Wellstar Kennestone Regional Medical Center

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45841 Based on review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to furnish adequate nursing services for three patients (P) (P1, P2, P3) reviewed. Findings included: Cross reference to A0396 relating to nursing care plan. The facility failed to ensure that nursing staff followed care plans for P1, P2, and P3. Cross reference to A0398 relating to supervision of contract staff. The facility failed to ensure that staff adhered to hospital policy and procedures by failing to follow physician orders for P3s care. Cross reference to A0405 relating to administration of drugs. The facility failed to ensure that medications were administered according to orders for P3.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45841 Based on review of policies and procedures, medical records, and staff interviews, it was determined that facility staff failed to ensure that patients’ care plans were followed regarding nutrition for three (P1, P2, P3) of three patients reviewed . Findings included: Review of policy titled “Nursing Plan of Care,” dated 12/29/2025, indicated, “Documentation of POC [Plan of Care] is completed in the electronic documentation application and other components of the patient’s medical record.” The policy also indicated, “Evaluate and document patient’s progress toward established goals.” Review of policy titled “Assessment of the Patient: Job Aid 1,” dated 11/02/2024, indicated that inpatient nursing was responsible for, “Physical, psychological, social, environment assessment-including nutrition and hydration status as well as functional status.” 1. Review of P1’s medical record, “Hospital Medicine History and Physical,” dated 01/30/2026 at 4:28 AM, revealed the facility admitted the patient due to a gastrointestinal bleed (GIB). Review of “Plan of Care” initiated 01/30/2026 revealed that P1 had a goal to maintain adequate nutritional intake. Interventions for staff included monitoring the percentage of each meal consumed and maintaining the patient on a modified diet as indicated per their order. Review of “Diet” orders revealed that P1 was placed on a regular, low residue/low fiber diet on 01/30/2026 at 10:54 AM. Review of the medical record failed to include documentation of percentage of meals consumed after their diet order was placed on 01/30/2026 at 10:54 AM. During an interview on 03/11/2026 at 1:55 PM, the Manager of the Clinical Decision Unit (MCDU) acknowledged that there was no documentation of meal consumption for P1. 2. P2s record revealed that the facility admitted the patient on 02/15/2026. A review of P2s “Hospital Medicine History and Physical,” dated 02/15/2026 at 5:13 PM, revealed that P2 was admitted with a gastrointestinal bleed (GIB) (bleeding in the intestines). P2s “Plan of Care” initiated 02/15/2026 revealed that P2 had a goal to maintain adequate nutritional intake. Interventions for staff included monitoring the percentage of each meal consumed and maintaining the patient on a modified diet as indicated per their order. A review of P2s “Diet” orders revealed that P2 was placed on a clear liquid diet on 02/15/2026 at 4:45 PM. Continued review of P2s “Diet” orders revealed that P2 was placed on a clear liquid diet on 02/16/2026 at 4:51 PM. Continued review of P2s “Diet” orders revealed that P2 was placed on a regular diet on 02/17/2026 at 7:53 AM. A review of P2s medical record failed to reveal documentation of percentage of meals consumed on 02/15/2026 for dinner; 02/16/2026 for dinner; or 02/17/2026 for breakfast, lunch, or dinner. During an interview on 03/11/2026 at 1:57 PM, the Manager of Clinical Decision Unit (MCDU) acknowledged that percentage of meals consumed was not documented for P2 on 02/15/2026, 02/16/2026, or 02/17/2026. 3. P3s medical record revealed the facility admitted the patient on 02/15/2026. P3s “Hospital Medicine History and Physical” dated 02/15/2026 at 4:23 PM, revealed that P3 was admitted for a Crohn’s Disease (chronic inflammatory bowel disease) flare with gastrointestinal bleeding. P3s “Plan of Care” initiated 02/16/2026 revealed that the patient had a goal to maintain adequate nutritional intake. Interventions for staff included monitoring the percentage of each meal consumed and maintaining the patient on a modified diet as indicated per their order. A review of P3s “Diet” orders revealed the following: A full liquid diet was ordered on 02/15/2026 at 4:42 PM. A soft mechanical diet was ordered on 02/16/2026 at 10:38 AM. A clear liquid diet was ordered on 02/17/2026 at 1:58 PM. A regular diet was ordered on 02/18/2026 at 11:36 AM. A clear liquid diet was ordered on 02/19/2026 at 10:18 AM. A full liquid diet that started on 02/19/2026 at 2:53 PM. A review of P3s “Percent Meals Eaten” flowsheet failed to reveal documentation on 02/15/2026 for dinner; 02/16/2026 for breakfast; 02/16/2026 for lunch; 02/17/2026 for dinner; 02/18/2026 for breakfast; 02/19/2026 for lunch; and 02/19/2026 for dinner. During an interview on 03/11/2026 at 2:00 PM, the Manager of Clinical Decision Unit (MCDU) acknowledged that the percentage of meal consumed was not documented for P3 on 02/15/2026 for dinner; 02/16/2026 for breakfast; 02/16/2026 for lunch; 02/17/2026 for dinner; 02/18/2026 for breakfast; 02/19/2026 for lunch; and 02/19/2026 for dinner.. The MCDU stated that the only documentation for 02/19/2026 lunch and dinner was that 0% of the supplement was consumed. During an interview on 03/11/2026 at 3:50 PM, Registered Nurse (RN) #5 stated that she monitored whether a patient was eating their meals and supplements, what their appetite was like, and their water intake. She stated it was a joint effort between nursing and the care partners, but the documentation was something that was overlooked; she made a lot of mental notes about it. During an interview on 03/11/2026 at 3:58 PM, RN #4 stated that the first step she took to monitor food and nutrition for her patients was to see which care partner she was working with and collaborate with them. She stated it could be hard to track food or supplements sometimes because patients did not always finish their meals on time, but she did the best to estimate what the patient had consumed or was going to consume. She stated that meals and nutrition were documented under the oral intake section of the flowsheets. During a telephone interview on 03/11/2026 at 4:15 PM, Registered Dietician (RD) #7 stated that there was a flowsheet that supplements could be documented on by nursing staff; if it was not documented there, she would speak with the patient to see if they were drinking the supplement, how many a day they were drinking, and if the supplements were coming on their meal trays. During an interview on 03/11/2026 at 5:40 PM, Assistant Nurse Manager (ANM) #6 stated that staff were expected to document intake and output on all patients.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45841 Based on review of policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that staff implemented physician orders for a bowel preparation prior to a procedure for one patient (P) (P3) of three patients reviewed, which resulted in the procedure being aborted. Findings included: Review of policy titled “Diagnostic and Therapeutic Orders,” dated 02/16/2026, indicated, “It is [the health system’s name] policy to promote timely order acknowledgment, accuracy in order implementation, and adherence to principles of patient safety.” A review of P3s “Consultation Note,” dated 02/16/2026 at 8:56 AM, revealed a gastroenterology provider recommended that P3 go for a flexible sigmoidoscopy (a flexible tube inserted to examine the rectum and lower colon). A review of P3s “Other Orders” revealed that an order was entered on 02/16/2026 at 10:13 AM, for a tap water enema to be administered on 02/17/2026 at 6:00 AM. In addition, a tap water enema was to be administered on 02/17/2026 at 6:30 AM A review of P3s medical record failed to reveal documentation that P3 received a tap water enema on 02/17/2026 at 6:00 AM or 6:30AM. P3s “Operative Note,” dated 02/17/2026, revealed the patient’s flexible sigmoidoscopy procedure was aborted due to poor bowel preparation “with stool and large clots present.” During an interview on 03/11/2026 at 3:58 PM, Registered Nurse (RN) #4 stated that nurses were notified via a work list in the electronic medical record software of what was ordered and needed completed, such as laboratory work or interventions, such as nasogastric tubes or enemas. During an interview on 03/11/2026 at 2:14 PM, the Manager of Clinical Decision Unit (MCDU) stated that there were no enemas documented as given for P3 on 02/17/2026 in the morning, and there were no notes from nursing staff as to why they were not given. During an interview on 03/11/2026 at 5:40 PM, Assistant Nurse Manager (ANM) #6 stated that staff could receive orders for interventions for patients in multiple ways, including verbally, in person, or the orders may populate in the electronic medical record software. She stated that staff were expected to review orders and implement them in the ordered timeframe. She stated that if there was an issue with being able to complete an order, staff were expected to escalate the issue to a provider, and preferably, document the conversation, especially if it could delay care.”

