m. with a discharge diagnosis of Sepsis, Pre-Syncope (feeling that you are about to faint), Hypertension, Type 2 Diabetes Mellitus, Paroxysmal Atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and Acute Kidney Injury on Chronic Kidney Disease (slow deterioration of kidney function or persistent kidney dysfunction). P#2 was documented to be discharged in a stable condition with home health. A review of the “Lactic Acid - Architect” policy, no policy number, effective 12/11/16, last revised 9/14/23, revealed the principle and purpose was that the lactic acid assay was used for the quantitation of lactic acid in human plasma. Quality Control, a minimum of two levels of controls (normal and abnormal) were to be run every 24 hours or reagent use, with each new reagent pack and after calibration. A review of the “Patient Rights and Responsibilities” policy, no policy number, no effective date last revised 5/2/23 revealed: A. Patients’ Basic Rights: All patients at a hospital owned and/or operated by Northside shall receive information on patient rights, responsibilities, and ethics. All patients at a Hospital shall have the following responsibilities: Personal Safety. Patients are responsible for reporting perceived risks in their care and unexpected changes in their condition. Patients are responsible for asking questions when they do not understand what they have been told about their care or what they are expected to do. A review of the “Plan for Providing Patient Care” policy, policy number 10087, effective date 9/9/2020, last reviewed 9/20/22 revealed Planning for Patient Care Services. The Board of Trustees retains the overall responsibility for the safety and quality of care, treatment and services provided at Northside. A review of the “Sample Collect by Venipuncture” policy, Policy #24668, effective 9/4/09, last reviewed 9/26/23 revealed the purpose was to establish guidelines for the collection of blood samples by venipuncture and to minimize or eliminate the following causes of unsatisfactory blood specimens or sample collection: unacceptable amount of hemolysis, collection of specimens without adequate preparation of the patient. Policy. To perform a venipuncture with proper patient identification and in a timely manner, with minimal discomfort to the patient and with the minimal amount of blood withdrawn to satisfactorily perform testing requested. A review of the “Sample Collection by Skin Puncture” policy, Policy #15041, effective 9/13/23, last reviewed 6/1/10 revealed standard procedures and protocols for proper specimen collection are established to prevent pre-analytical errors and protect against complications and patient mismanagement that can otherwise arise when specimens are improperly collected. A telephone interview took place in the board room on 1/3/24 at 9:35 a.m. with Registered Nurse (RN) AA who stated that she usually followed the doctor’s orders on laboratory tests/values. RN AA stated that she has never reported a normal lactic acid value to a doctor. RN AA stated that if the patient requested that the tests be stopped, then she would reach out and ask the doctor. RN AA further stated that the laboratory technicians usually took the blood samples, except it was a central line, then the Registered Nurse would take the sample. A telephone interview took place in the board room on 1/3/24 at 9:45 a.m. with Registered Nurse (RN) BB who stated that if a patient came in with a high lactic acid value, she would inform the doctor who will put in orders that the nurses would follow through. RN BB stated that if a patient continuously had a normal lactic acid value, she would call the doctor and ask if they (the doctors) wanted to continue with the order. RN BB also stated that she had never reported a normal lactic acid value, that it was the doctor that would decide if they wanted to continue with the order or not. An interview took place in the board room on 1/3/24 at 10:10 a.m. with Laboratory Technician (LT) CC who stated that she always followed the doctors’ orders on blood draws/samples, and she would check the orders before going to see a patient. LT CC stated that she did not look at previous results/values of a patient’s laboratory results because she believed if the doctor did not want the orders to continue, they would put a stop to it. LT CC stated that she called the attention of the nurse to P#2 if the lactic acid check was still needed to be done when she noticed she (LT CC) just saw him (P#2) about an hour and half ago, and also took a sample. LT CC stated that the nurse spoke to the doctor, and the doctor cancelled the order. A telephone interview took place in the board room on 1/3/24 at 10:20 a.m. with Registered Nurse (RN) DD who stated that Lactic acid checks/blood samples were based on the doctor’s orders. RN DD stated that if the Lactic acid values were normal on two or three tests, then she would personally inform the doctor if the orders were to be continued. RN DD further stated that she was not 100% sure what the hospital policy stated about Lactic acid checks/blood draws. An interview took place in the board room on 1/3/24 at 10:35 a.m. with Medical Doctor (MD) EE who stated that he saw P#2 on day two following his (P#2) admission, and he (MD EE) discontinued the lactic acid check/blood draws because the values had been normal. MD EE stated that discontinuing the lactic acid checks/blood draws was based on the severity of the condition of the patient. MD EE also stated that because sepsis was suspected in P#2, the criteria was to monitor the serial lactate. A telephone interview took place in the board room on 1/3/24 at 10:45 a.m. with Medical Doctor (MD) FF who stated that he saw P#2 just for one day. MD FF stated that the initial concern for P#2 was sepsis and because the lactic acid was initially high. MD FF stated that they (the doctors) accidentally left the lactic acid blood draws to continue, which was why the samples were continually checked despite the levels were within normal range. MD FF further stated that the order should have been stopped if the levels were within normal range on two or three occasions. An interview took place in the board room on 1/3/24 at 11:00 a.m. with Registered Nurse (RN) GG who stated that she could not recall P#2. RN GG stated that if a patient’s lactic acid laboratory values were within normal range and the order was still ongoing, she would notify the doctor and also confirm with the charge nurse if another laboratory test was required. An interview took place in the board room on 1/3/24 at 11:35 a.m. with Medical Doctor (MD) HH who stated that she initially admitted P#2 in the Emergency Room (E.R.) MD HH stated that P#2 came in with concerns of lactic acid as the lactic acid was very high. MD HH stated that the check box to stop the lactic acid was not checked, which was why the order continued. MD HH stated that this was an oversight. A telephone interview took place in the board room on 1/3/24 at 12:30 p.m. with Registered Nurse (RN) JJ who stated that P#2’s family had complained about the frequent blood draws/samples, and she (RN JJ) went to look at the doctor’s orders. RN JJ stated that the doctor had put in the blood draws/checks every four hours, and she (RN JJ) was only following the doctor’s orders. RN JJ further stated that when P#2’s family complained, she (RN JJ) informed the doctor, and the doctor cancelled the order.”