Savannah Health Services LLC DBA Memorial Health University Medical Center

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 49318 Based on medical record review, policy and procedures, and staff interviews, it was determined that the facility failed to ensure an effective discharge planning process by discharging 1 of 5 sampled patients without confirming that ordered home health services had been approved and arranged prior to discharge. This failure had the potential to result in a delay in necessary post hospital care and placed the patient at risk for an unsafe transition from the hospital to the home setting. Findings include: A review of the facility’s policy titled, “Discharge Planning: Role of Healthcare Team,” policy number 16508093, last revised 12/2023, revealed the purpose of this policy is to provide a systematic process of collaboration among the healthcare team and patient/family in planning for the patient’s discharge. Procedure: A. Discharge planning process. 1. Case Manager (RN or SW) will initiate the discharge planning process through review of the patient record and estimation of date of discharge on patients identified as high risk for readmission or in need of post-acute services. A. Case management (RN Care Coordinator or Social Worker) discharge planning protocol: 1. Identify patients who are in need of discharge planning through: a. Case Management Discharge Planning Evaluation Reassessment of discharge plan b. Multi-disciplinary Rounds c. Specific MD or nursing referrals for services 2. Inform patients of availability of case managers to assist with their discharge needs a. Service listed in the facility’s Patient Rights and Responsibilities, distributed by Registration. B. Assess and identify high risk discharge indicators. 1. Admitting Patient Care Nurse assess and identify high risk discharge indicators upon admission and make referral to the appropriate discipline for follow-up, (i.e. Case Manager, Dietary, Pastoral Care etc.) a. This is done to proactively identify potential discharge barriers which may unnecessarily increase length of stay and impact patient outcomes. Referrals of this nature do not require a physician order. C. Initiate a discharge plan of care. 1. Attending Physician, Staff Nurse, Case Manager (RN or SW) will initiate a discharge plan of care based on the following: a. Assessment of clinical needs including current level of functioning in performing activities of daily living. b. Assessment of patient and/or family social needs, including financial resources, level of education and ability to process and understand information, communication skills, and availability of social support systems, (i.e. church, family, friends, etc.) c. Assessment of patient goals and treatment preferences. F. Engage patient and/or family in discharge planning. 1. Case Manager (RN or SW) will engage patient and/or family to participate in discharge planning activities. Provide on-going education to explain expected patient outcomes. Discuss vendor options and inquire about preferences prior to the coordination of services indicated on the discharge plan of care. a. When Home Health, Hospice, DME, IPR, LTACH, or Skilled Nursing facilities are needed upon discharge, patients are presented a list of providers to include quality ratings and resource use measures where required. b. Document patient choice in the electronic health record using facility Patient Choice form and/or in the Case Manager documentation. G. Referral 1. Case Manager (RN or SW) will execute referral and required patient information will be provided using electronic referral system or manual facsimile as necessary. Documenting the referral and coordinated services in the medical record. a. If No vendor preference is specified by the patient, the RN Care Coordinator or SW Discharge Planner will use an electronic referring system for referrals or manual facsimile as necessary. H. Transfer 1. Post-Acute a. Case Manager (RN or SW) will confirm post-acute acceptance and document confirmation in the EMR. b. Case Manager (RN or SW) or Case Management Assistant will ensure Patient Choice Letter (and IMM if applicable) completed and uploaded to EMR. c. Case Manager (RN or SW) will confirm EMR documents are available to the post-acute provider. d. Case Manager (RN or SW) will inform patient/patient representative of pending discharge date. e. Case Manager (RN or SW) will inform IDT of post-acute and transport arrangements. A telephone interview was conducted with Registered Nurse (RN) AA on 07/07/2026, at 9:06 AM. RN AA stated that she did not remember the P1. RN AA stated that when a patient has a midline catheter it’s usually because they were a hard stick, needed continuous IV fluids or antibiotics. RN AA stated that there is no reason a patient should be discharged with a midline catheter left in place. RN AA stated that if it was a Peripherally Inserted Central Catheter (PICC) line then that would stay in place and its usually for patients that are being discharged to a long-term care facility. RN AA also stated that when an order is put in to discontinue and IV that means take the IV out, but they do not take it out until the patient’s transportation arrives just in case something happens to the patient while they are waiting. An interview was conducted with RN BB on 07/07/2026, at 10:36 AM, in the conference room. RN BB stated that when a physician writes an order to discontinue the IV, it means to remove the IV. RN BB stated that a midline catheter would only be left in a patient if they are going to a facility that request a line to be left in or if a patient is discharged with home IV antibiotic set up. RN BB stated that home health could not request that a line be left in. RN BB also stated that there is a possibility that the line could have been taken out and not documented. An interview was conducted with Case Manager (CM) CC on 07/07/2026, at 11:00 AM, in the conference room. CM CC stated that P1’s daughter called and stated there was an issue with the home health agency and they had not heard from them. CM CC stated that when she looked into it, the original home health agency the request had been declined. CM CC stated that she sent out two other requests, and one of the two was accepted. CM CC then stated that there was not a discharge barrier to get an approval from a home health in order to discharge a patient. CM CC stated that there are certain situations where an approval is needed before a patient can be discharged home. CM stated that there was no order for P1 to be sent home with O2 (oxygen). CM CC further stated that P1’s O2 levels did not meet the criteria to be sent home with O2. A telephone interview was conducted with RN DD on 07/07/2026, at 6:56 PM. RN DD stated that she did remember taking care of P1 and that she was alert and oriented during the day. RN DD stated early in her shift, P1 complained about night shift members that were rude to her. RN DD also stated that P1 was to be discharged that day and she spoke to her daughter over the phone about her discharge. RN DD stated that EMS arrived and she took out P1’s pure wick and some peripheral IV’s, got her together and sent her home. RN DD stated that she was later told that she forgot to take out P1’s midline catheter. RN DD stated that she took out two peripheral IV’s in her arm, one in the right and one in the left. RN DD stated that P1 had multiple IV’s during the course of her stay, but she missed the one that was underneath her arm, and it was a failure on her part. RN DD further stated that if she had P1’s chart open in front of her, then she could have done things differently. An interview was conducted with CM HH on 07/08/2026, at 3:50 PM, in the conference room. CM HH stated that when a patient has been ordered home healthcare, she will make sure that it is approved and in place prior to the patient’s discharge. CM HH stated that if a patient is discharged late in the day, then she would send the referral and notify the home health agency that the patient has been discharged, and she would follow up with the agency the next day. CM HH stated that once she finds out a patient has been denied, she would send another referral and then inform the patient what was going on. CM HH stated that you have to “intentionally close the loop” by following up on all referrals to verify they have been completed and accepted, this ensures that patients are not discharged without services or assistance they may need. An interview was conducted with Social Worker (SW) KK on 07/09/2026, at 9:47 AM, in the conference room. SW KK stated that if the patient has an order for home health care, then you have to wait for an approval to make sure that services are in place, because if the patient is discharged and the provider cannot take the patient, then services are fragmented, which is not in the best interest of the patient. SW KK stated that if there is a pending status for home health services, then the patient should not be discharged until it is approved.”

“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: 49318 Based on medical record review, policy and procedures, and staff interviews, it was determined that the facility failed to ensure 1 of 5 sampled patients received care in a safe setting, placing the patient at risk for harm. These failures resulted in P1 remaining in an unsafe condition: 1. When it was determined that the nursing staff failed to ensure that the peripheral Intravenous (IV) line (a thin, flexible tube used to administer fluids, medications, and blood products directly into a patient’s bloodstream) was removed upon discharge home on 06/23/2026. 2. When it was determined that the facility failed to verify approval and acceptance for ordered home health services prior to discharge home on 06/23/2026, placing the patient at risk for an interruption in necessary post discharge care. Findings Include: A review of the flow sheets dated 06/11/2026, revealed P1 had a 22g peripheral IV placed in her posterior right hand. Additional review revealed on 06/12/2026 at 1541, P1 had a 20-gauge(g) midline catheter placed in her left upper arm (LUA) for sustainable IV access and a 20g Peripheral Intravenous Line (PIV) placed in the left wrist for additional access . A review of the physician discharge orders dated 06/23/2026, at 0953, revealed an order was placed to discontinue IV. A review of the nursing flow sheets, nursing notes and discharge summary revealed there was no documentation of Peripheral IV catheter removal. A review of Case Management (CM) progress notes dated 06/22/2026 at 4:25 PM, revealed orders were submitted for Home Healthcare (HHC). A review of the facility’s CM referral response history revealed on 06/23/2026, at 11:11 AM, the HH referral was declined. P1 was discharged home via EMS on 06/23/2026, at 1213. A review of the Facility’s CM referral response history revealed on 06/30/2026, at 12:50 PM, another referral was sent to a different Home Health agency, who accepted P1 and the provider start date was 07/02/2026. A review of facility’s policy titled Patient Rights, policy number 20408916, last revised 07/2026, revealed that the purpose of this policy is the commitment to treat all patients with respect and dignity is an obligation of every facility healthcare colleague and a fundamental principle of being part of the facility healthcare. We recognize the diverse backgrounds and cultural needs of our patients and strive to foster an inclusive environment through the provision of culturally competent care. It is, therefore, the purpose of this policy to: o Ensure that there is no harassment, discrimination or distinction in: “ the availability of services; “ the