“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: 45841 Based on review of policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that medications were administered according to provider orders for one patient (P) (P3) of three patients reviewed. Findings included: Review of policy titled “Medication Administration,” dated 06/16/2025, indicated, “Place a written or electronic order on the patient’s chart prior to the administration of any medication, exception in situations where a delay in the therapy would compromise patient care (e.g. [exempli gratia; for example] pain, nausea, or the development of a life-threatening condition) or is otherwise allowed by an approved standing order.” A review of P3s “Other Orders” revealed an order was entered on 02/16/2026 at 10:42 AM for a mesalamine suppository (medication given rectally that works by reducing inflammation in the digestive tract), to be administered nightly. A review of P3s “Medication Administrations” flowsheet failed to reveal that P3 received mesalamine on 02/16/2026. During an interview 03/11/2026 at 2:32 PM, the Manager of Clinical Decision Unit (MCDU) explained that there was no evidence that P3 received a mesalamine suppository on the evening of 02/16/2026 and that the administration was cancelled. There was no documentation of the reason the administration was cancelled. During a telephone interview on 03/11/2026 at 4:31 PM, Registered Nurse (RN) #8 stated that for medication administration, she checked what time the medication was due, obtained it, confirmed the identity of the patient, and educated the patient on what they were to receive. She stated that if the patient did not want it, she sat it off to the side to return. RN #8 stated that she remembered P3 refused mesalamine multiple times. Per RN #8, if a medication was refused, it would be documented in the medical record. During an interview on 03/11/2026 at 5:40 PM, Assistant Nurse Manager (ANM) #6 stated if a medication could not be given, it was expected that it be documented, such as if a patient refused or the patient was not able to have anything by mouth.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 45841 Based on review of policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that patients’ nutritional needs were met for one patient (P) (P3) of three patients reviewed when ordered nutrition supplements were not given. Findings included: Review of policy titled “Enteral and Oral Nutrition Products,” dated 04/11/2025, indicated the “Documentation of Enteral Nutrition and Oral Nutrition Supplements” in the medical record was the responsibility of “Nursing.” Review of policy titled “Assessment of the Patient: Job Aid 1,” dated 11/02/2024, indicated that inpatient nursing was responsible for, “Physical, psychological, social, environment assessment-including nutrition and hydration status as well as functional status.” A review of P3s “Nourishments” orders revealed that an order was entered on 02/18/2026 at 8:44 AM for an orange high protein gelatin supplement with lunch. Continued review of P3s “Nourishments” orders revealed an order entered on 02/19/2026 at 3:02 PM for a nutritional peptide supplement to be provided with breakfast, lunch, and dinner. A review P3s “Diet Supplements” flowsheet revealed “none” for breakfast on 02/19/2026 at 7:51 AM and “none” for lunch on 02/19/2026 at 12:00 PM. Documentation revealed no evidence of the patient receiving a supplement with dinner on 02/19/2026. During an interview on 03/11/2026 at 2:00 PM, the Manager of Clinical Decision Unit (MCDU) stated that the only documentation nutrition documented for Patient #3 from 02/19/2026 lunch and dinner was that 0% of the supplement was consumed, but it did not specify which supplement. She stated that the type of supplement was not something that was documented. During an interview on 03/11/2026 at 3:50 PM, Registered Nurse (RN) #5 stated that she monitored whether a patient was eating their meals and supplements, what their appetite was like, and their water intake. She stated it was a joint effort between nursing staff and the care partners, but the documentation was something that was overlooked; she made a lot of mental notes about it. During an interview on 03/11/2026 at 3:58 PM, RN #4 stated that the first step she took to monitor food and nutrition for her patients was to see which care partner she was working with and collaborate with them. She stated it could be hard to track food or supplements sometimes because patients did not always finish their meals on time, but she did the best to estimate what the patient had consumed or was going to consume. She stated that meals and nutrition were documented under the oral intake section of the flowsheets. During a telephone interview on 03/11/2026 at 4:15 PM, Registered Dietician (RD) #7 stated that there was a flowsheet that supplements could be documented on by nursing staff; if it was not documented there, she would speak with the patient to see if they were drinking the supplement, how many a day they were drinking, and if the supplements were coming on their meal trays. During an interview on 03/11/2026 at 5:40 PM, Assistant Nurse Manager (ANM) #6 stated that staff were expected to document intake and output on all patients.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 52769 Based on medical record reviews, facility policies and procedures, and staff interviews, it was determined that the facility failed to administer a prescribed nutritional supplement (Juven) and failed to implement pressure injury prevention measures, including repositioning every two hours for one patient (P) #1 of four sampled patients (P#1, P#2, P#3, and P#4) reviewed. This failure potentially contributed to the development of multiple hospital acquired wounds for P#1. Findings included: A review of the facility’s Inpatient Admission Log revealed that P#1 was admitted to the facility on 10/16/25. A review of the emergency department (ED) notes on 10/16/25 at 1:37 p.m. revealed that P#1 used a wheelchair to get around due to wounds on her left foot that were not healing. A continued review documented that P#1 had a history of diabetes and osteomyelitis (a severe bone infection). 1. A review of the lead dieticians note signed on 11/3/25 at 8:49 a.m. revealed that P#1’s nutritional support should have included Juven (nutritional supplement for wound healing) once daily for wound healing. A review of the diet orders on Juven, as a nutritional supplement was ordered on 11/11/25 at 12:48 p.m. A review of the medical record flowsheet, failed to document that Juven was given to P#1 from admission on 10/17/25 to discharge on 1/21/26. Review of the medical record on 10/17/25 at 12:02 p.m. revealed that Certified Wound Ostomy Nurse (CWON) BB assessed P#1’s skin and noted the left foot medial was pink with no drainage and surrounding skin was callous (hardened and thickened). Note documented on 10/17/25 at 2:18 p.m. by CWON BB revealed that P#1 had an abscess on her right leg that appeared to be grape size. CWON BB suggested a consultation with a podiatrist for a possible incision and drainage (I&D). CWON BB also noted dry cracked skin on left foot from an old wound. 2. A review of P#1’s nursing flow sheet failed to reveal documentation of turning at the following times: 11/3/25 (2:00 p.m. to 8:00 p.m. and 8:00 p.m. to 4 a.m.) 11/4/25 (12:00 p.m. to 8:00 p.m.) 11//5/25 (8:00 a.m. to 6:00 p.m.) 11/5/25 (8:00 a.m. to 8:00 p.m.) 11/7/25 (8:00 a.m. to 4:00 p.m.) 11/9/25 (2:00 p.m. to 8:00 p.m.) 11/10/25 (8:00 a.m. to 12:00 p.m.) 11/11/25 (6:00 a.m. to 10:00 a.m.) 11/12/25 (7:20 a.m. to 8:00 p.m.) 11/13/25 (4:00 p.m. to 8:00 p.m.) 12/1/25 (8:15 a.m. to 12:00 p.m. and 6:00 p.m. to 8:00 a.m. on 12/2/25) 12/2/25 (10:00 a.m. to 3:15 p.m. and 5:20 p.m. to 2:00 a.m. 12/2/25) 12/24/25 (4:00 a.m. to 8:00 a.m.) 12/25/25 (2:00 a.m. to 8:00 a.m. and 10:00 p.m. to 7:00 a.m. on 12/26/25) A review of the wound assessment flowsheet revealed the following wound assessments: 1. Wound Soft Tissue Necrosis Abdomen Anterior; Right -Date First Assessed: 10/28/25 3:04 a.m. Present on Original Admission: No. Site Assessment 12/10/25: Adherent; Dry; Tan; Slough, 2 cm long 4 cm wide, 6.28 cm surface area. 2. Wound Soft Tissue Necrosis Leg Anterior; Proximal; Right; Medial Date First Assessed: 10/28/25 3:07 a.m. Site Assessment: Adherent; Dry; Tan;Slough, 1.5 length, 4 cm width, 4.71 cm surface area. 3. Wound Buttocks Left; Right Date First Assessed: 10/28/25 3:15 a.m. Site Assessment: Pink; Yellow; Slough; Epithelialization (crucial process of repairing damaged surface). 2 cm length, 1.5 cm width, surface area 2.35 4. Wound Pressure Injury Heel Left Date First Assessed: 11/03/25 12:57 p.m. Site Assessment: Dry; Yellow; Slough; Pink; Epithelialization; Fragile, length 1 cm, width 1 cm, surface area 0.79 cm. 5. Wound Surgical Chest Date First Assessed: 11/07/25 1:44 p.m. 6. Wound Knee Anterior; Right; Medial Date First Assessed: 12/24/25 1:23 p.m. 7. Wound Leg Right; Lateral; Medial; Lower Date First Assessed: 01/01/26 1:00 p.m. A review of the flowsheet Braden scale documented on 10/24/25 revealed a score of 17 and decreased throughout P#’1 hospital stay to a score of six on 1/19/26. A review of the facility’s policy titled “Maintenance of Skin Integrity Job Aid,” policy #PS-48-03, published 11/21/25, revealed that maintenance of skin integrity included provision of care to patients as listed below to prevent skin breakdown Assessed reddened areas over bony prominences o Repositioned patients in bed or chair every two hours if unable to reposition self o Instructed patients on the causes and prevention of skin breakdown o Kept skin clean, dry, and moisturized o Used skin protective wipes or skin sealant under tape with dressing changes o Used moisturizers or emollient lotions for dry skin o Maintained the head of the bed at the lowest degree of elevation consistent with the medical condition. o Used proper positioning, transferred, and turned techniques to prevent injury or friction o Limited the use of adhesive products on thin, fragile skin o Avoided the use of donut devices, and may use a pressure reduction chair cushion o Avoided massage over skeletal prominences and discolored/hyperemic areas o Minimized skin exposure to moisture from incontinence, perspiration, or wound drainage o Documented areas of redness that do not disappear within 30 minutes or any breaks in the skin o Notified Wound Care when assistance was needed A review of the facility’s policy titled “Nursing Plan of Care for High-Risk Pressure Injury Prevention Job Aid,” policy #PS-48-02, last revised 2/12/24, revealed that for patients with a Braden score of 17 or less or a Braden QD score greater than or equal to 13: o If the patient had impaired mobility, reposition every two hours, more frequently if necessary o Positioned patient in a 30? lateral position o Do not position on the area of impaired skin integrity o If the patient was in a chair, reposition every hour, more frequently if necessary o Instructed patients to perform weight shifts every 15 minutes if possible o Limited chair time to one hour if the patient had ischial or sacral wound o Used a chair pressure-relieving cushion o Used proper positioning, transferring, and turning techniques to prevent skin injury by friction or shearing forces o Maintained the head of the bed at the lowest degree of elevation consistent with the medical condition o Used a knee catch with head of bed elevation to prevent friction and shearing o Used foam dressings, pillows, wedges, or blankets to pad skeletal prominences from direct pressure, especially between the knees o Floated heels off bed with pillows placed vertically under leg; use pressure reduction boots o Activated heel suspension on Total Care Bed®, if applicable o Instructed the patient and family on the causes and prevention of skin breakdown o Notified the dietitian of clinical indicators of high risk. Review of policy titled “Wound, Ostomy, Continence Nursing Consultation, Assessment and Evaluation,” policy #PS-22, published 4/25/2024, revealed that the WOC (wound care nurse) RN collaborates with all members of the healthcare team to provide a comprehensive plan of care for patients with selective disorders of gastrointestinal, genitourinary, and integumentary systems. A consultation with a WOC RN may be initiated by a physician, patient, or any member of the healthcare team and occurs within 72 hours of request for consult. The WOC RN develops a plan of care and initiates wound treatment as appropriate. A review of the facility’s policy titled “Prevention of Pressure Injuries,” policy #PS-48, published 11/21/25, revealed that the registered nurse assessed all skin surfaces (including skeletal prominences) on admission and every shift, and assessed patients at risk for developing pressure injury using the Braden or Braden QD Scale, depending on the patient population. RN or Licensed Practical Nurse (LPN) was to consult a dietitian for patients with clinical indicators of high risk for impaired skin integrity. A review of the facility’s policy titled “Patient Diet Orders and Meal Delivery Standards,” policy #NC-10-01, published 5/9/25, revealed that patient diet orders were to be communicated in the Electronic Health Record to minimize errors related to transcription. A diet order would be entered in the medical record prior to the patient receiving any food or nutritional product. A review of the facility’s policy titled “Medical Nutrition Therapy (MNT) Order Writing Privileges Job Aid 1,” policy #NC-90 Job Aid 1, published 5/9/25, revealed that Oral Nutrition Supplements (ONS) and modular supplements to help patients meet metabolic needs could be ordered for a patient without an MNT Consult. Vitamin and Mineral Supplementation for patients with increased nutrient needs and/or wound healing. Amounts will vary based on the patient’s disease state. During an interview with Certified Wound Ostomy Nurse (CWON) BB on 1/21/26 at 10:00 a.m. in the conference room, CWON BB reported that a wound consult was initiated for P#1 on 10/16/25 related to her lower extremities. CWON BB further reported that she evaluated P#1 on 10/17/25 and requested a podiatrist consultation and then signed off for wound care. CWON BB explained that she only assessed wounds that were put in for consultation. CWON BB acknowledged that she was consulted again on 10/28/25 and saw P#1 10/29/25. CWON BB reported that she was present in the room with the podiatrist and observed several wounds in P#1’s abdominal fold. CWON BB further reported that she ordered Hyziny cream (compound medication that protects the skin barrier) for P#1. CWON explained that the bedside nurse administered the cream and the wound care team reassessed the patient every seven to 10 days. CWON BB reported that it was standard protocol for any patient with a Braden score less than 18 to be turned every two hours. CWON BB further reported that they last assessed P#1 on 1/16/26 and received a new wound care consultation for P#1 on 1/19/26. During an interview with Nurse Manager (NM) CC on 1/21/26 at 10:13 a.m. in the conference room, she revealed that she reported that consultations came through physicians or nurses and that they had 72 hours to see the patient. NM CC further reported that her duties were to develop a plan of care, measure and classify wounds, and take pictures of the wounds. NM CC explained that she notified the nurse if there were changes in the patient’s wounds and would notify the physician if changes were significant. NM CC acknowledged that her team does not notify family members of wound changes but would explain it to them if they called to ask about it. NM CC reported that any patient with a Braden score of 17 or less received a Hospital Acquired Pressure Injury (HAPI) bundle (evidence-based intervention performed to prevent bedsores). During an interview with Registered Nurse (RN) DD on 1/21/26 at 10:37 a.m. in the conference room, she reported that she admitted P#1 on 10/16/25 at 4:10 p.m. with a thrombectomy. RN DD further reported that P#1 was initially unresponsive for at least two hours. RN DD stated that P#1 woke up about 5:30 p.m. or 6:00 p.m. but did not talk. RN DD reported that P#1 cried when she saw a family friend that was in the room. She further reported that the family friend informed her about the patient’s sisters and abusive partner. RN DD stated that she passed down the