admission, transfer or discharge of patients; or “ in the care provided based on age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law. o Ensure that all patients receiving care and/or patient representatives are informed of their rights. o Ensure that this policy is in alignment with federal, state and local regulations, the facility’s healthcare code of conduct, and pursuant to The Joint Commission (TJC) and other accreditation standards. POLICY: All Company-affiliated facilities will not tolerate harassment or discrimination or make a distinction in the availability of services; the admission, transfer or discharge of patients; or in the care provided based on age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law. All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient’s representative has questions regarding their rights. The written statement of patient rights must be provided to the patient in their preferred language or manner that can be understood. When necessary, interpreter services must be provided to ensure the patient and/or patient’s representative receive patient rights notification in a language and/or manner they understand. A review of the facility’s policy titled Assessment & Reassessment, policy number 17240230, last revised 02/2025, revealed that the goal of assessment is to determine the care, treatment, and services that will meet the patient’s initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services. Reassessment is the systematic review of patient specific data to prioritize needs and care of treatment based on changes, additional patient requests, and / or additional information. This process follows the evaluation step in the interdisciplinary process as the cycle of care continues. This document serves as an overview of the patient assessment and reassessment process at the facility. A full assessment involves obtaining relevant information from multiple sources. This may include obtaining information from the patient, a family member, or other sources including other providers. Sources might also include mediums that the patient has sought out to convey information to those who may provide care, treatment, or services. These include databases, medical jewelry, and paper or electronic documents. Whatever the source, information to complete a comprehensive assessment should be sought out from all available sources. Responsibility: Each discipline is responsible for the appropriate assessment and reassessment of patients under their care, taking into consideration their scope of practice, state licensure laws, applicable regulations and certifications. Each discipline must consider the importance of integrating information from the various assessments of the patient to identify and prioritize to the patient’s care needs. Interdisciplinary identification of patient needs and care priorities provides the foundation for care decisions. Inpatient and Outpatient Nursing Units: J. Vital signs for adult patients should include temperature, pulse, respirations, blood pressure and oxygen saturation no less frequently than every 8 hours. L. Unit specific policies or physician’s orders may dictate additional vital signs and/or assessment parameters and increased frequency based on patient population and/or diagnosis. Complete the remainder of the Admission Database as soon as possible but no later than 24 hours after admission to inpatient or outpatient unit. This includes: 1. Activities of daily living assessment (if age appropriate) 2. Skin Assessment 3. Discharge plan screening A review of the facility’s policy titled Discharge Planning: Role of Healthcare Team, policy number 16508093, last revised 12/2023, revealed the purpose of this policy is to provide a systematic process of collaboration among the healthcare team and patient/family in planning for the patient’s discharge. A. Case management (RN Care Coordinator or Social Worker) discharge planning protocol: 1. Identify patients who are in need of discharge planning through : a. Case Management Discharge Planning Evaluation Reassessment of discharge plan b. Multi-disciplinary Rounds c. Specific MD or nursing referrals for services 2. Inform patients of availability of case managers to assist with their discharge needs a. Service listed in the facility’s Patient Rights and Responsibilities, distributed by Registration. C. Initiate a discharge plan of care. 1. Attending Physician, Staff Nurse, Case Manager (RN or SW) will initiate a discharge plan of care based on the following: a. Assessment of clinical needs including current level of functioning in performing activities of daily living. b. Assessment of patient and/or family social needs, including financial resources, level of education and ability to process and understand information, communication skills, and availability of social support systems, (i.e. church, family, friends, etc.) c. Assessment of patient goals and treatment preferences. G. Referral 1. Case Manager (RN or SW) will execute referral and required patient information will be provided using electronic referral system or manual facsimile as necessary. Documenting the referral and coordinated services in the medical record. a. If No vendor preference is specified by the patient, the RN Care Coordinator or SW Discharge Planner will use an electronic referring system for referrals or manual facsimile as necessary. H. Transfer 1. Post-Acute a. Case Manager (RN or SW) will confirm post-acute acceptance and document confirmation in the EMR. b. Case Manager (RN or SW) or Case Management Assistant will ensure Patient Choice Letter (and IMM if applicable) completed and uploaded to EMR. c. Case Manager (RN or SW) will confirm EMR documents are available to the post-acute provider. d. Case Manager (RN or SW) will inform patient/patient representative of pending discharge date. e. Case Manager (RN or SW) will inform IDT of post-acute and transport arrangements. A telephone interview was conducted with Registered Nurse (RN) AA on 07/07/2026, at 9:06 AM. RN AA stated that she did not remember the P1. RN AA stated that when a patient has a midline catheter, it’s usually because they were a hard stick, needed continuous IV fluids or antibiotics. RN AA stated that there is no reason a patient should be discharged with a midline catheter left in place. RN AA stated that if it was a Peripherally Inserted Central Catheter (PICC) line then that would stay in place and its usual for patients that are being discharged to a long-term care facility. RN AA also stated that when an order is put in to discontinue and IV that means take the IV out, but they do not take it out until the patients transportation arrives just in case something happens to the patient while they are waiting. An interview was conducted with RN BB on 07/07/2026 at 10:36 AM, in the conference room. RN BB stated that when a physician writes an order to discontinue the IV, it means to remove the IV. RN BB stated that a midline catheter would only be left in a patient if they are going to a facility that requests a line to be left in or if a patient is discharged with home IV antibiotic set up. RN BB stated that home health could not request that a line be left in. RN BB also stated that there is a possibility that the line could have been taken out and not documented. An interview was conducted with Case Manager (CM) CC on 07/07/2026, at 11:00 AM, in the conference room. CM CC stated that P1’s daughter called and stated there was an issue with the home health agency and they had not heard from them. CM CC stated that when she looked into it, the original home health agency the request had been declined. CM CC stated that she sent out two other requests and one of the two was accepted. CM CC then stated that there was not a discharge barrier to get an approval from a home health agency in order to discharge a patient. CM CC stated that there are certain situations where an approval is needed before a patient can be discharged home. A telephone interview was conducted with RN DD on 07/07/2026, at 6:56 PM. RN DD stated that she did remember taking care of P1 and that she was alert and oriented during the day. RN DD stated early in her shift, P1 complained about night shift members that were rude to her. RN DD also stated that P1 was to be discharged that day and she spoke to her daughter over the phone about her discharge. RN DD stated that EMS arrived and she took out P1’s pure wick and some peripheral IV’s, got her together and sent her home. RN DD stated that she was later told that she forgot to take out P1’s midline catheter. RN DD stated that she took out two peripheral IV’s in her arm one in the right and one in the left. RN DD stated that P1 had multiple IV’s during the course of her stay, but she missed the one that was underneath her arm, and it was a failure on her part. RN DD further stated that if she had P1’s chart open in front of her, then she could have done things differently.”

“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: 49318 Based on medical record review, policy and procedures, facility documents and staff interviews, it was determined that the facility failed to provide necessary nursing care by failing to reposition one of five sample patients at least every two hours, based on the patients assessed risk, to prevent pressure injuries. This failure resulted in or had the potential to result in the development or worsening of pressure injuries and placed the patient at risk for avoidable harm. Findings Include: A review of the wound nurse Initial assessment dated 06/15/2026, at 0912, revealed P5 was consulted for redness to buttocks and posterior thighs. P5 was unable to offload independently or participate. At the time of the assessment P5 had excessive secretions. P5 also had an agiliti adapt bed (self-adjusting foam-filled mattress) for offloading assistance and injury prevention in her current state. Her skin appeared to be breaking down with incontinence related moisture associated skin injury. P5 was also assessed for Irritant Contact Dermatitis (a non-allergic skin inflammation caused by direct damage to the skins protective barrier). A review of the wound nurse treatment note dated 06/17/2026, revealed wound care was following P5 for assessment and treatment of a sacral wound. Additional review revealed P5 was often moist and unable to care for activities of daily living (ADL)(basic selfcare task), unable to turn or reposition herself. A review of the nursing flow sheets dated 06/15/2026. through 07/06/2026. revealed P5 was turned and repositioned on the following dates and times: Abbreviation Key: Left (L), Right (R), Supine (S) 06/15/2026 at 0305 06/16/2026-No documented turns 06/17/2026 at 0121,1007-S, 2010-L, 2200-S, 2304-L 06/18/2026 at 0000-L, 0539-S 06/19/2026- No documented turns 06/20/2026- No documented turns 06/21/2026 at 2113-R 06/22/2026 at 0251-L 06/23/2026-No documented turns 06/24/2026 at 1100 06/25/2026 at 0436 06/27/2026 at 1838-S 06/28/2026 at 2344 06/29/2026- No documented turns 06/30/2026 at 0420-S, 1154-S 07/01/2026 at 1215-L 07/02/2026- No documented turns 07/03/2026- No documented turns 07/04/2026- No documented turns 07/05/2026- No documented turns 07/06/2026- 0841-S A review of P5’s Braden Scale risk assessment documented on 05/24/2026, at 0410, through 07/06/2026, at 1100, revealed a score ranging from 8 to 14, indicating the patient was at significant risk for pressure injury development. A review of the facility’s policy titled, “Assessment & Reassessment,” policy number 17240230, last revised 02/2025, revealed that the goal of assessment is to determine the care, treatment, and services that will meet the patient’s initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services. Identifying and delivering the right care, treatment, and services depends on the following three processes: 16. Collecting information about the patient’s health history as well as physical, functional, and psychosocial status 17. Analyzing the information in order to understand the patient’s needs for care, treatment, and services 18. Making care, treatment, and services decisions based on the analysis of information collected. The depth and frequency of assessment depends on a number of factors, including the patient’s needs, program goals, and the care, treatment, and services provided. Assessment activities may vary between settings, as defined by the hospital’s leaders. Information gathered at the patient’s first contact may indicate the need for more data or a more intensive assessment. At a minimum, the need for further assessment is determined by the care, treatment, and services sought; the patient’s presenting condition(s); and whether the patient agrees to the recommended care, treatment, and services. Policy Statement: All patient care providers involved in the provision of patient care, including the assessing patient needs; planning care, treatment, or services; providing care, treatment or services; and coordinating care treatment or services at the facility. This practice applies to all inpatients and outpatients: neonates, pediatrics, adolescents, adults, and geriatrics patient populations. The following steps are performed in assessment: Assessment is the systematic collection and review of the patient-specific data, problems and/or needs as per the scope of practice for each discipline. Data refers to uninterrupted material, facts, or clinical observation collected during an assessment or reassessment activity. Data includes subjective, objective, physical, clinical, environmental, psychosocial, spiritual, cultural, rehabilitative, safety, nutritional, and educational needs including end-of- life care. The data are analyzed to create information necessary to decide the approach to meet care of treatment needs. A nursing assessment is completed when nursing care will be provided regardless of setting. Assessment includes, but is not limited to, the following as appropriate: e. Symptoms that might be associated with a disease, condition, or treatment (such as pain, nausea or dyspnea); f. Patients perception of the effectiveness of, and any side effects related to, his or her medications; Reassessment is the systematic review of patient specific data to prioritize needs and care of treatment based on changes, additional patient requests, and / or additional information. This process follows the evaluation step in the interdisciplinary process as the cycle of care continues. This document serves as an overview of the patient assessment and reassessment process at the facility. A full assessment involves obtaining relevant information from multiple sources. This may include obtaining information from the patient, a family member, or other sources including other providers. Sources might also include mediums that the patient has sought out to convey information to those who may provide care, treatment, or services. These include databases, medical jewelry, and paper or electronic documents. Whatever the source, information to complete a comprehensive assessment should be sought out from all available sources. Responsibility: Each discipline is responsible for the appropriate assessment and reassessment of patients under their care, taking into consideration their scope of practice, state licensure laws, applicable regulations and certifications. Each discipline must consider the importance of integrating information from the various assessments of the patient to identify and prioritize to the patient’s care needs. Interdisciplinary identification of patient needs and care priorities provides the foundation for care decisions. Inpatient and Outpatient Nursing Units: J. Vital signs for adult patients should include temperature, pulse, respirations, blood pressure and oxygen saturation no less frequently than every 8 hours. L. Unit specific policies or physician’s orders may dictate additional vital signs and/or assessment parameters and increased frequency based on patient population and/or diagnosis. Complete the remainder of the Admission Database as soon as possible but no later than 24 hours after admission to inpatient or outpatient unit. This includes: 19. Activities of daily living assessment (if age appropriate) 20. Skin Assessment 21. Discharge plan screening A review of the facility policy titled, “Pressure Injury Prevention-Adult and Pediatric Patients,” policy number 20224930, last revised 05/2026, revealed the purpose of this policy is to outline expectations for risk assessment, physical assessment, application of interventions, and documentation for the prevention of pressure injuries. TOOLS: Adult patients > 18 years of age will be assessed using the Braden II scale: o Score < 18 = At Risk o Score > 19 = Not at Risk 1. Injury assessment 2. If any wound(s) are present and captured in initial assessment, it would not be considered a hospital acquired pressure injury (HAPI) ii. During stay 1. If new pressure injury acquired during hospital stay (after completion of initial skin assessment), would be attributed as a HAPI 2. Notification: a. Any new or worsening patient wounds should be reported to a provider and documentation captured in the Manage/Refer/Contact/Notify intervention within the HER A review of the facility’s wound care power point documents dated 03/2026 revealed: Pressure Injury Prevention- Skin Bundle “ Reposition q 2 hrs (bed) “ Hourly (chair) “ Offload heels “ Moisture Management Braden Scale-Adult Skin Risk Assessment Measures “ Sensory Perception “ Moisture “ Out of Bed Activity “ In Bed Mobility “ Nutrition “ Friction and Shear Score< 18= AT RISK to develop a pressure injury Score>19= not at risk Skin Bundle Products for Pressure Injury Prevention No order required -Turning & Repositioning “ Body Alignment Wedge-foam positioner “ Pillows-for thin, small patient Pressure Injury Prevention/Incontinence: Prevention of Skin Breakdown “ Reposition patients every 2 hours An interview was conducted with Case Manager (CM) EE on 07/08/2026, at 1:44 PM, in the conference room. CM EE stated that long stay patients would be assigned a complex case manager. Complex case managers will manage cases for patients with extended stays in the facility, may need long term facility placement, no payor source etc. In some cases, the facility could provide a single case agreement (assuming the financial responsibility for a patient) to be sent to a long-term care facility pending payor source approval). The facility would then have to work with other facilities that are willing to enter this agreement also. An interview was conducted with CM FF on 07/08/2026, at 2:10 PM, in the conference room. CM FF stated that patients usually get assigned to her when there is no discharge plan in place. CM FF stated that she got P5 when she was already a few weeks in and she did not have a did not have a discharge plan in place. CM FF stated that once she received P5 as a patient she reached out to the P5’s family to see what type of discharge arrangements could be made and the family expressed they could not care for her at home. CM FF stated that the family had a first choice for P5 if she was going to be transferred to a skilled nursing facility, they wanted her closer to home. CM FF stated that the family expressed concerns about P5’s care while she was in the Intensive Care Unit (ICU) and stated that the providers and the nurses were inconsistent with the information she was given concerning P5’s progress. CM FF stated that P5’s transfer was scheduled one week before it happened, and the family was notified and they were in contact with the receiving facility prior to the transfer. CM FF stated that the family had to do sign-in paperwork at the receiving facility or P5 would not be accepted into the facility. An interview was conducted with Registered Nurse (RN) GG on 07/08/2026, at 2:25 PM, in the conference room. RN GG stated that chart reviews are performed most recently medication administration. RN GG stated that there was an opportunity to improve consistency in documenting. RN GG stated that charting by exception and evidence based clinical documentation is a corporate mechanism. RN GG also stated that the standard of care for turning a patient if they are dependent is they are turned every two hours. RN GG stated that nurses would chart if turns did not happen, but not when turns did happen. RN GG stated that patient care technicians are also able to document turns. An interview was conducted with CM HH on 07/08/2026, at 3:50 PM, in the conference room. CM HH stated that she was the initial case manager for P5 when she was admitted and saw her a couple of times before she was moved to another unit. CM HH stated that she remembered P5’s family being very aggressive and difficult to deal with from the beginning. CM HH stated that after P5 was given a diagnosis, she tried to go back and speak to the family about discharge placement and what was to be expected since P5 did not have a payor source. CM HH stated that she was out of work for a few days and when she came back P5 had been transferred to another unit. CM HH stated that P5’s family wanted certain medications discontinued because they felt it was the medication that was causing her not to wake up. A telephone interview was conducted with RN II on 07/08/2026 at 5:59 PM. RN II stated that she did not directly take care of P5 but she did remember her and her injuries. RN II stated that she spoke with the family a few times and they were upset because they would not release patient information to someone that was not listed in her record. RN II stated that she remembers another nurse stating that the family was upset about some of the medications P5 was being administered. RN II stated that klonopin is a medication that is administered to calm the brain, it can be given for anxiety and seizures. RN II stated that on the medical surgical floor it is difficult to document turns. RN II stated that turns every two hours (Q2) are put in the order set and the turns should be documented as often as possible because it is a part of the standard of care. RN stated that it does not always get perfectly documented. RN II stated that she could not think of any reason that turns would not have been documented for four to five days. RN II further stated that there is a specific place in the “Daily Cares” tab where turns should be documented, but turns could also be documented in the “Activities” tab. A telephone interview was conducted with RN JJ on 07/08/2026, at 6:12 PM. RN JJ stated that she did take care of P5 and received a call from her daughter to check her progress and see if she had been administered klonopin. RN JJ informed P5’s daughter that she did administer klonopin as it was ordered. RN JJ stated that P5’s daughter questioned why P5 remained on the medication, stating that it was supposed to be discontinued because it was preventing her from waking up. RN JJ stated that she was unaware of that because there was no order to discontinue the medication. RN JJ stated P5’s daughter requested to speak to the physician, so she sent a message to the physician as requested. RN JJ stated that she did remember turning P5 every two hours, but it was hard to document every two hours when you have six patients, so she doesn’t always prioritize documenting. RN JJ stated that in the Electronic Medical Record (EMR) she documented patient turns in the “Activities” tab.”