information about P#1 abusive partner to the oncoming nurse. RN DD reported that she did a skin assessment and discovered that P#1 had healed wounds that looked good. RN DD further reported that she put in wound consultation. RN DD stated that she turned P#1 every two hours when she was first admitted to Neuro ICU. A phone interview was conducted with the Wound Ostomy Care Nurse (WOCN) GG on 1/21/26 at 11:07 a.m. WOCN GG did not recall P#1 but acknowledged that once a consult was received, her team assessed patients within 72 hours. WOCN GG reported that patients are reassessed every seven to 10 days. WOCN GG also reported that wound care should be done twice a day or as needed with soilage. WOCN further reported that it was the bedside nurse’s responsibility to change the dressing on patients with wounds. WOCN stated that pictures were taken of the wound during the initial consultation and again during follow-ups. During an interview with the Lead Dietitian (LD) KK, on 1/22/26 at 9:30 a.m. in the conference room, he stated that a comprehensive nutrition assessment was conducted on P#1 on 10/17/25, and Juven (a therapeutic nutritional powder designed to support wound healing) was recommended twice daily in addition to a high protein diet. LD KK explained that he had to trust the nurse to give the supplement because there was not a specific place to chart it in the medical record. LD KK further explained that the only place to chart that Juven was given to P#1 was in the flowsheet of the P#1’s chart under “Supplement Consumed (%).” LD KK acknowledged that he could not find any documentation that confirmed documentation of P#1 receiving the supplement. LD KK reported that the Interdisciplinary Team rounded on P#1 everyday per protocol in the intensive care unit (ICU) but there were no summaries of the meetings to state whether P#1 received Juven. During an interview with the Director of Nursing (DON) LL on 1/22/26 at 9:30 a.m. in the conference room, she reported that the supplement given to patients to assist with wound healing came from the kitchen up to the unit on the patient’s tray. DON LL further reported that the supplement should have been documented in the patient’s chart under the flow sheet. DON LL explained that the interdisciplinary team rounded daily on patients in the ICU and included the patient’s doctor, nurse, dietician, pharmacist, charge nurse and social worker. DON LL continued to explain that some of the discussions that took place during the interdisciplinary meeting included the clinical course, medication history, expectations going forward, and social barriers. DON LL acknowledged that she did not see documentation in the flow sheet supporting that P#1 was given the nutritional supplement to assist with wound healing. DON LL further reported that the nutritional supplement Juven, was documented to be given to P#1 in the LD KK’s note on 10/17/26 but not in his orders. DON LL verbalized that she saw an order for the nutritional supplement by the cardiac surgeon assistant on 11/7/25 but did not see where it was documented that P#1 received the supplement.”

“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: 40979 Based on review of policy an procedures, video recording, ambulance trip report, medical records video surveillance, incident report and investigation, and staff interviews, it was determined that the facility failed to provide a Medical Screening Exam (MSE) to one patient (P) (P#1) of 20 sampled patients, when P#1 arrived to the emergency department (ED) for complaints of severe back pain on 4/29/25 and was denied assistance getting from the personal vehicle to the facility entrance. Findings: Cross refer to A2406 as it relates to the facility’s failure to ensure that P#1 received 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: 40979 Based on review of policy and procedures, video recording, ambulance trip report, medical records video surveillance, incident report and investigation, staff interviews and review of facility policies and procedures, it was determined that the facility failed to provide a Medical Screening Exam (MSE) to one patient (P) (P#1) of 20 sampled patients, when P#1 arrived to the emergency department (ED) for complaints of severe back pain on 4/29/25 and was unable to transfer to a wheelchair. Facility staff refused to assist with a stretcher and instructed the driver of the personal vehicle to go off of hospital property and call 911 if they needed assistance with a stretcher. Findings: A review of the facility’s “Emergency Medical Treatment and Labor Act - EMTALA” policy, Policy #LD-108, last reviewed 5/6/22 revealed, the policy of Wellstar Health System to comply with the Emergency Medical Treatment & Active Labor Act (EMTALA) 42 CFR § 489.24, 42 CFR § 489.20 and subsequent federal interpretive guidelines and state regulations. If a patient “Comes to the Emergency Department” The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department, including ancillary services routinely available, to determine if an “emergency medical condition” exists. A review of video surveillance recording of ED entrance dated 4/29/25 with a timestamp of 11:37 a.m. revealed the following: 11:38:11 P#1 and female driver arrive in personal vehicle, gray SUV to the ED entrance 11:38:32 Female driver, wearing blue t-shirt and blue shorts, walks into ED entrance and speaks to Ambassador (AMB) DD 11:39:04 AMD DD walks over to the triage desk and speaks with RN II and US CC 11:39:09 Female driver joins AMB DD at triage desk and speak with Registered Nurse (RN) II and Unit Secretary (US) CC 11:39:40 AMB DD walks away from the conversation and returns outside 11:40:10 Female driver returns to her car; RN II and US CC follow behind and AMB DD brings wheelchair to the car 11:40:19 Female driver opens the back door of her car 11:40:29 Security Officer (SO) EE walks out of the ED entrance 11:40:30 Female driver stands at her car doorway speaking with RN II and US CC; AMB DD remains on the scene during the beginning of the conversation 11:40:55 AMB DD walks away; SO EE remains on the scene during the conversation between RN II, US CC and female driver. 11:43:24 SO EE walks away from the scene and back through the ED entrance 11:43:44 SO EE walks back out of the ED and stands at the ED entrance doors as the conversation continues 11:44:37 Female driver closes the back door of her car; RN II removes the wheelchair, and US CC remained standing next to the car 11:44:53 Female driver and P#1 drive away A review of the Emergency Medical Services (EMS) Trip Report revealed that the ambulance arrived at the scene at 12:07 p.m. on 4/29/25. Continued review revealed that the ambulance arrived at the facility’s ED at 12:43 p.m. A review of the Trip Report ‘Narrative’ revealed that Metro Unit 205 dispatched to business for reports of a male pt CC (chief complaint) non-traumatic back pain immediate response from crew. Upon EMS arrival, P#1 was lying left lateral recumbent in the backseat of a car. 41 Y/O (year old) M (male) with non-traumatic back pain. P#1 states today, he is unable to bear any weight on his left side without unbearable pain. He states the only way he is pain-free is when lying left lateral recumbent, and states he is unable to seat [sic] in a wheelchair. P#1’s wife drove him to {the facility}, they were unable to get him out of the car into triage and told them to leave the hospital property and call 911. P#1 ambulatory with assistance on scene, assisted to stretcher and placed left lateral recumbent with side rails up and 5-point harness in place. At destination, P#1 taken to ED room and moved from stretcher to bed via sheet slide. A review of P#1’s medical record ‘Visit Information’ revealed that P#1 arrived at 4/29/25 at 12:33 p.m. with a chief complaint of nontraumatic back pain, not ambulatory. An “ED Provider Note’ at 1:18 p.m. revealed that P#1 review of systems was positive for back pain. The ‘Physical Exam’ comments revealed that P#1 was uncomfortable appearing, lying on his left side. Unable to lie supine due to pain and unable to comply with physical exam due to pain. A continued review of the medical record ‘Physician Receiving Sign out Note’ dated 4/29/25 at 7:09 p.m. revealed that a review of the MRI was reassuring; the patient was able to ambulate and will be placed on low back pain care pathway. P#1 and spouse agreed with discharge. A review of the facility incident report #512687 dated 4/29/25 completed by Emergency Department Director (EDD) AA revealed that the event type was “Treatment Related. Failure to obtain appropriate assistance for ED patient”. Continued review revealed that immediate interventions that were put in place to prevent recurrence included staff educated/coached. A review of Incident Investigation #13875 dated 4/29/25, Summary of Investigation for Compliance Event #13875, revealed that P#1 arrived via EMS and had been picked up at a gas station. Wellstar Kennestone Hospital physician, received from a medic with Marietta Fire regarding the call Marietta Fire received from P#1 and his wife at the gas station. Continued review revealed that Assistant Vice President (AVP) BB spoke with P#1’s spouse on the day of the event that concluded with P#1’s wife stating that she was advised by facility staff that the policy of the facility was that only cardiac patients were assisted with a stretcher and that if the patient needed a stretcher, the patient could be transported off property and call 911. Continued review revealed AVP BB interviewed facility staff involved. An interview was conducted with Emergency Department Director (EDD) AA on 5/6/25 at 12:50 p.m. in the Risk Management conference room. EDD AA recalled the situation involving P#1 arriving to the Emergency Department (ED) on 4/29/25 with his wife via their personal car and had been notified by Assistant Vice President (AVP) BB. He continued to explain that he was told that P#1’s wife drove the patient to the hospital ED entrance, got out the car and spoke to RN II and US CC. He continued to explain that he was told that P#1’s wife asked for assistance getting her husband out of her car and that he was in pain and unable to sit or ambulate. EDD AA continued to explain that he was told that the two nurses and unit secretary went to P#1’s car with a wheelchair to assist in getting him out of the car and into the wheelchair. He continued to say that P#1’s wife asked for a stretcher because her husband was in pain and could not sit up. He continued to explain that he was told that security officer (SO) EE came outside to intervene and attempt to resolve the issue when P#1 and his wife drove off. EDD AA stated that he was not privy to the conversation between RN II and P#1’s wife. He continued to explain that AVP BB had the conversation with RN II regarding the situation. EDD AA confirmed that stretchers can be brought out to the ED drop off for any patient who needs one. He confirmed that stretchers are not only used for cardiac patients. EMTALA training is required to be completed as part of employee annual training. An interview was conducted with Assistant Vice President of Emergency Services (AVP) BB on 5/6/25 at 1:49 p.m. in the Risk Management conference room. AVP BB recalled that she had been alerted to a situation on 4/29/25 in the afternoon. AVP BB recalled that the information received was that P#1 had presented to the ED entrance and was not rendered assistance. AVP BB reviewed the ED tracking board and noting that P#1 was still in the ED, went to speak with P#1 and spouse. P#1’s wife explained what happened and that she felt she had no other choice but to go off-site and call 911 because the ED nurse would not get a stretcher for her husband who could not sit down. AVP BB stated that she did speak with RN II whose account was a little different from the wife’s however, she stated that RN II reported that P#1’s wife insisted on having a stretcher for her husband. She continued to explain that RN II stated that she advised P#1’s wife that she needed to assess her husband first and that P#1’s wife just got upset and drove off and that she did not have time to stop her. AVP BB stated that RN II should have got a stretcher from the ED where we keep the stretchers for situations like this, not only for cardiac patients. AVP BB stated that an internal investigation was completed and additional EMTALA training was developed to add to the existing EMTALA training. AVP BB confirmed that stretchers are available in the ED for any patient that requires or requests one for their medical treatment. An interview was conducted with Unit Secretary (US) CC on 5/6/25 at 1:45 p.m. in the Risk Management conference room. US CC recalled the incident involving P#1 when his wife brought him to the hospital to be seen last week. He continued to explain that he was at the front desk with RN II when AMB DD came in from outside and stated that there was a patient outside who needed a stretcher. He continued to explain that he and RN II went outside with a wheelchair to assist the patient in getting out of the car. He stated that often times he is called upon to help patients get in and out of wheelchairs and brought into the ED or out to their car. He continued to explain that when he and RN II approached P#1’s car, his wife was standing with the backdoor open and blocking our access to her husband. US CC stated that P#1’s wife stated that her husband needed a bed and could not sit in a wheelchair. He continued to explain that P#1’s wife stated that she drove 1.5 (one and half) hours away to come to this hospital and was told over the phone that there will be a stretcher available for him. He continued to explain that P#1’s wife and RN II were outside going back and forth for approximately eight or nine minutes and that RN II basically said we are not bringing a stretcher out here. US CC stated that after a few minutes SO EE came outside where we were and asked if he could help, RN II told SO EE that we were trying to help P#1 get out of the car. He continued to explain that he did see P#1 in the back seat, and he appeared to be hurt but he could not see his face because he was lying face down and did not say anything while we were standing at his car. He continued to explain that P#1’s wife seem to get frustrated after going back and forth and just left. An interview was conducted with Ambassador (AMB) DD on 5/6/25 at 2:10 p.m. in the Risk Management conference room. AMB DD stated that she is a contract employee through Cornerstone Parking. She continued to explain that it is her responsibility to assist patients that are arriving to the ED by providing a wheelchair, assisting the patient out of the car, into the lobby and put them in the triage line to be seen. AMB DD recalled the incident involving P#1 and his wife who arrived to the ED in the personal vehicle. She continued to say that P#1’s wife asked her for a stretcher for her husband. AMB DD stated that she offered a wheelchair and P#1’s wife stated that her husband could not sit in a wheelchair and needed a bed. She continued to explain that she went inside to the front desk and told RN II that the patient outside is requesting a stretcher. AMB DD stated that is when RN II and US CC came outside to assist P#1 and his wife heard RN II tell P#1’s wife that stretchers were not provided unless there was a cardiac risk situation, and right now he (P#1) would need to get in the wheelchair. She continued to explain that she heard RN II tell the wife that she could call 911 but, she had to go off campus to do that. She continued to explain that she heard P#1’s wife say what do you expect me to do, my husband is in pain and needs to be seen. AMB DD stated she did not hear RN II’s response to P#1’s wife’s question because another car drove up and she walked away after that. AMB DD stated that she did not hear the interaction SO EE had with the patient or with RN II. AMB DD stated that she had not received EMTALA training with her company or with this facility. An interview was conducted with Security Officer (SO) EE on 5/6/25 at 2:50 p.m. in the Risk Management conference room. SO EE recalled the incident that involved P#1 and had observed RN II and US CC outside the ED entrance having a loud discussion at P#1’s car door. He continued to explain that he walked outside to see if there was anything he could do to assist the staff in resolving the issue. SO EE stated that when he approached the