“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: 49318 Based on medical record review, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that all licensed nurses who are working at the hospital must adhere to the policies and procedures of the hospital. When it was determined that the nursing staff failed to ensure that the peripheral Intravenous (IV) line (a thin, flexible tube used to administer fluids, medications, and blood products directly into a patient’s bloodstream) was removed prior to discharge for 1 of 5 sampled patients, which placed the patient at risk for complications associated with a retained peripheral IV catheter following discharge. Findings Include: A review of the flow sheets dated 06/11/2026, revealed P1 had a 22g peripheral IV placed in her posterior right hand. Additional review revealed on 06/12/2026, at 1541, P1 had a 20-gauge(g) midline catheter placed in her left upper arm (LUA) for sustainable IV access and a 20g Peripheral Intravenous Line (PIV) placed in the left wrist for additional access. A review of the physician discharge orders dated 06/23/2026, at 0953, revealed an order was placed to discontinue IV. A review of the nursing flow sheets, nursing notes and discharge summary revealed there was no documentation of Peripheral IV catheter removal. A review of the facility’s policy titled, “Assessment & Reassessment,” policy number 17240230, last revised 02/2025, revealed that the goal of assessment is to determine the care, treatment, and services that will meet the patient’s initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment, and services. Identifying and delivering the right care, treatment, and services depends on the following three processes: 4. Collecting information about the patient’s health history as well as physical, functional, and psychosocial status 5. Analyzing the information in order to understand the patient’s needs for care, treatment, and services 6. Making care, treatment, and services decisions based on the analysis of information collected. The depth and frequency of assessment depends on a number of factors, including the patient’s needs, program goals, and the care, treatment, and services provided. Assessment activities may vary between settings, as defined by the hospital’s leaders. Information gathered at the patient’s first contact may indicate the need for more data or a more intensive assessment. At a minimum, the need for further assessment is determined by the care, treatment, and services sought; the patient’s presenting condition(s); and whether the patient agrees to the recommended care, treatment, and services. Policy Statement: All patient care providers involved in the provision of patient care, including the assessing patient needs; planning care, treatment, or services; providing care, treatment or services; and coordinating care treatment or services at the facility. This practice applies to all inpatients and outpatients: neonates, pediatrics, adolescents, adults, and geriatrics patient populations. The following steps are performed in assessment: Assessment is the systematic collection and review of the patient-specific data, problems and/or needs as per the scope of practice for each discipline. Data refers to uninterrupted material, facts, or clinical observation collected during an assessment or reassessment activity. Data includes subjective, objective, physical, clinical, environmental, psychosocial, spiritual, cultural, rehabilitative, safety, nutritional, and educational needs including end-of- life care. The data are analyzed to create information necessary to decide the approach to meet care of treatment needs. A nursing assessment is completed when nursing care will be provided regardless of setting. Assessment includes, but is not limited to, the following as appropriate: a. Symptoms that might be associated with a disease, condition, or treatment (such as pain, nausea or dyspnea); b. Patients perception of the effectiveness of, and any side effects related to, his or her medications; Reassessment is the systematic review of patient specific data to prioritize needs and care of treatment based on changes, additional patient requests, and / or additional information. This process follows the evaluation step in the interdisciplinary process as the cycle of care continues. This document serves as an overview of the patient assessment and reassessment process at the facility. A full assessment involves obtaining relevant information from multiple sources. This may include obtaining information from the patient, a family member, or other sources including other providers. Sources might also include mediums that the patient has sought out to convey information to those who may provide care, treatment, or services. These include databases, medical jewelry, and paper or electronic documents. Whatever the source, information to complete a comprehensive assessment should be sought out from all available sources. Responsibility: Each discipline is responsible for the appropriate assessment and reassessment of patients under their care, taking into consideration their scope of practice, state licensure laws, applicable regulations and certifications. Each discipline must consider the importance of integrating information from the various assessments of the patient to identify and prioritize to the patient’s care needs. Interdisciplinary identification of patient needs and care priorities provides the foundation for care decisions. Inpatient and Outpatient Nursing Units: J. Vital signs for adult patients should include temperature, pulse, respirations, blood pressure and oxygen saturation no less frequently than every 8 hours. L. Unit specific policies or physician’s orders may dictate additional vital signs and/or assessment parameters and increased frequency based on patient population and/or diagnosis. Complete the remainder of the Admission Database as soon as possible but no later than 24 hours after admission to inpatient or outpatient unit. This includes: 7. Activities of daily living assessment (if age appropriate) 8. Skin Assessment 9. Discharge plan screening A telephone interview was conducted with Registered Nurse (RN) AA on 07/07/2026, at 9:06 AM. RN AA stated that she did not remember the P1. RN AA stated that when a patient has a midline catheter, it’s usually because they were a hard stick, needed continuous IV fluids or antibiotics. RN AA stated that there is no reason a patient should be discharged with a midline catheter left in place. RN AA stated that if it was a Peripherally Inserted Central Catheter (PICC) line then that would stay in place and its usual for patients that are being discharged to a long-term care facility. RN AA also stated that when an order is put in to discontinue and IV, that means take the IV out, but they do not take it out until the patients transportation arrives just in case something happens to the patient while they are waiting. An interview was conducted with RN BB on 07/07/2026, at 10:36, in the conference room. RN BB stated that when a physician writes an order to discontinue the IV, it means to remove the IV. RN BB stated that a midline catheter would only be left in a patient if they are going to a facility that request a line to be left in or if a patient is discharged with home IV antibiotic set up. RN BB stated that home health could not request that a line be left in. RN BB also stated that there is a possibility that the line could have been taken out and not documented. A telephone interview was conducted with RN DD on 07/07/2026, at 6:56 PM. RN DD stated that she did remember taking care of P1 and that she was alert and oriented during the day. RN DD stated early in her shift P1 complained about night shift members that were rude to her. RN DD also stated that P1 was to be discharged that day and she spoke to her daughter over the phone about her discharge. RN DD stated that EMS arrived and she took out P1’s pure wick and some peripheral IV’s, got her together and sent her home. RN DD stated that she was later told that she forgot to take out P1’s midline catheter. RN DD stated that she took out two peripheral IV’s in her arm, one in the right and one in the left. RN DD stated that P1 had multiple IV’s during the course of her stay, but she missed the one that was underneath her arm, and it was a failure on her part. RN DD further stated that if she had P1’s chart open in front of her, then she could have done things differently. An interview was conducted with RN II on 07/09/2026, at 10:24 AM, in the conference room. RN II stated that the primary nurse should be aware of all the IV access points when discharging a patient. RN II also stated that a patient should never be allowed to get dressed without making sure that all the IV access points are taken out.”

“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: 47718 Based on a review of medical records, facility policies and procedures, and staff interviews, it was determined that nursing staff failed to ensure that one patient (P) (P#1) of three patients (P#1, P#2, and P#3) reviewed received a medication as ordered by the physician. Specifically, the nursing staff failed to administer the medication, Zenpep (a digestive enzyme supplement used to replace enzymes when the body does not have enough of its own) to P#1 as per physician orders. Findings include: A review of medical records revealed that P#1 arrived at the facility’s emergency department (ED) on 11/3/25 at 3:42 p.m. with a diagnosis of gastrointestinal bleeding (blood loss from the digestive tract due to injury or disease). A review of the Medication Administration Record (MAR) revealed the following active orders for Zenpep: “ An order dated 11/5/25 at 11:40 a.m. for Zenpep 40,000 units, two capsules with meals and one capsule with snacks, up to eight times per day. “ An order dated 11/5/25 at 12:27 p.m. for Zenpep with similar dosing instructions on a PRN basis. “ An order dated 11/5/25 at 1:10 p.m. for Zenpep to be administered two times daily with meals. Documentation revealed that Zenpep was administered on 11/5/25 at 2:51 p.m. The documentation failed to reveal additional doses for 11/5/25. Documentation revealed Zenpep was administered on 11/7/25 at 10:45 a.m. The documentation failed to reveal additional doses for 11/7/25. A review of the facility’s policy titled “Medication Management,” policy #18762131, last revised 10/2025, revealed that medications were to be administered as ordered. For medication administration to be considered “timely,” medications must be administered within a 2-hour window (1 hour before the scheduled time and up to 1 hour after). A review of the facility’s policy titled “Assessment and Reassessment,” policy #17240230, last revised 2/2025, revealed that all patient care providers were involved in the provision of patient care, including the assessment of patient needs; planning care, treatment, or services; providing care, treatment, or services; and coordinating care treatment or services at the facility. A telephone interview was conducted in the facility’s conference room on 12/23/25 at 9:20 a.m. with Gastroenterologist (GST) AA, who stated that the medication (Zen-pep) was important, but it would not affect P#1’s overall level of care, and the goal was to administer the medication two to three capsules (60,000 to 80,000 units) with meals depending on the strength of the medication. GST AA stated that if a dose was missed, it could cause increased diarrhea. An interview was conducted in the facility’s conference room on 12/23/25 at 10:00 a.m. with Charge Nurse (CN) CC, who stated that he had requested that GST AA add a PRN (as required) dose of the medication for P#1, so the medication could be taken at any time when P#1 was eating instead of the scheduled dose, which may be challenging due to the different timings in meal time and medication administration time.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 47718 Based on review of medical records, facility policies, and staff interviews, the facility’s staff failed to ensure complete and accurate documentation of blood transfusion administration. Specifically, the facility failed to document the end time of a blood transfusion for one patient (P) (P#1) of three patients reviewed (P#1, P#2, and P#3). Findings include: A review of medical record revealed that P#1 arrived at the facility’s emergency department (ED) on 11/3/25 at 3:42 p.m. with a diagnosis of gastrointestinal bleeding (blood loss from the digestive tract due to injury or disease). A review of the physician orders revealed that one unit of packed red blood cells (RBCs- concentrated form of red blood cells used to treat significant blood loss or severe anemia) was ordered for P#1 on 11/6/25 at 4:17 a.m. A continued review of P#1’s medical record revealed the blood transfusion was initiated on 11/6/25 at 7:46 a.m. Documentation failed to reveal when the blood transfusion was completed. Additionally, there was no documentation to demonstrate that post-transfusion monitoring and completion requirements were met. A review of the facility’s policy titled “Patient Rights,” policy #13838417, last approved 7/2023, revealed that all patients were to be treated in a manner that preserved their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. Patients had the right to receive considerate and respectful care, including consideration of cultural, spiritual, psychosocial, and personal values, beliefs, and preferences. A review of the facility’s policy titled “Blood and Blood Components Administration/Auto Transfusion,” policy #12690842, last approved 7/2023, revealed that RN, LPN, Physician, or APP should remove the blood bag and tubing when blood administration is completed. The blood administration tubing and blood filter could be used for the infusion of up to two units of blood, but no longer than four hours from the time of initial use. The RN, LPN, Physician, or APP should obtain post-transfusion vital signs and complete the transfusion in the Epic blood administration flow sheet. The RN, LPN, Physician, or APP should document the amount of blood product infused in the Epic blood administration flow sheet. The RN, LPN, Physician, or APP should document the patient’s tolerance and significant findings in the medical record. An interview was conducted in the facility’s conference room on 12/23/25 at 11:15 a.m. with Registered Nurse (RN) EE, who stated that she could not recall if P#1 had a blood transfusion, and why the stop time was not documented. An interview was conducted in the facility’s conference room on 12/23/25 at 11:25 a.m. with Patient Safety Manager (PSM) JJ, who stated that the stop-time of the blood transfusion should have been documented in the electronic medical record (EMR).”