P#1’s wife, RN II and US CC at the car he could hear P#1’s wife continuously asking for a stretcher and she stated that her husband could not sit down in a wheelchair. He continued to explain that he heard RN II trying to explain the P#1’s wife that if you let us try and get him out of the car we can get him treated but the wife continued to ask for a stretcher. SO EE stated that he heard RN II say to P#1’s wife that the first part of treatment is to get him out of the car, get him to triage and once he is assessed then we’ll be able to better understand his next course of treatment. SO EE stated that P#1’s wife wanted P#1 to be placed on a stretcher and to go straight to the back and she did not want to wait in the waiting room. He continued to explain that he heard a comment made that stretchers were used for cardiac arrest patients or gunshot victims and wheelchairs were used for patients in regular pain. He stated that he was not sure if it was RN II or US CC who made the statement. He continued to explain that RN II and P#1’s wife continued going back and forth for a few minutes and he could see P#1 lying face down in the back seat, but he did not say anything during the interaction. SO EE continued to say that RN II stated to P#1’s wife let’s just try and get him in the chair and that is when P#1’s wife stated that she will drive off and call 911 and they will put him in a bed. He continued to explain that RN II stated to P#1’s wife if that’s what you want to do, that’s fine but we prefer you to put him in the wheelchair. He continued to say that P#1’s wife stated that if he gets into the wheelchair how long will he have to sit in the lobby and RN II stated that she could not answer that question because he has not been assessed yet. SO EE recalled that P#1’s wife closed the car door and drove off after that. SO EE stated that he is familiar with EMTALA from his employment at this facility and other facilities. He stated that he has completed EMTALA training at this facility. A telephone interview was conducted with Nurse Manager (NM) FF on 5/7/25 at 10:28 a.m. NM FF stated that she was aware of the possible EMTALA violation concerning P#1. NM FF explained that EMTALA was constantly talked about in meetings and included in other training, as well as annual training and that stretchers were readily available in the ED for any patient who required one or asked for one. She continued to explain that she had brought out a stretcher for patients in the past and they were not restricted to cardiac patients. NM FF stated that the comment Registered Nurse (RN) II made to P#1 and his wife about stretchers only being available for cardiac patients was not true. She continued to say that she was on duty the day of the incident and RN II did not escalate the issue to leadership for resolution in order to provide care to the patient. An interview was conducted with Registered Nurse (RN) GG on 5/7/25 at 10:52 a.m. in the Risk Management conference room. RN GG recalled P#1 arrived via Emergency Medical Services (EMS) through our ambulance bay last week. She continued to explain that the ambulance crew explained to her that the patient initially arrived via personal car to the front of the ED and requested a stretcher because of his pain. P#1’s wife left the facility and went to a gas station across the street and called 911 for an ambulance to come to the hospital. RN GG continued to explain that she never spoke to P#1’s wife during this time. She continued to say that she began her assessment of the patient, and his vitals were within normal range; however, he was unable to sit upright. RN GG stated that after the assessment it was determined that he could not go to the waiting room was placed in a EMS room for further treatment. A telephone interview was conducted with Registered Nurse (RN) II on 5/7/25 at 11:15 a.m. RN II recalled P#1 and his wife when they arrived at the ED last week. She had been sitting at the desk and AMB DD came in and stated that the patient who just pulled up needs a stretcher. She recalled that she and US CC walked outside with a wheelchair to assess what was going on. P#1 was lying face down in the backseat of their car and his wife was standing at the door blocking our access to her husband. She continued to explain that P#1’s wife would not give her an opportunity to access her husband to determine why she was asking for a stretcher. RN II recalled that she tried to convince P#1’s wife to allow them to try and to get him in the wheelchair and get him in the hospital to be assessed for treatment. She continued to explain that P#1’s wife was insistent on a stretcher and would not allow her to assess P#1. RN II recalled that P#1’s wife stated that she would call 911 for an ambulance. She continued to explain that she advised P#1’s wife that she could not tell her what she can or cannot do; however, an ambulance would not come to the hospital to pick up your husband. RN II recalled that once P#1’s made this remark she (RN II) turned to call the charge nurse for assistance. P#1’s wife got in the car and drove away. RN II stated that she did not advise P#1’s wife to call 911 and she did not tell P#1’s wife that stretchers were only used for cardiac patients. She stated that she has been a nurse for over 20 years and would never tell a patient something like that. RN II stated that she understands what EMTALA is and has completed EMTALA training and feels she tried to assist P#1 the best way she could.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45841 Based on record review, staff interviews, and facility policy review, the facility failed to ensure that licensed nurses adhered to hospital policies for two patients (P) (P#1 and P#5) of five patients reviewed when facility staff failed to complete an assessment on P#1 until approximately 17 hours after admission to the nursing unit and when facility staff failed to assess blood pressure of P#2 for approximately two and one half hours during an infusion of Levophed (used to treat life-threatening low blood pressure). Findings included: Review of facility policy titled “Assessment of the Patient Job Aid 1,” revised on 04/05/2023, indicated an assessment in acute care should be completed “Within 12 hours of arrival for admissions.” The policy also indicated a re-assessment should be conducted in acute care, “At a minimum of every 12 hours.” The policy revealed content for nursing-inpatient assessment should include, “Physical, psychological, social, environmental assessment ? including nutrition and hydration status as well as functional status.” Review of facility policy titled “Assessment of the Patient,” dated 04/25/2024, indicated healthcare professionals should “Reassess the patient” at the following times: - “After an invasive procedure - After a non-invasive procedure - When there is a significant change in condition or diagnosis - Upon transfer to a different level of care or specialty unit. Review of facility policy titled “Delivery of Patient and/or Family Education,” dated 04/17/2023, indicated, “A. It is the responsibility of all healthcare team members to provide patient and family education that will foster patient self-management, promote patient safety, and achieve the desired state of wellness as defined in partnership with the patient/family and care providers. B. Patients and/or families will receive individualized education that incorporates specific learning needs, relevant healthcare information, and learning style preference.” The policy also indicated, “4.3 “Document discharge instructions.” “A completed copy of discharge instructions will be provided to the patient and/or family prior to discharge. Discharge instructions include but are not limited to the following: activity, diet, medications, follow up appointments, and when to call the doctor.” Review of facility policy titled “Care and Documentation of Critical Care Patients,” dated 02/12/2024, indicated, “E. Assess and document vital signs (blood pressure, pulse, respirations, and oxygen saturation) every two hours or more frequently as warranted by clinical status.” 1. Review of the “Hospital Medicine History and Physical” document for P#1 revealed the facility admitted the patient on 07/01/2023. Review of the “Events” documentation for P#1 revealed the patient was transferred from the emergency department to an inpatient bed on 07/01/2023 at 3:42 p.m. A “Charting Type” flowsheet revealed staff started an admission assessment for P#1 on 07/01/2023 at 5:27 p.m., however, only the neurological physical assessment was completed. The flowsheets revealed a complete physical assessment was not completed until 07/02/2023 at 9:00 a.m., approximately 17 hours after admission to the inpatient unit, when a nurse completed a shift assessment. Review of the “Operative Note,” dated 12/08/2023 (second hospital admission) for P#1 revealed that the patient had a left knee contracture and failed quadriceps tendon repair. The note revealed the patient had been walking with a flexed hip and knee due to a knee contracture and arthrofibrosis. Per the note, the patient had been using a knee caddy and a walker. The note revealed the provider explained that the risks of surgery including bleeding, and Patient #1 expressed understanding and desired intervention. The note revealed P#1 had an external fixator device applied to the femur and tibia bones of the left leg. The note revealed a “strut” was applied to the external device and “will be gradually corrected each day, breakfast, lunch, dinner, and before [the patient] goes to bed” until the patient achieved full extension of the knee. Per the note, the strut was locked, numbered, and a tape arrow was placed so the patient would know which way to turn the strut. According to the note, the physician went to the recovery room two times to teach the patient how to work the device. The note revealed the gradual correction of the knee contracture would be performed over the next few weeks and frame time would be 10 weeks. The note revealed silver sponges and Kerlix were wrapped around each pin that was attached to the bone and protruding through the skin. Per the note, the pin on the femur was stitched to minimize blood loss because the patient was on a blood thinner. Review of the “OR [Operating Room] Nursing” note dated 12/06/2023 at 12:40 p.m., for P#1 revealed the nurse “Placed chucks on bed due to left leg oozy.” Review of the “OR Nursing” note dated 12/08/2023 at 2:06 p.m., for P#1 revealed the nurse notified the physician that the “patient left leg is oozing.” Review of the “OR Nursing” note dated 12/08/2023 at 2:40 p.m., for P#1 revealed the patient was transferred to another unit. The note revealed the patient was “keenly responsive” with stable vital signs and no apparent distress. An “Events” report revealed P#1 was transferred from the Post Anesthesia Care Unit (PACU) to an outpatient extended stay bed on 12/08/2023 at 3:00 p.m. After being moved to a different level of care, there was no documented evidence a re-assessment of the patient was completed until 12/08/2023 at 8:00 p.m., approximately five hours after leaving the PACU after surgery. A “Charting Type” flowsheet indicated there was no documented evidence that neurological, peripheral vascular, neurovascular, or surgical wound site assessments were completed until 12/08/2023 at 8:00 PM, when a shift assessment was completed; according to the assessment, P#1 had bleeding to the left surgical wound site. Review of the “Provider Notification” flowsheet for P#1 revealed that on 12/08/2023 at 8:02 p.m., staff sent the provider a message that the patient had “large, copious amounts of blood” from the fixator insertion sites. A “Physician Discharge Summary” dated 12/13/2023 at 1:51 p.m., revealed that P#1 was discharged in good condition. The summary revealed that the external fixator on the left lower extremity was in place with no active drainage, and the pin sites were clean, dry, and intact. Per the summary, the patient’s disposition was to home with activity as tolerated, a regular diet, nutritional supplements, and instructions to keep the wound clean and dry and enforce the dressing as needed. Per the summary, the patient was to follow up with the physician in two weeks. A “Nursing Note” dated 12/13/2023 at 4:05 p.m., revealed RN #7 documented that P#1’s spouse informed the nurse that an “existing blister” on the patient’s heel had ruptured. The note revealed a padded dressing was applied and the area was wrapped with Kerlix. A “Nursing Note” dated 12/13/2023 at 5:44 p.m., revealed that the discharge instructions had been reviewed with P#1, and all questions had been answered. The note revealed the patient verbalized understanding and follow up instructions had been reviewed with the patient. “Written Discharge Information” revealed the P#1 was hospitalized from 12/08/2023 to 12/13/2023. The Written Discharge Information did not contain any individualized information for the patient related to the surgical procedure or care for the surgical site, external fixator device, or the wound to the heel. During an interview on 09/20/2024 at 3:26 p.m., the Executive Director of Regulatory (EDR) stated that P#1 did not have an admission physical assessment on 07/01/2023 when they were admitted, and night shift did not document a physical assessment of the patient. The EDR stated that the only physical assessment documented for P#1 on 07/01/2023 was a neurologic assessment. The EDR stated the patient’s first fully documented physical assessment was on 07/02/2023 at 9:00 a.m. During an interview on 09/20/2024 at 3:44 p.m., the EDR stated that the nurse that accepted P#1 for admission from the PACU did not document a re-assessment of the patient after the patient’s invasive procedure and transfer to a new level of care. The EDR stated that due to the nurse’s lack of documentation, it was unknown whether the patient’s surgical site had been bleeding since arrival to the floor or if it was new when the night shift nurse assessed the patient and notified the provider. During an interview on 09/20/2024 at 3:53 p.m., the EDR stated that the discharge instructions were not individualized for P#1’s needs. The EDR stated there was a note from the nurse that the patient was verbally given discharge instructions, but the take-home discharge instructions did not address the needs or reason for being in the hospital. During an interview on 09/20/2024 at 11:00 p.m., Registered Nurse (RN) #7 stated no assessment was completed when P#1 arrived on 12/08/2023 at 3:00 PM. RN #7 stated the nurse that admitted the patient was a float nurse from another unit and RN #7 did not know why the nurse did not complete an assessment. 2. Physician order for P#2 for intravenous (IV) norepinephrine (Levophed) (used to treat life-threatening low blood pressure). 4 milligrams (mg)/250 milliliters (mL) (standard premix) was placed on 05/31/2024 at 12:03 a.m. to start on 05/31/2024 at 1:00 a.m., with an end date of 06/06/2024 at 1:24 p.m. A Levophed “Highlights of Prescribing Information” document revised 11/2020 revealed the medication was indicated “for restoration of blood pressure in adult patients with acute hypotensive states.” The prescribing information section “2.2 Dosage” indicated “Monitor blood pressure every two minutes until the desired hemodynamic effect is achieved, and then monitor blood pressure every five minutes for the duration of the infusion.” A “Vital Signs” flowsheet revealed staff documented that P#2’s blood pressure on 06/02/2024 at 10:30 a.m., was 88/56 millimeters of mercury (mmHg). Per P#2’s “Medication Administration” record, the patient received Levophed on 06/02/2024. However, per the Vital Signs flowsheet, there was no documented evidence staff monitored P#2’s blood pressure again until 06/02/2024 at 1:00 PM, which was approximately 2.5 hours between blood pressure checks while Levophed was infusing. During an interview on 09/20/2024 at 12:23 p.m., Registered Nurse (RN) #6 stated blood pressures should be re-assessed every 15 minutes during IV vasopressor administration and every five minutes when titrating the medication. During an interview on 09/20/2024 at 4:15 p.m., the Executive Director of Regulatory (EDR) stated that blood pressures for P#2 were not documented on 06/02/2024 from 10:30 AM to 1:00 p.m., and there was no documentation to indicate that P#2 was in a different department or in a procedure during that time.”