“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: 47717 Based on review of medical records, policy and procedures and staff interviews, it was determined that facility staff failed to reposition patients per protocol contributing to the development of pressure ulcers (localized damage to the skin as a result of usually long-term pressure) for one patient (P) (P#1) of four sampled patients. Findings include: A review of P#1’s medical record revealed P#1 was admitted to the facility on 12/02/2024 with a diagnosis of Cerebrovascular accident (CVA-medical term for a stroke). A review of P#1’s Braden Scale Chart” for Predicting Pressure Sore Risk” (scale used to predict the probability of developing a pressure sore) revealed a score of 7-12. (score less than 9 indicates a patient was as severe risk for developing pressure sores and score of 10-12 indicates that a patient was at high risk for the development of pressure sores) A review of the ‘Daily Cares and Safety Flowsheet’ revealed that P#1 was turned on the following dates with times: 12-2-24 1000 12-3-24 0243, 2000 12-4-24 2000 12-5-24 0000, 0400, 0700, 2200 12-6-24 0000, 0200, 0400, 0800, 1100, 1600, 2000 12-7-24 0000, 0400, 0800, 1100, 1600, 2300 12-8-24 0800, 1000, 1200, 1400, 1600, 1841, 1935 12-9-24 0800, 1000, 1200, 1400, 1600, 1800, 2114 12-10-24 0800, 1000, 1200, 1400, 1916 12-11-24 1317, 2000 12-12-24 2000 12-13-24 0800, 2000 12-14-24 0726, 0812, 1105, 1302, 2043 12-15-24 0717, 2051 12-16-24 0715, 1919 12-17-24 0715, 1900 12-18-24 0715 12-19-24 0720 12-20-24 2000 12-21-24 0000, 0400, 0952, 1915 12-22-24 0950 12-23-24 0932, 1915 12-24-24 2000 12-25-24 1953 12-26-24 0748, 2003 12-27-24 0800, 2330 12-28-24 0800, 1200, 1600 12-29-24 0800, 1200, 1600 12-30-24 0800, 1200, 1600, 2000 12-31-24 0100, 0800, 1200, 1600, 2300 1-1-25 0731 1-2-25 0000, 1117, 2030 1-3-25 0733, 2149 1-4-25 0742, 1945 1-5-25 0656 1-6-25 0800, 1200, 1600 1-7-25 0800, 1200, 1600, 1915, 2000 1-8-25 0000, 0800, 1200, 1800, 1915 1-9-25 0000, 0400, 0600, 0700, 1100, 1300, 1500, 1700, 2043 1-10-25 0800, 2000, 2222 1-11-25 0230, 0800, 1924, 2130 1-12-25 0713, 2243 1-13-25 0800, 2032 1-14-25 0000, 0200, 0400, 0651, 0800 1-15-25 2000 1-16-25 0800, 2000 1-17-25 0800, 1901 1-18-25 0800, 1901 1-19-25 0739, 1901 1-20-25 0715, 1915 1-21-25 0745, 1937, 1944 1-22-25 0715, 1923 1-23-25 0715, 2025 1-24-25 0800, 1923 1-25-25 1747, 1921 1-26-25 1712, 1953 1-27-25 2011 1-28-25 0800, 1000, 1206, 1400, 1600, 1800, 2232 1-29-25 0700, 0900, 1100, 1300, 1500, 1755, 2000, 2200 1-30-25 0000, 0200, 0400, 0600, 0755, 2051 1-31-25 0714, 2000 2-1-25 0801, 1910, 2000 2-2-25 0000, 0200, 0600, 0753, 2240 2-3-25 0000, 0200, 0600, 0810, 2200 2-4-25 0200, 0400, 0807, 2031 2-5-25 0720, 1916 2-6-25 none 2-7-25 none 2-8-25 0934, 2108 2-9-25 0714, 0904, 1010, 1431, 1805 2-10-25 1243 2-11-25 none 2-12-25 0951, 2023 2-13-25 1915 2-14-25 1628, 2200 2-15-25 none 2-16-25 1504 2-17-25 1626, 2000 2-18-25 0757, 2000 2-19-25 1032, 2026 2-20-25 1153, 1416, 1745, 2200 2-21-25 0001, 0400, 0600 2-22-25 1900, 2100, 2300 2-23-25 0300, 0500, 0700, 0825, 1041, 1419, 1545, 2045, 2330 2-24-25 0240, 0400, 0630, 0815, 1028, 1505, 1815 2-25-25 0852, 1028, 1525, 1801, 2000, 2200 2-26-25 0001, 0201, 0400, 0620, 0830, 1045, 1230, 1412, 1645, 1839, 1934, 2134, 2230, 2359 2-27-25 0200, 0400, 0610, 2030 2-28-25 0000, 2241 3-1-25 1900, 2101, 2300 3-2-25 0100, 0300, 0500, 0800, 1000, 1240, 1400, 1600, 1614, 1800 A further review of P#1 medical record’s ‘Wound Flow Sheet’ revealed that on: 12-9-24 a new wound was assessed on the buttocks measuring 5.5 cm x 1.8 cm and 0.2 cm in depth. A wound care consult was placed, and the wound was treated with Fiber/Silver-Silicone adhering foam. 1-7-25 a skin tear was assessed on P#1’s left side of her vagina. There was no drainage and it was treated with zinc oxide paste by wound management. 2-26-25 a pressure injury was assessed on P#1’s right ear. No drainage noted. The wound measured .9 cm x 0.4 cm. It was cleansed and left open to air by wound management. An interview was conducted in the conference room on 3/4/26 at 9:20 a.m. with Nursing Director (ND) AA. ND AA revealed she had not rounded on P#1. ND AA further explained that the standard of care for any patient with a Braden Score of seven (7)-12 was turning every two (2) hours. ND AA stated that typically the nurse transferring the patient from the floor notified the patient’s family that the patient has been transferred to another floor. An interview was conducted in the conference room on 3/4/26 at 9:27 a.m. with Nurse Manager (NM) CC. According to NM CC, she made daily rounds on patients and speaks with family members. NM CC recalled that P#1’s family members voiced concerns about the care provided to P#1 in the neuro intensive care unit. The family members felt that the staff were giving up on P#1 too quickly regarding her condition from her stroke. NM CC also met with P#1’s sister who was concerned about the importance of turning the patient. NM CC stated P#1 was repositioned every two (2) hours and received proper nutrition. NM CC never saw fluid coming from P#1’s ear. NM CC explained that it was not standard procedure to notify family when patients were moved to a lower level of care. NM CC stated the physician usually notify’ s the family, not the nursing staff. NM CC explained that the physician usually discussed code status and other plans of care during that time. If patients were not being turned, it was documented in the chart. NM CC stated that the facility uses ‘Evidence Based Clinical Documentation’ (EBCD). NM CC explained that with EBCD, basic standard of care activities such as baths, oral hygiene and repositioning were not charted. An interview was conducted in the conference room on 3/4/26 at 9:37 a.m. with NM BB. NM BB stated P#1’s sisters were her (P#1) point of contact and they were concerned about her care plan and about the brain death testing. NM BB did not recall fluid coming from P#1’s ear. NM BB stated that the primary nurse was responsible for calling the patient’s family when a patient was being moved to another floor. She explained that patients were turned every two hours, assessed for nutrition, and placed wedges and padding between legs and under the heels. Staff follow EBCD charting guidelines. An interview was conducted in the conference room on 3/4/25 at 10:10 a.m. with Vice President of Quality, Risk Management, and Patient Safety (VP) FF. She revealed that Evidence Based Clinical Documentation (EBCD) was initiated to decrease the amount of documentation that the staff are required to do. VF FF also revealed it was created to allow the staff to have more contact with the patient and spend less time documenting. VP FF explained that the corporate leadership developed guidelines for how to document basic standards of care that are given, for example oral care, turning patients every two hours, and deep vein thrombosis prophylaxis. VP FF stated it was expected that if staff did not complete the patient care task, then they would document that it not being done. A telephone interview was conducted on 3/4/26 at 10:45 a.m. with Patient Care Technician (PCT) GG. PCT GG stated she turns patient every two hours. She stated she sets a reminder on her phone. PCT GG did not know if there was a place in the medical record to document patient turns. PCT GG denied any communication with P#1’s family. A telephone interview was conducted on 3/4/26 at 10:48 a.m. with Registered Nurse (RN) HH. RN HH stated that P#1’s family member called daily for updates on her condition. RN HH stated that she turned P#1 every two hours when she was her patient and documented under the “skin” tab in the medical record. RN HH did not remember P#1’s family complaining about drainage coming from her ear. RN HH recalled being told in orientation that patient turning needed to be documented once a day. A telephone interview was conducted on 3/4/26 at 10:55 am with RN II. RN II stated that when she took care of P#1 there were no concerns from her family members and did not see drainage coming from P#1’s ears. RN II explained that staff was responsible for notifying the patients family when patients were transferred off of a unit. RN II stated that the physician also usually communicates to the family. RN II explained that a Braden Score was documented once a day. s RN II explained that since it is understood that patients were turned every two hours, turning was documented once per shift. RN II stated that sometimes she documents more than one time. A telephone interview was conducted on 3/4/2025 at 11:20 a.m. with RN JJ. RN JJ stated she remembers patient and had her for one shift. RN JJ stated that she turned her patient’s every two hours, puts wedges between their legs and pads under their heels to prevent pressure wounds. RN JJ stated she tried to document every time she turned her patients. RN JJ called family members when her assigned patients were transferred to another unit. A review of the facility’s “Critical Care Mobility Protocol” revealed that for Level One Modified Mobility patients are to be repositioned every two hours with active and passive range of motion with turns . A review of the facility’s policy titled “Pressure Injury Prevention-Adults,” Policy# 14728558, last revised 02/2024, revealed that the purpose of this policy is to: 1. Outline expectations for pressure injury risk assessment and skin assessment. 2. Provide evidence-based guidelines for pressure injury prevention based on a patient’s individual risk factors. 3. Establish documentation requirements related to pressure injury prevention. Adult patients 18 years of age or older will be assessed for pressure injury risk using the Braden II Scale. A score of less than or equal to 18 is considered at risk. POLICY: A. Pressure Injury Risk and Skin Assessment: 1. All adult patients will be assessed for pressure injury risk using the Braden II Scale at the following intervals: a. upon admission or bed hold in ED b. each shift c. following a decline in medical condition d. upon transfer to a different nursing unit 2. A full head-to-toe skin assessment must be performed and documented on all adult patients at the following intervals: a. upon admission or bed hold in ED b. each shift c. following a decline in medical condition d. upon transfer to a different nursing unit 3. The clinician will use visual, touch and palpation techniques when assessing the skin to differentiate temperature and tissue differences. 4. Particular focus will be given to the skin over bony prominences including the sacrum, heels, hips, elbows, occiput and any areas under medical devices including but not limited to: condom catheters, CPAP/BIPAP masks, oxygen tubing, ET tubes, NG or NJ tubes, lower extremity compression stockings/devices, removable splints/ braces, any device securement apparatus. 5. Assess for signs of skin maceration in areas exposed to moisture as well as skin folds and creases. 6. Use the following techniques to aid in assessment of darker skin tones: a. Establish baseline skin tone in an area not frequently exposed to ultraviolet radiation. b. Use adequate lighting; the best lighting includes ambient or natural sources. Appropriate lighting also includes halogen lamp or flashlight (eg., cell phone, or pen light). c. Thoroughly cleanse area to be assessed. Remove bodily fluids and any skin care products. d. Compare skin area to be assessed to surrounding unaffected area. e. Compare same area to be assessed to opposite laterality when possible. 7. Preventive dressings should be lifted each shift to assess the skin underneath the dressing for breakdown. 8. Any skin alterations or wounds found upon skin assessments will be documented in the electronic medical record and appropriate action taken. B. Pressure Injury Prevention Measures: 1. Interventions to prevent pressure injury (or further skin injury) will be applied based on the Braden risk score and each precipitating risk factor identified. (See attachment #1) 2. Braden subscale scores and additional risk factors (i.e. use of pressors, history of a previous pressure injury) should be considered when identifying interventions to be implemented, even if the overall score indicates a patient may not be at risk. 3. The measures taken to reduce pressure injury risk for each patient will be documented in the electronic medical record. 4. Patient and/or family members will be provided with pressure injury prevention education.”