“DISCHARGE PLANNING-FREEDOM OF CHOICE CFR(s): The hospital , as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services and must, when possible, respect the patient’s or the patient’s representative goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patients. This Standard is not met as evidenced by: 40979 Based on medical record review, incident report, staff interviews, and policies and procedures the allegation is substantiated. Findings: A review of facility’s medical record revealed P#1 was seen in the emergency department (ED) on 3/4/24 at 2:58 p.m. for aggressive behavior. Review of physical exam dated 3/4/24 at 3:57 p.m. revealed skin: findings: bruising present. No erythema or rash. Comments: scattered small bruises and abrasions, No large wounds or lacerations. Review ED Course notes dated 3/4/24 at 18:56 revealed A PP covering psychiatric hold area was updated regarding plan for patient. He will follow up on urinalysis and urine drug screen. We are currently pending mental health evaluation to assist with crisis placement. Care coordination has also been consulted for assistance Review of ED Provider Re-Evaluation note dated 3/5/24 at 17:36 revealed physical exam re-assessment patient 1013; pt has been medically cleared; awaiting inpatient placement. Review of nursing note dated 3/4/24 at 18:15 revealed Pt arrives with binder of all medical treatment psychiatrist phone number. Parents provided staff with copies to help ease with ongoing care. Parents would like to be notified of care and hospital dispo (disposition). Review of nursing note dated 3/5/24 at 21:39 revealed Nurse to nurse with Miles, RN at Ridgeview Smyrna with accepting provider Dr. Nkwocha. Transportation to be arranged after 1 AM per staff. Review of nursing note dated 3/6/24 at 11:42 revealed PD (police department) called for ETA, per operator, they are dispatching an officer now. Review of nursing note dated 3/6/24 at 19:25 revealed SO here to transfer to Rdgeview [sic] Smyrna ambulated out of department with officers and steady gait belongings was sent home with family. A review of incident report #381445 dated 3/12/24 revealed follow up note details on 3/14/24 at 8:00 am with behavioral health service line medical director, ED Psychiatrist, DON with North Fulton ED, EDON with Cobb ED, Assistant Vice President of Behavioral Health Service Line, Compliance, Risk Management Coordination regarding concern. We discussed opportunities across the system to better serve this vulnerable patient population. We discussed designated sensory rooms and carts. Increased communication pathways. Strategies for cleanliness of patient care areas in the presence of extreme aggression and potential harm to staff. A decision was made for both the ES and BH (Behavioral Health) service lines to personally meet with P#1’s mom and partner with her to better serve these patients and their families. Continued review revealed updated note details 3/14/24 11:04 am emails to P#1’s mom asking if we could meet with her. After several email exchanges a meeting was set up for Friday 3/29/24 at 3:00 p.m. An interview was conducted with Emergency Department Director (EDD) AA on 3/26/24 at 12:30 p.m. in the administration conference room. EDD AA stated that he was familiar with P#1 and his stay in the ED earlier this month. He continued to explain that during P#1 stay in the ED he remained agitated, combative and physically assaulting staff. He stated that due to his unpredictability he was transferred to the behavioral health facility by a Cobb County Sherrif. He continued to explain that Cobb County and Marietta city Sherrif officers will provide transportation for some patients if there is a safety issue. EDD AA stated that there should have been a conversation between the behavioral health liaisons with P#1’s family prior to the transfer. An interview was conducted with Behavioral Health Liaison (BHL) BB on 3/26/24 at 12:50 p.m. in the administration conference room. BHL BB stated that she did recall P#1 and is very familiar with his case from previous admissions to the hospital. She continued to explain that when she arrive to work the morning after P#1’s admission in the ED (emergency department) she assumed from her experience that it would be difficult to find placement for P#1 due to his diagnosis of autism spectrum. She stated that she initially had a conversation with P#1’s mom to determine what her wishes were for P#1 upon discharge. BHL stated that mom requested assistance in finding placement for P#1 because home would not be a safe discharge. She continued to explain that at the time of the conversation with P#1’s mom P#1 had not been medically clear to be discharged yet and therefore she was working with MD EE to find other alternatives. BHL BB confirmed that she did speak with P#1’s mom again during his stay in the ED. She confirmed that she did not speak with P#1’s mom after P#1 was medically cleared and that she did not speak with P#1’s mom once placement was secured. A telephone interview was conducted with Registered Nurse (RN) CC on 3/26/24 at 5:10 p.m. RN CC stated that she did recall P#1 and providing care to him during his admission to the emergency department (ED). She continued to explain that she works the evening shift and each time she went to his room he was resting comfortably. RN CC stated that when patients are transferred to another facility the care coordination department will send out requests to all the nearest facilities and the first facility to accept the patient is where the patient will be transferred to. She continued to explain that if there is a patient who has violent tendencies it is not uncommon to contact the local Sherriff’s office for transportation assistance. RN CC stated that the RN on duty at the time of P#1’s discharge and/or behavioral health assessor would have been responsible for notifying P#1’s family of his discharge and transfer to another facility. A telephone interview was conducted with Registered Nurse (RN) DD on 3/27/24 at 8:15 a.m. RN DD stated that she did recall P#1 during his stay in the emergency department (ED). She continued to explain that she was not the RN on duty to care for P#1 however she was on duty when he was transferred by sheriff office to the mental health facility. RN DD stated that she handled the sheriff P#1’s paperwork and personal items. She continued to explain that she did not meet P#1’s family during his stay in the ED however, P#1’s father called the ED a few days after his discharged looking for him and she spoke to his father and then his mother who were upset that they did not know he was transferred to another facility. RN DD stated that she did not call P#1’s family prior to the transfer because he is over the age of 18 and to her knowledge there was no information in his chart regarding a medical power of attorney. She continued to explain that usually the Behavioral Health Assessor would contact the family to update them on their loved ones status. A telephone interview was conducted with Medical Doctor (MD) EE on 3/27/24 at 9:00 a.m. MD EE stated that he did recall P#1 during his stay in the emergency department. He continued to explain that his only interaction with P#1’s family was at admission. MD EE stated that he did follow up with speaking to P#1 outpatient psychiatrist who made the suggestion to change his medication. MD EE stated that a change was made to P#1 medication to stabilize the patient and adjustments were made to regulate his heart rate. He continued to explain that he did not expect P#1 to be accepted to any facility in the city because patients with his diagnosis and severe agitation generally do not get accepted to a mental health facility. MD EE continued to explain that when he left the facility for the day, he had ot been accepted anywhere and when he returned to work the next morning he was accepted to Ridgeview. He continued to explain that usually it is the responsibility of the RN to contact the patient’s family regarding a change in condition and/or transfers for anyone with his diagnosis. A review of the facility’s “Disposition Planning” policy, Policy #CC-15-01, last revision January 2017, revealed purpose is to define a process to ensure continuity of high quality, cost effective patient care by facilitating appropriate patient and family participation in planning for a patient’s health care needs. 1. Assessment: The physician will direct the Disposition Planning efforts, provide orders and approve plans for continuity of care. 2. Implementation: the health care team’s on-going responsibility is to assess a patient’s potential health care needs and to educate the patient/family in the management of the care required. A review of the facility’s “Patients’ Rights and Responsibilities” policy, Policy #RI-01-01, last revision July 2016, revealed purpose to define a process to delineate the rights and responsibilities that a Patient has within the Wellstar Health System. 1. The patient has the right to access treatment and services. 2. The patient has the right to respect. 3. The patient has the right to effective communication. 3.4 to have diagnosis and treatment options explained including the need for transfer if necessary. 4. The patient has a right to be involved in care decision and to involve others. A review of the facility’s “Patient Transfer Into and Within Wellstar Hospitals and Outside of Wellstar” policy, Policy #CC-05-01, last reviewed October 2020, revealed Transfers outside of Wellstar. 2.4 Notify the Administrative Supervisor or unit charge nurse/director if a nurse or other qualified personnel needs to accompany the patient to the receiving facility. Supervisor or unit charge nurse/director will be notified, and arrangements will be made. 2.6 Ensure the patient, or their representative, consents to the transfer. Obtain written consent and document in the patient medical record.”