“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: 47717 Based on review of medical records, EMS (emergency medical services) report, facility’s video surveillance, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#1) out of 20 patients who presented to the Emergency Department (ED) with psychiatric complaints Specifically, the facility failed to discharge and readmit P#1 after he (P#1) left the ED and was returned by law enforcement which resulted in P#1 not receiving an appropriate medical screening examination after returning to the hospital’s ED. Cross refer to A-2406 as it relates to the facility’s failure to provide an appropriate Medical Screening Examination for P#1, when he presented to the ED with psychiatric complaints.”

“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: 47717 Based on review of medical records, EMS (emergency medical services) report, facility’s video surveillance, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#1) out of 20 patients who presented to the Emergency Department (ED) with psychiatric complaints. Specifically, the facility failed to discharge and readmit P#1 after he (P#1) left the ED and was returned by law enforcement which resulted in P#1 not receiving an appropriate medical screening examination after returning to the hospital’s ED. Cross refer to A-2406 as it relates to the facility’s failure to provide an appropriate Medical Screening Examination for P#1, when he presented to the ED with psychiatric complaints. Findings include: The Emergency Medical Services (EMS) trip report dated 12/18/24 at 1833 was reviewed. The section of the narrative revealed in part, “Dispatched ...behavioral Disturbance ... Pt (Patient) was located upstairs taking with PD (Police Department). Pt. wife stated that the patient has a history of Dementia and that she had MPOA (medical power of attorney). Pt wife reports that they had an argument and it turned violent as the patient started to hit and break things. Pt wife wants the Pt. transported. FD (Fire Department) and PD on scene report that the Pt. did state that the Pt had stated stuff about SI (Suicidal Ideation) and HI (Homicidal Ideation), But Pt denies it in the presence of EMS. Pt Stated that the argument started because he is unable to drive and he was wanting to go to the store for smokeless tobacco. Pt is alert and oriented x 4. Pt denies any SI or HI thoughts. Pt denies any pain. Pt. Skin is warm and dry ... Pt agreed to with EMS to the hospital ...Pt was transported to Memorial. .. P#1 was nonviolent with EMS and still denied any suicidal or homicidal thoughts. Further review of the EMS report revealed that EMS staff called the hospital prior to arriving to the hospital’s ED. A report was given to the staff that Patient #1 was experiencing “Psychiatric Problem/Abnormal behavior/Suicide attempt” and emergent. P#1 was wheeled to the Emergency Department (ED) room A41 ... Verbal report was given to the ED nurse”. Documentation on the EMS report revealed the Primary Impression: Behavioral/Psychiatric disorder. The Medical History was listed as Behavior: Dementia (with Behavioral disturbance; CV (cardiovascular) -Primary Hypertensin; Endocrine -Diabetes Non-Insulin Dependent. A review of the video surveillance while P#1 was in the ED reveals the following: AMB HALL 4 TIMELINE 12/18/2024 7:13:05 PM P#1 brought in through EMS Bay 7:18:40 PM Vitals are taken from P#1. 7:28:27- 7:28:51 PM Nurse talks to P#1 7:29:40 PM P#1 moved to hall between D and A pods by medics. 7:37:37 - 7:39:04 PM Woman in tan Sweatshirt speaks with P#1 7:41:48- 7:41:59 PM Same woman speaks to P#1 confirms bracelet number. 8:04:09- 8:05:03 PM Doctor speaks with P#1 8:10:10-8:12:00 PM Nurse speaks to woman in lobby. 9:20:06-9:21:52 PM Woman (Wife) speaks with Triage desk nurse a few times 9:22:25 PM Woman and other male walk out of waiting room to silver SUV (Sports Utility Vehicle) in ED lot 9:52:20 PM Nurse gets P#1 up from stretcher and walks him out. 9:54:04 PM Nurse brings P#1 to waiting room and sits him down. 9:56:24 PM Nurse comes out and brings P#1 out lobby doors, speaks with man in who walks out into parking lot and appears to speak with people in silver SUV and returns shortly and has another conversation with Nurse and the Nurse brings P#1 back in. 9:59:24 PM Nurse brings P#1 back to waiting area and sits him down. 10:39:38 PM P#1 gets up and walks to main hallway 10:40:28 PM P#1 tries to enter hospital through main doors from ED 10:41:46 PM P#1 finds bathroom after asking security 10:43:45 PM P#1 returns to waiting area 10:52:22 PM Nurse retrieves P#1 from waiting area and brings him to back 10:54:45 PM P#1 placed in bed in AMB Hall 4 10:55:06 PM Woman comes back into ED lobby speaks to triage desk for a minute and then goes back to sit in waiting room. 10:56:42 PM Nurse brings P#1 food 10:56:56- 11:00:40 PM Woman goes to bathroom 11:05:50-11:06:57 PM Nurse brings woman into back and speaks with her in front of triage then woman leaves and walks to silver SUV. 11:09:48 PM Silver SUV leaves parking lot 11:37:10 PM P#1 is given blanket 12/19/2024 12:40:55 AM P#1 appears to be registering again with staff member 1:09:23 AM P#1 gets up from bed 1:10:23 AM P#1 speaks to nurse and walks toward triage 1:14:03 AM P#1 returns to B-pod and walks down hall towards back hallway 1:16:22 AM P#1 is exiting through Rx hallway 1:17:53 AM P#1 walking out ACI (A.C. Institute) walkway and crossing lot 1:23:10 AM P#1 walking on roadway SE (Southeast) side of another hospital located in the area 1:23:57 AM P#1 walks on another hospital located on access road 2:46:30 AM P#1 brought back to ED by the City Police Department 2:47:11 AM P#1 put in bed in A pod 8:03:35 PM P#1 bed moved nearer to D-pod 12/20/2024 2:22:14 AM P#1 transported by EMS from ED A review of P#1’s medical record revealed he was admitted to the Emergency Department (ED) on 12/18/24 at 7:14 p.m. P#1 chief complaint was for psychiatric evaluation after physical altercation with his wife at home. His admitting diagnosis was restlessness and agitation. P#1 medical history included vascular dementia (dementia caused by vascular problems), type two (2) diabetes mellitus (inability to regulate glucose), atrial fibrillation (irregular heartbeat), hypercholesterolemia (high cholesterol), hypertension (high blood pressure) and nicotine dependence (a chronic condition where there is a strong need for nicotine). Further review revealed that on arrival to the ED P#1 was pleasant, answering all questions appropriately. P#1 was evaluated by MD (Medical Doctor) FF on arrival and who documented that P#1 was calm, very relaxed and was laughing and very jovial. MD FF further documented that P#1 was not suicidal or homicidal and that he felt comfortable with P#1 being discharged but the family felt that he (P#1) was unsafe. MD FF further documented that P#1’s wife was the only person at the home and family felt that P#1 would potentially harm her. A further review of P#1’s chart revealed the family did not feel comfortable taking him home. MD FF documented that this seems to be a reoccurring problem and at this time P#1 did not meet criteria for a 1013 (involuntary admission) nor did he meet criteria for admission with no active complaints. The decision was made by MD FF that P#1 would be observed in the ED and have case management get involved on the morning of 12/19/24. The facility failed to ensure that an appropriate medical screening examination was provided that was in capability and of the hospital’s ED. This was evidenced by failing to ensure that a psychiatric evaluation was provided related to the patient’s history of Dementia, Police Department stated patient expressing suicidal and homicidal ideations, and chief complaint of psychiatric evaluation. Further review of P#1’s medical record revealed P#1’s nurse was attending to a critical patient on 12/19/24 around 2:00 a.m. When she returned around 3:00 a.m. P#1 was not in his bed. She notified the charge nurse who then notified security and the house supervisor. P#1 was found approximately one hour later by the city police and returned to the ED safely with no harm. At 10:36 a.m. on 12/19/24 MD JJ was called to the bedside by the nurses. MD JJ spoke with P#1’s wife as well as his son on the phone. The son informed MD JJ that he was a neurologist (medical doctor who specializes in the diagnosis and treatment of disorders and diseases of the brain, spinal cord and nervous system) out of state. P#1 son did provide additional information stating that P#1 has had vascular dementia with increasing agitation and inability to care for himself over the past few weeks or longer. P#1’s chart further revealed that his son informed MD JJ that on multiple occasions the police and first responders have been called to the home due to agitation/behavior disturbances. The son also revealed this behavior had been escalating at home although P#1 had been calm and cooperative in the ED and he had no complaints at that time. MD JJ documented that P#1’s son stated he spoke with a Geri-psych facility in another county that had agreed to accept P#1 if he was placed on 1013 for inability to care for himself. MD JJ documented that at the request of wife/son in conjunction with additional information, he did believe this was reasonable. MD JJ documented he planned on placing patient on 1013 and transferring him to the psychiatric facility. MD JJ further documented that the family did describe episodes of agitation with psychotic features, threatening behavior towards his wife and MD JJ felt there was a component of psychiatric illness/decompensation in addition to dementia contributing to his presentation today and P#1 would benefit from stabilization from a geriatric psychiatric facility. A 1013 form was signed by MD JJ on 12/19/24 at 10:36 a.m. P#1 was transferred to the psychiatric facility on 12/20/24 at 2:32 a.m. The facility failed to ensure that their policy was followed as evidenced by the facility failed to ensure that upon the patient’s initial return after elopement a re-assessment was initially done upon the patient’s return to the ED; and vital signs were not obtained until 5 hours after the patient returned to the ED. Additionally, the facility failed to ensure the patient was placed in Pod D after the after the patient was placed on a involuntary hold. A review of the facility policy titled “Leaving Hospital Before Discharge “ID 11175366, last Revised 02/2022, revealed in part, the policy provided guidelines to clinical personnel for patients that leave the hospital before discharge orders have been written by a provider. Further review of the “Policy Statement” revealed in part, “Patient have the right to leave unless the patient lacks decision making capacity.” The section of the policy titled “C. Procedure for Elopement of Patient without Decision Making Capacity; Minor; or patient with Involuntary Hold” revealed the policy. The nurse shall assess the potential for elopement at admission. a. Patients at risk for elopement include but are not limited to those who have documented history of ...those who are cognitively impaired ...2. The nurse would communicate that the patient has been assesses to be at risk for elopement to Security Department ...If elopement occurs: ... The nurse would notify the patient’s family 9. The nurse would hold the room while attempts were made to locate the patient leaving the hospital. 10. Upon return to the hospital, the nurse would notify parties of the patient’s return, including the Leaving Hospital Before Discharge. Notify attending physician of the patient’s return to hospital. ..or have Emergency Department physician perform exam.” The facility’s policy titled, “EMTALA - Medical Screening Examination and Stabilization “, policy #11175306, last revised 05/2022 was reviewed. The policy revealed that the purpose of the policy was to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer of the individual. Continued review revealed, Procedure: 1. When an MSE is required, a hospital must provide an appropriate MSE within the capability of the hospital ’ s emergency department, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. An MSE is required when: a. The individual comes to an ED of a hospital and a request is made by the individual or on the individual ’ s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition ... 3. Extent of MSE e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual’s signs and symptoms: i. Depending on the individual’s presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures. iii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others ... ii. Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary stabilizing treatment. A review of the facility ’ s policy titled, “Involuntary Hold “, policy #13838401, last revised 08/2020, revealed that the purpose of the policy was to define the process for caring for involuntary patients while in the ED or medical unit. Continued review revealed, Procedure: A. For all involuntary patients, whether medically cleared or not: 1. Place the original 1013/2013 form on the patient chart 2. Physician shall place an involuntary order in the electronic medical record 3. Physician shall place an order for psychiatry consult 4. The charge nurse will complete a form as stated for a one-on-one sitter. a. One-to-one sitter is not required if the patient is in ED (Pod D). C. Involuntary patients who have been medically cleared in the ED: 1. These patients should be placed in Pod D. 2. An assessment or reassessment is to be documented. a. Initially on arrival to ED b. With change in patient condition c. Behavioral Health Reassessment to be completed every shift minimally. An interview was conducted in the conference room with Director of Patient Safety (DPS) AA on 12/30/24 at 9:43 a.m. He has been employed in this position for one (1) year. When discussing video surveillance DPS AA stated he was familiar with this patient. He revealed P#1 had a stroke and ended up with dementia. DPS further revealed he spoke with P#1’s son stating the Crisis Intervention Team was called to P#1 home and decided he needed to be transferred to a named hospital. DPS AA stated the Emergency Department was very busy that night and P#1 had to be placed in a hallway bed. He further stated the physician talked to P#1 and said he was alert and oriented. DPS AA stated P#1’s son said physician did not speak to wife. DPS AA stated another patient in the hallway had a seizure and P#1’s nurse had to take care of the emergency. P#1’s nurse said she went to discharge the patient to the wife, and she refused to take him home because she was scared. The physician agreed to keep P#1 in the ED and have case management consulted for placement for him. DPS AA stated it was during the seizure event when P#1 left the ED without anyone knowing. An interview was conducted in the conference room with ED Nurse Manager (NM) CC 12/30/24 at 11:10 a.m. NM CC remembers P#1 revealing he was brought into the ED via Emergency Medical Services (EMS) after having alteration with wife at home. NM CC further recalled that the ED physician evaluated P#1, determined that P#1 did not need to be admitted to hospital and did not meet criteria for 1013 and marked him to be discharged home. NM CC further revealed P#1’s nurse spoke with wife regarding P#1 being discharged home. The wife did not want to take him back home fearing for her safety. P#1’s nurse notified the charge nurse and P#1 was brought back to ED for case management consult. NM CC stated P#1 was not a 1013 at this time. P#1 was placed in a care space (hallway bed) in the ED and proceeded to leave the facility while awaiting case management to evaluate him in the morning. His nurse did not see him leave. After his nurse finished taking care of a critical patient, she realized P#1 was not in his care space. She notified the charge nurse, security and nursing supervisor. The city Police Department (PD) was notified by security. The city PD found P#1 on (name of ) Ave and brought P#1 back to the facility. NM CC did not recall if nurses informed wife that P#1 left. An interview was conducted on 12/30/24 at 1:00 p.m. via telephone with the Nursing Supervisor (NS) DD. NS DD recalls getting a call around midnight on 12/18/24 from P#1’s son asking that P#1 being placed on a 1013 so he could be placed in a behavior health facility. NS DD revealed he spoke with MD FF. MD FF revealed P#1 had already been discharged and was sitting in the waiting room waiting for his wife to return to pick him up. MD FF revealed to NS DD that P#1 was alert and oriented and did not meet criteria for a 1013. MD FF stated P#1 could not be admitted against his will since he was alert and oriented and did not appear to be a threat to himself or others at that time. NS DD also spoke with RN II, who was the charge nurse on night shift for 12/18/24 and he agreed with MD FF that P#1 did not meet 1013 criteria. MD FF agreed to bring P#1 back into the ED and have case management get involve with evaluating him for facility placement in the morning. P#1 was brought back into the ED and place in a bed in the hallway to wait for case management the next morning. NS DD received a call from RN II around 1:00 a.m. regarding P#1 leaving the facility without notification to staff. RN II had already notified security, and security notified the city Police Department. NS DD stated he went to the ED and within 10 minutes of receiving the call P#1’s son called him regarding P#1 not being in the ED. NS DD further revealed the protocol for a patient receiving a psychiatric evaluation in the ED is to evaluate whether or not the patient was a danger to himself or others, can he care for himself, if not, does he have someone to care for him. NS DD further revealed he believes P#1 became tired of being in the ED waiting for case management and decided to leave. NS DD also stated that MD FF could not justify signing a 1013 and taking away P#1’s rights. An interview was conducted on 12/30/24 at 2:50 p.m. via telephone with the Emergency Department (ED) Medical Director (MD) EE. MD EE was made aware of the situation with P#1 from MD FF and MD JJ. MD EE stated she was not in the ED when the incident occurred but was able to speak with Patient #1 during the remainder of his visit in the ED the next day. MD EE revealed P#1 had a history of dementia and that he had gotten upset with his wife at home for not taking him to buy some tobacco products. MD EE further revealed that MD FF evaluated P#1 on arrival to the ED and documented that he did not meet 1013 criteria. P#1 was not suicidal or homicidal and that he was stable to be discharged from the ED. MD EE was informed the family did not want P#1 to be discharged because his wife was fearful of her safety. MD FF agreed to hold P#1 until case management could evaluate him the next morning. MD EE further revealed that MD JJ spoke with son on the morning of 12/19/24. The son revealed to MD JJ that he had arranged for P#1 to be accepted at a behavior health facility in another county, but he would have to have a signed 1013 to be able to be transferred. MD EE stated MD JJ agreed to sign the 1013 and P#1 was transferred out. MD EE further revealed the protocol for meeting criteria for a 1013 is the ED physician gets a history by talking to the patient and family and seeing if the patient has a history of mental illness. MD EE stated the 1013 signed for P#1 was done as a favor to the family so they could get placement for his dementia. During a telephone interview on 12/30/24 at 5:00 p.m. with Licensed Practical Nurse (LPN) GG remembered P#1.. He arrived by stretcher via EMS and LPN GG remembers EMS telling her P#1 had an altercation with his wife and that he needed to be evaluated for aggression. LPN GG remembers keeping P#1 in the waiting room so P#1 would not become agitated, and updated P#1’s wife on numerous occasions. P#1’s wife informed LPN GG that she was concerned that his dementia was getting worse. She also informed LPN GG that P#1 had not seen a neurologist since being in Savannah. LPN GG informed MD FF. LPN GG stated P#1’s wife left the waiting area at one time to go to her car and charge her phone. When P#1 was discharged LPN GG attempted to call P#1’s wife with the number on his medical record. She was not able to contact her. P#1 called his wife on his cell phone at that time, and she answered. LPN GG stated the conversation was on speaker. P#1 informed his wife that he was being discharged and that she needed to come in and get the discharge instructions and pick him up. LPN GG stated P#1’s wife informed him she was not taking him home and hung up on him. LPN GG also revealed that P#1 had no recall of having an altercation with his wife. LPN GG stated she called P#1’s wife, and she informed her that she needed to talk to her son. LPN GG informed P#1’s wife to call and speak with the charge nurse. LPN GG stated the son called her and stated that it was not okay to discharge his father (P#1) and that it was an unsafe discharge. The son stated his mother was not safe if P#1 was discharged. LPN GG further stated that she put the son and hold and informed RN II of the call. RN II spoke with the son and transferred him to NS DD. LPN GG then saw that P#1 was readmitted for case management to get involved. LPN GG stated P#1 was then moved to a different area so he would not be stimulated then she did not take care of him any longer. During an interview via telephone on 12/31/24 at 7:20 a.m. with Registered Nurse (RN) II, he explained that he was the charge nurse on the night shift. RN II recalled P#1 and that he was pleasant and recalled that P#1 spoke of his love for his family. He was not assigned to P#1 but did speak with him. RN II stated he was notified that P#1 had left the ED, and he followed protocol. RN II stated he called security, and security notified the city police department. During an interview via telephone on 12/31/24 at 7:30 a.m. RN HH recalled that P#1 was her patient after being brought back into the ED to wait for case management the next morning. RN HH recalled that P#1 was pleasant, he was in a hall bed, and she gave him food to eat. RN HH stated she did not speak with his wife. RN HH stated the protocol for a patient leaving the ED without notification is to notify the charge nurse and the charge nurse would notify security and the city police department. RN HH also stated that while she took care of P#1 he was not a 1013. During a telephone interview on 12/31/24 at 3:20 p.m., MD JJ stated that he became aware of P#1 when he was asked by a nurse on 12/19/24 to speak to the patient due to family members wanting P#1 to be admitted to a behavioral health facility. MD JJ recalled that P#1 had vascular dementia, and he (MD JJ) was informed by the son and P#1’s wife that law enforcement had been called to their home a number of times due to behavior disturbances. MD JJ stated that P#1’s son presented himself as a neurologist and stated he had found a behavioral health facility that was willing to accept P#1; but P#1 needed to have a signed 1013 form stating he could not care for himself. MD JJ thought since the son had gone through all the steps to find placement for P#1 then he would help him by signing the 1013 form. MD JJ ordered basic blood work required for a transfer to a behavior health facility and P#1 was transferred without incident.”

“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: 46188 Based on review of medical records, Emergency Medical Services, Prehospital Patient Care Report, Complete Version 3.5, policy and procedures, Medical Staff Rules and Regulations and interviews with staff, it was determined that the facility failed to ensure that an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital’s emergency department to include available ancillary services (psychiatrist services) to determine whether or not an emergency medical condition existed, for one patient (P) (P#1) of 20 sampled patients. P#1 presented to the facility’s ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness). P#1 was discharged to home on 10/31/24 at 3:52 a.m. P#1 was readmitted to the facility’s ED on 11/2/24 at 4:39 p.m. on an involuntary hold from an outside facility. Findings included: Cross refer to A-2406 as it relates to the facility’s failure to provide an appropriate medical screening exam within the capability of the hospital’s emergency department.”

“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: 46188 Based on review of medical records, Emergency Medical Services, Prehospital Patient Care Report, Complete Version 3.5, policy and procedures, Medical Staff Rules and Regulations and interviews with staff, it was determined that the facility failed to ensure that an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital’s emergency department to include available ancillary services (psychiatrist services) to determine whether or not an emergency medical condition existed, for one patient (P) (P#1) of 20 sampled patients. P#1 presented to the facility’s ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness). P#1 was discharged to home on 10/31/24 at 3:52 a.m. P#1 was readmitted to the facility’s ED on 11/2/24 at 4:39 p.m. on an involuntary hold from an outside facility. Findings included: The Emergency Service Report, Prehospital Patient Care Report Complete Version 3.5 for patient #1 dated 10/30/2024 was reviewed. The report revealed the Chief Complaint as “Altered Mental Status.” Further review revealed in part, “Patient is a 28 Years old Male complaining of altered mental status for 10 minutes. Pt. found wondering around parking lot by PD (Police Department). Patient is not verbally responsive. Patient follows commands after multiple requests. Patient is minimally cooperative with vital signs and assessment prior to loading in ambulance ...Patient has a known history of delta 8(a psychoactive substance found in Cannabis sativa plant) use per PD. Patient going to Memorial ED (Emergency Department) for eval (Evaluation) ...Vitals were assessed as 10:30 2024 9:12 PM GCS (Glascow coma scale-tool used to assess level of consciousness)- 11 (drowsy or obtunded) ... Alert ...Pulse 125 (normal heart rate 60-100) ...10/30/2024 9:18 PM ...Alert ...Pulse: 131 ...BP (Blood Pressure -normal 120/80) ...Medications administered:.. Normal Saline Dose: Keep vein open ...IV (intravenous) site: (L) Left Hand ...Other Symptoms: Excessive sweating ...Behavior, strange and inexplicable ...Report called into ED ...Disposition: Patient Treated and Transported.” A review of P#1’s medical record revealed that P#1 presented to the facility’s ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness), (Pt (patient) ...after Police called EMS for AMS/Anxiety. Hx (History) substance abuse. Pt. following commands but nonverbal in triage. BGL (Blood glucose level) 215 (normal 60-100). Pt. Tachycardiac (fast heart rate) on arrival). Continued review of P#1’s medical record revealed that P#1 was triaged on 10/30/24 at 9:50 p.m. and assigned an acuity level of two (Emergent). The patient’s ED triage vital signs at 9:52 PM were listed as BP 179/107, Heart rater of 120 beats per minute. P#1 was ordered a chest x-ray, computed tomography (CT) (imaging to create detailed pictures) scan of the head, and electrocardiogram (a test that measure the electrical activity of the heart), laboratory blood work, urine analysis, and a urine drug screen panel. A review of an “ED Provider Note” dated 10/30/24 at 10:17 p.m. (Physical Examination) by ED Medical Doctor (MD) BB revealed that P#1: Cardiovascular: Tachycardiac; Neurological: Mental Status: He is alert; Comments: Patient was, not talking but looks around and moves all extremities; Psychiatric: with a mood and affect as normal. Further review revealed, “Medical Decision Making: This patient presents with altered mental status. Differential diagnosis includes electrolyte abnormality, accidental drug overdose, stroke, intracerebral hemorrhage, urinary tract infection encephalopathy, pneumonia, or other infection. The patient will be monitored closely throughout the emergency department stay. Their disposition will depend on their work-up results and frequent re-evaluations ... Course. Pt. much improved ...ED consult: none. ED Reevaluation: None. Clinical Impression: Diagnoses: Altered mental status, unspecified altered mental status type Tetrahydrocannabinol (THC) use disorder, mild abuse ...Disposition: Discharge Stable” There was no documentation in the MR by the ED provider to indicate the patient started speaking, and there was no reassessment of the patient’s mentation. The MSE was not appropriate as evidenced by failing to ensure a psychiatric evaluation (ancillary services) was provided that was within the capability of the hospital’s ED to determine whether or not an emergency medical condition existed. The medical record dated November 2, 2024, revealed that Patient #1 returned to the hospital’s ED for a “Psychiatric Evaluation” Further review of the medical record revealed the patient’s Mom called for psychiatric care because the patient has been roaming around different cities and states due to paranoia. P#1 tested positive for urine tetrahydro cannabinoid (THC-chemical compound, responsible for altered state of perception). Continued review of P#1’s medical record revealed that on 10/31/24 at 12:29 a.m., Registered Nurse (RN) AA conducted a suicide risk screening and noted that P#1 had no risk identified. On 10/31/24 at 12:29 a.m., RN AA noted that P#1 was alert and oriented to person, place, time, and situation and was ambulatory. Continued review of P#1’s medical record revealed that on 10/31/24 at 3:10 a.m. had a heart rate of 98 beats per minute, respirations of 16 breaths per minute (normal was 12 to 20), blood pressure of 154/91, and oxygen saturation of 99% on room air P#1 was discharged on 10/31/24 at 3:52 a.m. to home, ambulatory, with discharge instructions. The patient was discharged to self-care there was no documentation in the medical record to indicate that any family member was contacted. A review of the facility’s “Rules and Regulations “, last revised 3/25/22, revealed, 1.1, 6, Medical Screening Examination: a. Any individual who comes to the Medical Center Emergency Department requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). The purpose of the MSE is to determine if the individual is experiencing an emergency condition. A review of the facility’s policy titled, “EMTALA - Medical Screening Examination and Stabilization “, policy #11175306, last revised 05/2022, revealed that the purpose of the policy was to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer of the individual. Continued review revealed, Procedure: 1. When an MSE is required, a hospital must provide an appropriate MSE within the capability of the hospital ’ s emergency department, including ancillary services routinely available to the ED, to determine whether an EMC exists. An MSE is required when: a. The individual comes to an ED of a hospital and a request is made by the individual or on the individual ’ s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition. A review of the facility’s policy titled, “Discharge Planning: Role of Healthcare Team “, policy #16508093, last revised 12/2023, revealed that the purpose of the policy was to provide a systematic process of collaboration among the healthcare team and patient/family in planning for the patient ’ s discharge. Continued review revealed, Procedure: A. Assess and identify high risk discharge indicators 1. Admitting Patient Care Nurse will assess and identify high risk discharge indicators upon admission and make a referral to the appropriate discipline. During a telephone interview on 11/14/24 at 8:01 a.m., Medical Doctor (MD) BB. MD BB recalled that P#1 presented with a complaint of altered mental status (AMS). MD BB said that for patients who present with this complaint, he would order a urine drug screen, blood work, and any pertinent imaging to help determine the cause of the alteration. MD BB recalled that P#1 tested positive for cannabis and in his experience, this sometimes causes patients to be momentarily altered. MD BB recalled that the plan was to observe P#1 for a while and then determine the best course of action for P#1. MD BB recalled that P#1 was always alert just refused to verbally communicate. MD BB recalled that after some time P#1 did speak and was alert and oriented. MD BB said that if patients do not pose an immediate threat to themselves or others and are medically cleared, then the plan is to monitor them and then discharge them as appropriate. MD BB said that nursing staff help with providing resources to patients who are discharging from the ED and require it. MD BB said that this can range from shelters to obtaining rides. MD BB recalled that P#1 did not present as a psychiatric patient when MD BB provided care for him on 10/30/24. MD BB recalled that P#1 presented as a more drug-related AMS patient and after P#1 began to speak and demonstrated being oriented then MD BB felt comfortable in discharging him. During a telephone interview on 11/13/24 at 3:41 p.m., Medical Director MM said that she has been the Medical Director of the emergency department (ED) for almost nine months. Medical Director MM said that the biggest decision point to see if a patient is stabilized and ready for discharge from the ED is when the physician is deciding on whether the patient must be on a 1013 hold or not. Medical Director MM said that for many psychiatric patients, if there is not a medical concern but more of a psychiatric concern, then the physician must determine whether that patient requires further treatment, inpatient versus outpatient. Medical Director MM said that if a patient can be safely discharged from a medical standpoint and is alert, oriented, with a reasonable mood and affect then physicians may discharge these individuals and provide them with follow up resources as appropriate. Medical Director MM said that if the patient requires further examination and treatment or would benefit from seeing a psychiatrist then these patients should be placed on a 1013 hold for further examination and placement.”